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 Theron’s 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.
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 Surgeon—Dr. 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 email@example.com