What can I do about the bags under my eyes?

Baggy lower eyelids are actually caused by the fat that pouches out from inside the orbit (eye socket). The thin skin and muscle that hold the fat in place loosen as we age. Combined with the gradual loss of the youthful fullness of our faces, these fat pockets become even more prominent. In some of us it’s genetic. At least once a week I’ll have a patient stare at their reflection in the hand mirror and—with that deep sigh of resignation—say: “I’ve had them my whole life, just like my mother/father.”

No matter the cause, under-eye bags can make you look tired and sad when you’re not, and it’s just not a good look for anyone.

In case you’re one of those fortunate few who are too young and/or genetically blessed to even know what I’m talking about, below are some obvious examples contrasting Charlize Therons youthful, flat “lid-cheek” junction with the separation of the lower lid and cheek and the tear trough that occurs as we get older, such as in Donald Sutherland:

So, what are the options for taking care of this less-than-desirable problem?

1) Surgery, of course :-)!

In the past, these lower lid fat pockets were simply removed, which temporarily improved things, but left the area looking hollow in later years. I see quite a few patients who, ten to fifteen years after this procedure, now want the “tear troughs” filled in again.

The more current procedure of Fat Transposition–developed by experts in this field about ten years ago—involves repositioning rather than just removing the fat. The bulging fat is released and allowed to drop into the hollow tear trough below.

Example:

Before Fat Transposition of Lower Eyelids
After Fat Transposition

These pictures are courtesy of Dr. Andrew Frankel, a Beverly Hills Facial Plastic Surgeon whose office is located at the world-famous Lasky Clinic. Not only is lower blepharoplasty one of the procedures he specializes in, but I am one of his very satisfied customers. ;-)

This amazing procedure that took years off my face is performed through an incision on the inside of the lower eyelid so there are virtually no scars. However, consider yourself warned. Fat transposition definitely involves more downtime than simple fat removal, with the kind of bruising that’s too dark to cover with even cement-based makeup. I remember about two weeks after I had the procedure done, one of my colleagues brought me as a date to a Craniofacial Society party. Yes, you read that correctly. It’s the select good-old-boys group of Craniofacial surgeons that have trained under the esteemed Henry Kawamoto at UCLA, which is basically the most prestigious thing a craniofacial surgeon can do. They have an exclusive gathering here in L.A. every Spring. It used to be a big black-tie affair at the Ritz Carlton, and the first time I went, at one point I found myself in the women’s lounge, having an hour-long alcohol-inspired heart-to-heart with Sharon Stone about how men suck. (By the way, she’s just as breathtaking up close as in pictures, and is—at least at that time, anyway, we haven’t exactly kept in touch–totally natural). But since the recession and budget cuts, well you know…over the years this event has morphed into a cocktail party at a restaurant on the promenade in Santa Monica. Not quite as glam.

Anyway, after five layers of professional makeup–though I looked like a hooker–at least you couldn’t tell I had surgery. Or so I thought. Until halfway through the evening when I caught a glimpse of myself in a decorative wall mirror and realized that the makeup was pretty much gone and that I was standing in the middle of a well-lit room with two big black eyes, surrounded by a bunch of male plastic surgeons, and I wasn’t fooling anyone.

Bottom line—it can be up to a two-week recovery that’s difficult to disguise, but four years later, it’s still totally worth it.

2) Filler injections in the tear troughs

If you don’t have the downtime or the funds to get rid of them, camouflaging your lower lid bags with filler injected right alongside in the hollow tear troughs can be a great alternative. Most plastic surgeons, facial plastic surgeons and oculoplastic surgeons perform this procedure right in the office.

See an example below:

Which Filler should my doctor be using?

