What’s the best procedure for eye bags? This question is an indication of the
level of confusion in the marketplace where physicians non-physicians device
manufacturers pharmaceutical companies and cosmetics manufacturers are
overwhelming the internet social media radio and television with claims of
offering the best solution for under-eye bags as an expert in helping people with
under eye bags since the early 1990s I’ll share with you my experience with
people who come to me after trying a lot of these new and improved ways to treat
under eye bags I’ll discuss my approach to evaluating under-eye bags and the
treatment strategies I developed for my patients I’m Dr. Amiya Prasad I’m a
Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic
and reconstructive surgeon I’ve been in practice in Manhattan and Long Island
for over 20 years I perform procedures to help people with their under eye bags
every day in my practice these procedures include lower eyelid surgery
and under eye filler treatments as well as lasers radiofrequency and PRP
procedures which are used to improve the under eye skin I also specialize in
revision procedures for treatments done by physicians and non-physicians these
procedures include dissolving under-eye fillers and addressing complications of
lower eyelid from I back surgeries such as lower eyelid retraction and ectropion
during consultation for under-eye bags I find that a lot of my patients come in
with a list of solutions which they learn after doing lengthy internet
research another group of patients come in after they’ve tried several
so-called non-invasive procedures which either didn’t work or actually made them
look even worse in the course of these discussions there is a common element to
these stories typically they report that they went to someone and that they were
recommended to have a procedure with a new device or an injectable as a shotgun
approach these so-called latest breakthroughs are aggressively promoted
and not surprisingly discounted as an incentive if something works so well why
should you need an incentive other than a successful result
so what was missing what was missing was a proper analysis of the anatomy and an
unbiased discussion about what are the factors which contribute to them looking
tired with under-eye bags so what I say to my patients is let’s clearly define
the problem before we plan the solution when you have under-eye bags which are
constantly present regardless of the amount you sleep the anatomic issue is
most often lower eyelid fat prolapse lower eyelid fat prolapse means that the
fact that is under your eyes herniates forward which we call fat herniation
this problem is generally associated with genetics as well as aging and other
variables such as allergies and sinus problems staying on anatomy I also look
at the bone structure in particular the cheekbone structure I often see prolapse
of fat forward occurring at the same time there is a deficiency in cheek
projection when referring to the cheek I mean the area just below the lower
eyelid seen from a front view as well as the cheek bone which is the high point
on the side next to the eye it’s not unusual for me to see a patient who
feels that they have under eye hollowness as their primary issue
the presence of under-eye bags this makes sense when you understand that the
relationship of the cheek projection to their fat prolapse this perception of
hollow is also caused by the contrast between the height of the under-eye bag
which is like a hill next to the hollow which is a valley resulting in the
perception of a hollow appearance the higher the hill the deeper the valley or
hollow in addition I look at the skin quality in terms of wrinkles tone and
discolorations it’s important to understand that the eyelid skin is the
thinnest skin in the body at about 1/2 millimeter in thickness the
recommendations I make to my patients is based on my experience as a cosmetic
eyelid surgery specialist with experience in multiple surgical and
non-surgical approaches I also own several lasers and radiofrequency
devices and I personally perform injectable treatments such as hyaluronic
acid fillers and neurotoxins the point is that I don’t have a bias based on any
limitation in education or training I select with my patients the approach
which I feel is in their best interest to achieve an outcome that they will
likely to be satisfied with I don’t lease any devices and I have no other
pressures which would make the recommendations I make if I think a
device or technology is effective I buy it outright and I use it when it’s
appropriate that being said let’s look at what defines an effective solution
for under eye bags or any cosmetic procedure in my opinion the procedure
should be one that I would do for myself or a member of my family
this means it should be safe predictable and have minimal downtime safe is
defined by minimal risk of complication from the procedure itself and anything
that could be a risk to your health predictable means that as your doctor I
can confidently anticipate a level of improvement which can be
shown to you in before-and-after photos minimal downtime means being able to go
back to your normal life quickly without a protracted recovery period where
you’ll look at yourself for weeks and months after the procedure and wonder
when you’ll finally look the way you want so here’s what goes on in my mind
when I see a patient who comes in with puffy eyes is there puffiness slight
enough with the bone structure anatomy which would allow me to effectively
camouflage their puffiness with under eye filler much is promoting about
the use of hyaluronic acid fillers as a non-surgical solution for under-eye bags
there are certain anatomic limitations to this approach the term tear trough is
now something anyone doing internet research becomes familiar with this
trough has two boundaries the boundary closer to the eye is the prolapse fat
