Thank you for the question.
You submitted a photo and you state in your question that you’re 59-years-old and you’ve
been dealing with under eye bags and dark circles for quite some time.
You’re asking is blepharoplasty the best option for you or are there alternatives.
Well certainly, based on just the photos alone, I can give you my opinion about how I approach
patients like yourself in my own 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 certainly this
is a problem that we deal with every day and as an oculofacial plastic and reconstructive
surgeon, I can also give you some guidance as to the importance of the right approach
to your issue in terms of your eye health which is very important.
So to begin with, let’s start with first diagnosing or at least, my impression of what
I see when you describe the under eye bags.
The reason for those under eye bags is something called lower eyelid fat prolapse.
Lower eyelid fat prolapse means that the fat pockets that are normally around the eyes
pushes forward, herniates, creates these bulges.
MRI studies have actually shown that in a lot of people, these fat pockets actually
increase in size and volume resulting in these bulges.
So it is not just that it pushes forward and because of weakness in the tissue which is
often associated with aging but also there is often the increase in volume.
Now in addition, as people get older, there are also important elements that have to be
addressed when you are considering something to do for this problem and that includes the
integrity of the support structure of the lower eyelid.
One of the things about cosmetic eyelid surgery is that it is sometimes oversimplified by
a lot of my colleagues and when, unfortunately, when they perform this type of surgery, patients
will have problems such as lower eyelid retraction or the eyelid is pulled down or ectropion
or the eyelid is everted out and it has to do a lot with the integrity of the support
structures.
And this is where being an oculoplastic surgeon, I look for these things and I actually make
a point to address them at the time of surgery to prevent these types of problems.
So in terms of my general approach to a situation like yours, well to begin with, when I evaluate
a person who has similar issues, I make sure that I look at their dry eye history whether
or not they are on artificial tears, whether they have any issues with that.
That also is a factor on how the surgery is performed.
I look at the integrity of the muscle that supports the eyelid, the integrity of the
tendon that supports the eyelid and then I discuss basically the 2 basic different approaches
in addressing the fat pockets.
When we talk about blepharoplasty of the lower eyelids, there are two approaches: one is
the transcutaneous approach which is more commonly performed by, I would say, the majority
of general plastic surgeons and that is where the incision is made in the outside and the
transconjunctival approach which is done from the inside.
Now in my experience and my personal style, I generally prefer to do, even if people are
a little bit older, is something called a transconjunctival blepharoplasty where I address
the fat pockets but I maintain the integrity of the skin and muscle and support structures.
If the tendon needs to be reinforced, there are other procedures that are done in addition
to that but I like to keep that front part of the eyelid stable because the muscle under
the eyelid called the orbicularis oculi muscle is like a hammock and it holds things in place.
And a lot of times, well meaning colleagues will actually make an incision in the outside,
separate these layers and then trim off some skin and it ends up causing the eyelid to
evert or in doing the procedure this way, there is a loss of structural integrity of
the lower eyelid and that results in requiring additional surgery.
When people ask me, “What about these wrinkles under the eyes?”, I try to explain that
there is a difference between relative quantity of skin and relative quality of the skin.
And typically, I have found that we can address, there is very rarely a time where there is
a true excess of skin and usually it is more of the quality of the skin.
So how do we address the quality?
We address it with using platelet-rich plasma (PRP) which is derived from your own blood
to stimulate your body’s collagen and basically deal with the loss and thinning of the skin
with age as well as the use of lasers such as Fractional CO2 laser, fractional Erbium
laser or ablative of either type of lasers but basically to improve the skin quality
and improve the wrinkling.
The goal is not to create porcelain smoothness but to improve the appearance, improve the
discoloration and the dark circles.
Overwhelming majority of the time, people have an improvement and they want to further
enhance the eye and cheek area, this is where we talk about fillers and ongoing treatments
whether it’s platelet-rich plasma (PRP) and other things but a lot of times, once
people have their bags done, they are very happy not to have bags anymore and so they
may come in for other things.
Botox® and other complementary procedures always has a role in maximizing the aesthetics
of this area but certainly from my perspective, the critical decision is the type of surgery
being performed and the way to preserve the integrity of the eye and the eye health.
So meet with qualified, experienced cosmetic surgeons and understand these issues before
moving forward and go with who you feel comfortable with but I think you will find that this could
be a very nice and gratifying procedure.
Having getting rid of bags under the eyes, I feel it’s almost like doing a facelift.
It really brightens up the entire face.
So I hope that was helpful, I wish you the best of luck and thank you for your question.