Most plastic surgeons use Restylane® for under-the-eye injections, although some prefer Juvederm Ultra®. Regardless, it should be one of these two “thinner” hyaluronic acids. Perlane® and Juvederm Ultra® are too thick for this area, and will cause too much swelling. Make sure your doctor is putting it deep down on the bone—when you put these fillers close to the skin not only can you get lumps, but you get this bluish tint called the “Tyndall effect.” The only thing you can really do about that is use cover-up or have the filler removed with hyaluronidase injections. And under no circumstances should you ever have any filler BUT a hyaluronic acid injected under your eyes. Radiesse® and Artecoll®—longer-lasting and more permanent fillers that contain hydroxyapatite and polymethylmethacrylate respectively– can lead to permanent bumps and disfigurement in this area. Some surgeons prefer using fat injections (your own, of course) but that means you also have to take it from somewhere else on your body, and in most of our hands, the results are not as predictable, as some of the fat resorbs, and some of it can actually grow (see the Fat is your friend post.)

The downtime with fillers in this area is variable. As I recommended in the Duck Lips post, take arnica one week prior to the injection, try to avoid ibuprofen-containing medications, and don’t have it done on the day of or within a week of any social events where you care if somebody notices. Although the bruising is usually much less severe than after surgery, and easier to cover with makeup like Dermablend,™ if you’ve never done this before and you’re nervous about it, go slow. No matter how deep your under-eye hollows, don’t do more than one syringe split between both sides at a time. It can swell a lot, and you can always do small amounts and come back and get more when the swelling goes down a week or so later.

How long do these injections last?

I have found that this depends more on the individual patient rather than which filler I use. Some people metabolize this stuff faster than others (the one advantage of having a slower metabolism is that your fillers will probably last longer) but overall, they stay longer in the upper than in the lower face since there is less movement.

I have seen under-eye fillers last anywhere from a few months to a year—average about five months—but one thing I will say is that even though hyaluronic acids are not supposed to be “permanent,” it is my experience that they are definitely cumulative. That is, the area never seems to go back to as hollow as it was originally, and this goes for all over the face including lips and nasolabial folds.

Don’t these under-eye injections hurt?

Actually, not really. It is surprisingly one of the least sensitive areas on the face to inject, and now even more so since all of the fillers come with local anesthetic mixed in already.

What can I do about my “Festoons”?

I had a question regarding treatment for festoons” and I actually learned something myself when I went to research this topic, since it’s not something I deal with often.

Festoons” are the swelling that happens below the lower eyelids on the cheek area, just south of the lower-lid bags themselves.

They can sometimes be improved by treating the underlying medical condition like fluid retention or allergies, but the really stretched-out, sun-damaged, aging skin is hard to fix. According to my local festoon expert Dr. Chris Zoumalian, a well-respected Oculoplastic Surgeon here in Beverly Hills, these malar mounds” can actually look worse after the lower lid bags are taken care of, a midface lift won’t usually work, and there are no great direct surgical procedures for the festoons themselves.

I have also spoken with Lasky-trained Beverly Hills Facial Plastic Surgeon Dr. Aric Park, and Dr. David Stoker, a well-established Plastic Surgeon here in Beverly Hills and Marina Del Rey, and they agree with Dr. Zoumalian.

So that was a lot of bad news. Is there anything that can be done for them?

They can sometimes be camouflaged with filler, though not as easily as under-eye bags. I’ve done this for patients, filling in that “line” on the upper cheek, and it’s okay.

During my internet research I did come across a Facial Plastic SurgeonDr. Adam Scheiner in Tampa, Florida–who has a special laser technique to take care of festoons scarlessly called the Reset. However I was unable to decipher from his website what that laser is exactly. I’m assuming it’s some sort of CO2 laser, since tightening up that area would require super-aggressive skin resurfacing.

So although I am always skeptical when there is one person who has the magic answer to something that is such a problem for all of the other well-trained, brilliant surgeons out there, if you live in the Tampa area, it’s probably worth at least checking him out. From what I can see, he seems to have cornered the festoon market—or at least the search engines—because he owns every good image of festoons that I could find on the internet, and in an undownloadable form. I don’t know him personally, but he looks like a nice enough guy in his website picture, and he does have some impressive before-and-afters at adamscheinermd.com

And if anyone has had any success with treatment of their festoons and would like to share, please do! You can email in your anonymous tips to lipoqueen@gmail.com

Happy Sunday!

XO

LQ

19 comments
  1. Susan said:

    Lot’s of good info here…I’m always concerned which filler is best for which problem area.My husband will be inquiring too.He’s got the under eye thing happening.

