Thank you for your question. You submitted several photos and you state
in your question that you are 39-years-old and you are concerned about basically 2 main
issues. The under eye bags as well as the wrinkles under your eyes when you smile and
you are looking for long-term solutions. Well, I can certainly give you some guidance
as to how I approach these types of questions in my practice. A little bit of background,
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
and treating patients with under eye bags and wrinkles around the eyes is one of the
most common issues that we deal in our practice and it is very important that you really understand
the basis of any suggested treatment because when you look for solutions you are going
to be overwhelmed by the number of solutions that are being offered.
So to begin with, the first thing is to understand is how to separate the anatomical basis for
each of these problems and how I generally approach these particular issues. Let’s
start with the under eye bags. The under eye bags represents something called lower eyelid
fat prolapse. Lower eyelid fat prolapse means that the fat pockets that are normally around
the eye pushes forward and creates this bulge and that bulge remains whether you have a
lot of rest, whether you have plenty of sleep or no sleep, there’s often tremendous amount
of puffiness that lingers all the time. Generally, this is a genetic trait and very often people
say I inherit this from a parent and will also state that they’ve had some form of
under eye bag ever since they were a teenager. So when it comes to under eye bags the strategy
for someone with the level of puffiness that you have is a surgical strategy and even though
it might sound a little bit intimidating it’s actually the most definitive procedure in
my opinion.
When you look at possible solutions you are going to be also see the possibility of the
use of a filler such as Restylane or Juvederm to try to hide the bags and this is something
that we do also in our practice but when I see people with a certain threshold of puffiness
then the definitive procedure is usually something called lower eyelid blepharoplasty.
In lower eyelid blepharoplasty we’re doing a surgical procedure to address the under
eye fat pockets. Now the question is do you do this to remove skin? Or do you do this
without removing skin? Well, in my opinion and my experience most of the time especially
with someone who is only 39-years-old there isn’t an issue of excess skin, it is more
of a skin quality issue so I would typically do something called transconjunctival blepharoplasty.
This is a procedure where the fat pockets are addressed from the inside of the eyelid.
This way there is no external scar and the true shape and contour of the eyes remain
the same. This is very important because a very common problem with the external approach
for a lot of people is that they end up having lower eyelid retraction or sagging or change
in the shape of the eye and it’s been my experience that this approach has been consistently
successful and I’ve been at this over 20 years.
Now, that addresses the fat pockets. What do we then do about the skin quality because
a lot of times people will think what about all the excess skin? They naturally think
that if someone does liposuction for fat around the stomach they would have extra skin around
the eyes like you would have if you lost a lot of weight around the stomach. Well, the
anatomy is different. It’s not a question of skin sagging but it is about the skin quality.
For skin quality, I typically do a combination of laser using something like fractional CO2
laser and I use something called platelet-rich plasma (PRP). Platelet-rich plasma (PRP) is
derived from your own blood and it has all the growth factors that are necessary when
you have an injury and what that does is it stimulates collagen, blood supply and other
things that help improve skin quality. So we work from the inside and the outside using
the laser for the outside, platelet-rich plasma (PRP) for the inside.
Now as far as the wrinkles when you smile this falls under a category called dynamic
wrinkles. Dynamic wrinkles are wrinkles that result when muscles are activated. Now dynamic
wrinkles cannot be treated permanently or long-term the same way as fat pockets because
the muscles responsible for this contraction are important for proper eyelid function but
what we can do is use a drug like Botox® or Dysport® to relax those muscles. You know
the drugs can be used to reduce the contraction of those muscles so those wrinkles become
less pronounced.
Now, in terms of long-term results you are dealing with certain things like a surgical
solution for the fat pockets that does have a very good long-term benefit. 5-10 years
depending on a person’s aging process and the fat pockets usually don’t come back
in the same way. If there is going the be a little bit of fat prolapse you can always
do something later but as far as treatment for skin quality and for the dynamic wrinkles
usually that involves some type of maintenance process or maintenance plan and it depends
and as always customized to the individual patient.
So, I recommend you to meet with qualified, experienced cosmetic surgeons and learn about
these options and don’t be intimidated by the surgical solution in my practice going
back 20 years, I made it a mission to try to simplify and reduce the things that cause
the greatest anxiety for patients to consider surgery so in our office we have Joint Commission-certified
facilities. In our office we have Joint Commission-certified facilities and we do everything under local
anesthesia with LITE™ sedation which means that basically it’s like you come into an
office which has the operating room, has staff that is familiar with you and you’ll be
comfortable with and we do this with local anesthetic with a little bit of sedation so
we avoid general anesthesia and is somewhat comparable in some ways just getting injectables
and of course it is still a little bit more involved than that because it is still surgery.
I hope that was helpful, I wish you the best of luck, and thank you for your question.