the other boundary is a bone structure called the anterior lacrimal crest which
is part of a larger bone called the maxilla this bone defines how much you
can fill the tear trough before you exceed the capacity of the trough from
the front the height or projection of the prolapse fat defines the limit of
the fillers ability to diminish the relative prominence of the fat pocket
when the fat pocket and the anterior lateral crest are at about the same
height and there is a deep tear trough I can place a filler such as Restylane
with a blunt cannula and get a very nice result I often see people who had filler
place to camouflage their eye bags which resulted in their eye bags actually
looking worse I see this occur a lot when people insist that a doctor use
fillers when the fat pockets are much too prominent with no space for filler
placement these are the same people who believe
that they know enough to instruct the practitioner on how they should place
the fillers they end up looking worse and then they blame the practitioner for
their outcome when they really needed surgery and refused to accept the
reality that that’s the case I also see people who had too much filler placed
not only in the tear trough but also in the cheek from the front and sides
resulting in a disfiguring and unnaturally swollen appearance this
filler after being placed in the skin much too excessively causes swelling and
probably affects the lymphatic drainage system which further aggravates the
swelling in these patients I have to use large amounts of hyaluronidase to
dissolve the hyaluronic acid filler before doing anything else I often see
patients who did fillers for a few years to camouflage their under eye bags and
found that the fillers weren’t working so well as the fat prolapse became worse
and as facial volume loss from weight loss and aging progressed the next
question after establishing that the eye bags are caused by lower eyelid fat
prolapse is to what extent the individual fat compartments are
significantly herniating forward in the lower eyelid there are three compartment
which are also have deeper extensions and sub compartments the compartments
are the medial central and lateral fat pockets I have the patient look up in
several directions which make these fat pockets become more prominent I also
look at the supporting structure of the lower eyelid particularly the tendon
that is attached to the bone structure called the lateral canthal tendon when
the fat pockets are so prominent that filler cannot effectively be used for
blending a surgical option is appropriate
surgery is often portrayed particularly by non-surgeons as something to be
avoided at all costs I emphasize the word costs since these practitioners
cost their patients thousands upon thousands of dollars in useless
treatments it’s understandable that there are plenty of examples of
so-called botched plastic surgery in the media which contribute to this fear of
surgery I point out to my patients that the people who look natural after eyelid
surgery simply don’t draw attention so the fearful patient doesn’t get to
appreciate good cosmetic surgery results after so many years in practice a lot of
my patients come because they know someone I operated on and they like the
way the person I operated on looks resistance to surgery is also driven by
the fears related to anesthesia and anesthesia related complications in my
practice I perform eyelid surgery under local anesthesia with the LITE IV
sedation as opposed to general anesthesia where you’re paralyzed and
placed on a respirator to keep you alive my patients recover quickly and walk out
comfortable and happily thanking my staff before they go home as far as the
type of surgery is concerned my preferred approach to under-eye bags is
called transconjunctival blepharoplasty this is an approach where I address the
fat pockets from the inside of the eyelids in my hands my patients are able
to maintain the natural shape of their eyes which allows for retaining the
character of their eyes my objective when performing this type of eyelid
surgery is to create the appearance than you would have had if you never had
prolapsing fat pockets my patients recover quickly and go back to work in a
week often without any bruising as a side note I’ve seen patients who
reported having fillers done elsewhere and having been bruised for weeks
while my patients have minimal to no bruising one week after surgery
the next part is skin evaluation if you have lighter skin with wrinkles and
discolorations I often recommend fractional CO2 or erbium laser to
improve the skin quality and texture I also use PRP or platelet-rich plasma
which is a concentration of the healing factors from your blood which stimulate
collagen and blood supply resulting in better skin I use PRP for all skin types
and have found benefit for darker skin types who are not candidates for laser
as mentioned earlier the presence of fat prolapse resulting in under-eye bags is
often accompanied with a deficiency in cheek volume and projection associated
with genetics and aging bone structure determines the facial appearance more
significantly than anything else this means that addressing bone volume
can help you improve your appearance more effectively than any thermal energy
device or the latest innovations with threads the concept is called structural
volumizing where I use my experience performing facial implant surgery such
as the placement of cheek and chin implants to place long lasting
hyaluronic acid fillers I often enhance the cheeks at the same time I perform
surgery for under-eye bags the cheeks can be thought of as framing the eyes
and the balance of the cheeks with the eyes makes the whole face look better I
perform this placement without bruising and without any effect on the recovery
time after surgery I hope you found this information helpful thank you for your