  2. Dee Rennolds said:

    Thanks for all the information on use of fillers under the eyes. Do you have any feedback regarding the use of Sculptra for fat loss in the face due to aging? I’ve been trying to decipher the good and bad on-line and would appreciate your feedback.
    Love your blog,
    Dee

    • Hi Dee! Glad you’re getting some useful info. For the most part, I think Sculptra is amazing. The nurses and physicians I know that do it often LOVE it and I’ve seen some really impressive results. The patients are usually very happy, though it does take several treatments and can get kind of expensive, but much less expensive than a facelift. Also, Sculptra injections can “lift” areas on parts of your face that even a too-tight facelift cannot get to. There is a small incidence of granulomas (small hard bumps forming) but it’s pretty rare. The reason you see mixed reviews is because all fillers work differently on different people. Just make sure you go to someone experienced with Sculptra. Two great places to go in BH are Dr. John Joseph and Christine Nell and Kariann Erdmann at AVA MD. Hope that helps!
      XO
      LQ

  3. bo lamphear said:

    hello lipo queen! I was wondering the cost of this procedure (eye bag removal) for men. I am 47 and don’t want to break the bank.

    • Hello Bo! You know, it really depends on who’s doing it. Of course you want to go to the best specialist you can for lower lid blepharoplasty and fat transposition (“eye bag removal.”) In the Beverly Hills area where I practice, the price usually starts around at least $5500, including Operating Room and anesthesia fees, and goes up from there. I know it sounds like a lot of money, but having surgery is not something you want to skimp on. I’ve had this procedure myself and it was fantastic but if the lower eyelids are not done correctly, you can wind up with horrible complications. It also needs to be done at a reputable facility with a board-certified anesthesiologist. I have an associate Dr. Aric Park who specializes in this procedure and has reasonable prices. Other specialists in my area are Dr. Andrew Frankel (he’s my surgeon) and Dr. Michael Groth. If those numbers are still way too much, then I suggest you look into a University-based plastic surgery residency training program (here in L.A. it would be at USC or UCLA) where you can get discounted surgeries. Or, you can always try camouflaging the bags with Restylane injection. Hope this helps! Good luck!

  4. stacie said:

    I read your bog and loved it very imformative. I am 37 year old single mom of three and have been getting fillers under my eyes for about three years now. I am looking for something more permanent. Is there anything you can suggest? Oh also I am a smoker!

    • Hi Stacie,
      I’m glad you have found the blog helpful. As I am building the platform for my book, my goal is to make “Lipo Queen” a trusted source of information for all health and beauty-related questions.
      Without seeing pictures of you, this is what I can suggest:
      There is no permanent filler for under the eyes other than your own (autologous) fat. You should NEVER have any filler injected into your tear troughs except hyaluronic acid (preferably Restylane, but Juvederm Ultra could be okay.) NEVER have anyone inject Radiesse or Artecol (semi-permanent and permanent fillers) in the tear troughs. The only plastic surgeon in Los Angeles I know of who really prefers autologous fat over dermal fillers is Dr. Brian Novack (he is famous for being Demi Moore’s plastic surgeon, and for being extremely expensive but really excellent.) In fact, I had a patient once that I did some liposuction on, and she was an old patient of his, and when she went back to him for something else he yelled at her for letting me liposuction her and throw out the fat, which we both thought was pretty funny. But all kidding aside, injecting fat in the face is tricky, and you need to have it done by someone with experience, because not only can it disappear, but it can GROW if you gain weight, and then you really can’t get it out.

      In my opinion, the best option for “permanent” tear trough filler is lower lid fat transposition surgery(releasing the fat that sits inside your orbit to lay down in the hollow “tear trough.” I had this done over four years ago by Dr. Andrew Frankel at the Lasky Clinic in Beverly Hills and I am still extremely happy with it. Other Los Angeles surgeons I recommend for this procedure are: Dr. Aric Park, Dr. Michael Groth, and Dr. Chris Zoumalan.

      If you tell me which region of the country you live in, I can do a little research and find a colleague to recommend that you see in consultation to learn if you are a candidate for fat transposition.

      Hope this is helpful! Also, being a smoker is not ideal, and can impede wound healing, but probably would not make a tremendous difference in the outcome, since the face has such a good blood supply and there are no large incisions to heal. However, if you do go ahead with the procedure, your surgeon will most certainly discuss with you the increased risks of wound healing issues.
      Good luck and let me know what you decide to do!
      XO
      LQ

  5. Lynn said:

    Hi Lipo Queen–

    Great info. I’m wondering what to do after having fat transfer under the eyes and a little in the front cheek section and now one side seems to have either had a little fat placed too high on the cheek or something. Seems like a ‘malar pad’ from what I’ve read looking for festoons first and coming across that. Anyway, besides being a bit asymmetrical, it pushes up the eye on that side when I smile and makes it look a lot smaller. My doctor says he didn’t put fat there, but it wasn’t like that before. Can you take out a little fat with a syringe or something or what? Do you know? ALso, if you know someone good in the northern CA area that’d be great. Thanks.

    • Hi Lynn!
      Thanks for reading and glad you’re finding the blog helpful. That is a tricky problem, and while there are some people who are extremely good at it and comfortable with it (one of them is Demi Moore’s surgeon, Brian Novack here in L.A. but he is CRAZY expensive) that’s why I personally only really like putting fillers in the face that I know I can get out.Fat changes and grows and shrinks, and while I think that’s okay for injection in the breasts, I don’t like having that unpredictability on the face. However, I am sure that someone will be able to help you. I have once taken fat out with a smartlipo laser and that seemed to help (the cannula is just a millimeter so it leaves no scar). You might be able to have someone suction it out or inject steroids to shrink it. You really have to be careful with that stuff though, and make sure you go to someone really good, with a lot of experience in that specific area. I know of a few plastic surgeons in the SF area, but they mostly do breast surgery. Offhand I can’t think of anyone for this particular issue. If you tell me where you live, and ask around for names of surgeons from your friends, or people you trust, give me the names and I will look them up and see if I know any of them.
      Hope this is helpful!
      Good Luck!
      LQ

  6. jeannie hodges said:

    Thanks Lipo
    Queen, good read.
    i am back in town and on line

  7. lisa said:

    Hello! would love your advice as I’m very disappointed post blehps. I had a Beverly Hills Occuloplastic surgeon do my lower lids/fat repositioning (Another PS did the uppers simultaneously). However, I now have large bags right at the orbital rim, falling south onto the cheek.. Fluid retention, he says. He also said I am the most complex patient he has had and he was at a loss as to what to do. He tried 2 rounds of Medrol Dosepack, 3 injections of 5-FU to reduce the swelling (and the hardening of the fat that was re-positioned into the tear troughs)…to no avail. Manual compression- nothing. Lasix- nothing. So…he sent me to an allergist (lots of allergy meds did not take the fluid away) and a derm/PS ($200/consult) who wants to do skin tightening- Tri-Pollar and IPL. My personal derm suggests sculptra to lift the bag up a bit. She said the occuIoplastic surgeon took out too much fat. I spent $8500 for the upper and lower blephs…I just can’t justify spending any more money… plus. …how do I know any of these procedures will work? I’ll be in it another $2K! Not one doc is calling the bags “festoons”, but they aren’t calling them anything else either other than fluid retention. I’ve been tempted to go see Dr Sheiner in Tampa…but again…it’s more money.
    Any thoughts for a last shot at a surgeon in LA? This will drain my bank account soon. :( …and unfortunately, I still look tired or like I have a medical condition. It is beyond disheartening.
    Thanks for your suggestions…love the blog…lots of great info!

    • Hi Lisa,
      Thanks for reading and glad you’re finding the blog helpful.
      Sounds like you’ve been through a lot and it does sound like you have festoons (although I can’t say without seeing you). Most likely what happened is that you had them before the blepharoplasty, and the removal of the lower lid fat may have made them more obvious. This is a difficult problem and I don’t think there is going to be any one quick fix. My recommendation is to get a consultation from a facial plastic surgeon who might be able to do a few different things to balance out that area of your face. Probably they will start with a Fraxel or some kind of serious fractionated CO2 laser to tighten the skin in that area. From what it sounds like, I would probably not put any more filler like Sculptra in that area. These are the facial plastic surgeons in Beverly Hills that I know and trust to do the right thing:
      Dr. Andrew Frankel
      Dr. John Joseph

      Dr. Frankel actually did my lower lids five years ago (same thing you had) and also has lasers. Dr. Joseph is a huge expert with facial lasers and minimally invasive, in-office techniques.
      Check out their websites, and if you can, see both of them and see what you think.
      Good luck and let me know!

      XO
      LQ

      • lisa said:

        THANK YOU, LQ…will def let you know!!

  8. Tina said:

    What do you guys know of the plastic surgeon, Stanley Frilech in Beverly Hills?

    • Hello Tina,
      I don’t know him personally but as far as I know he has a good reputation. I have worked with scrub techs that work with him.
      XO
      LQ

  9. LAresident said:

    Hi LQ,

    Also, I was wondering if I could send you some pictures to show you what I mean? Is your email posted publically anywhere?
    I’m asian, male, and in my early 30′s. I saw a doctor that told me I had dark circles under my eyes and gave me perlane injections. It’s been about a week. She told me that the injections were along my bone but the actual ‘dent’ is in my eyelid which is higher than the bone (closer to my eye). I personally think that this actually makes it look a little worse because now my cheek is elevated above the level of the original ‘dent’ that’s on my eyelid. What do you think?

    I was thinking about going to another doctor
    What do you think about going to Dr Rivkin @ Westwide Aesthetics? I looked on yelp and he seems to have good reviews,

    • Hello Henry,
      You don’t need to send me pictures–I know what you’re talking about. It can take a couple of weeks for swelling to go away in that area, so that could be part of the problem. Also, I usually don’t use Perlane in the under eye area because I think it is a little thick, but that is my personal preference. Dr. Rivkin does have a good reputation for injectables. I would wait another week before doing anything. If things still don’t look the way you want them to, you may need to have the Perlane dissolved with Hyaluronidase and start over. Good luck and let me know if you need any more info!
      XO
      LQ

  10. Riss said:

    Hi~

    I’ve been looking into having my lower lids done due to constant puffy bags under my eyes. I’ve had the bags my whole life and they’ve only gotten worse as I’ve aged (35 y.o.) and endured the whole “you must be…tired, sick, exahusted” routine. I do have allergies, but take meds, including weekly allergy shots, to deal with them. This hasn’t impacted the bags though. Is there a reason I shouldn’t have the blepharoplasty done if I have allergies?

    I’ve found a surgeon who seems reputable but only does “transconjunctival laser blepharoplasty.” It sounds as if you recommend fat transposition as opposed to the laser so that the fat isn’t completely gone, correct? If so, any chance you could recommend a surgeon on the east coast, in the mid-atlantic region (NJ, MD, PA, DE, NY, VA)?

    Thank you!

    • Hi Riss and thanks for reading!
      Technically I am not able to “recommend” a specific procedure for a specific patient but what I can talk about is my own experience:
      1)I’ve seen a lot of patients who have had the “old” technique of just transconjunctival fat removal, and after several years, as they get older, it tends to look hollow and they want to get it filled in.

      2)I have been very happy with my lower bleph, which was done transconjunctival but with fat translocation (releasing the orbital septum, the “wall” that is holding the fat into that bulge, so that the fat can “spill out” down into the hollow area where it helps fill it in.) Mine was done six years ago and it is still great. I can heartily recommend my surgeon, Dr. Andrew Frankel in Beverly Hills. As far as someone in NYC, I don’t know them personally, but I checked with my Oculoplastic colleague here, Dr. Chris Zoumalan and he recommended having a consultation with Dr. Richard Lisman http://rlisman.eyeplastics.com and/or Dr. Rob Schwartz http://www.naturalfacedr.com/nyc-cosmetic-plastic-surgeon/
      Again, I cannot recommend what is exactly going to be the right thing for you, but you should be able to get honest consultations from these surgeons. Good luck and let me know how it goes!
      XO
      LQ

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