Your Questions
Your Questions
Q: Dr. Eppley, I am quite old (66 years old) andI want to know if there is help for severe under eye bags and puffiness?
A: At 66 years old you are far from being too old to have surgery to improve your lower eyes. Such surgeries are safely done on patients up into their 90s. The cause of under eye bags and puffiness is largely herniated orbital fat. As we age the ligaments that hold the fat around the under eye weaken. The fat then gradually spills over the lower bony rim creating the bags that you see. Since such fat is very susceptible to water retention it can get very puffy particularly in the morning or after very salty foods.
Such lower eyelid bags are not treatable by any creams or other topical treatment methods. They can be dramatically improved by surgical reduction/repositioning of the herniated orbital fat to smooth out the lower eyelid. Usually a small amount of lower eyelid skin is removed as well. This is known as a transcutaneous lower blepharoplasty. While there will be some temporary bruising and swelling after surgery, the improvement can be dramatic once it is fully healed weeks later.
If you have any pictures off of your phone that you cane send me I can give a definite opinion as to the benefits of this type of eyelid surgery for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Dr. Eppley, I am 20 years old but have had prominent “tear troughs” all of my life, my left tear trough being more prominent than my right. I am very interested in getting injectable fillers for that area. I was wondering if you would be able answer a few questions for me. Would you recommend fillers for my tear troughs? If so, what kind and how much filler would you most likely use? How much would it cost? Is this something that you perform often? Thank you for your time.
A: Based on just the one side view picture you have shown, you do not have a true tear trough deformity. Rather you have pseudo or seemingly tear troughs when in fact it is caused by something else. What it appears you have is congenital herniated lower eyelid fat pads. This causes a fullness/bulging/bags of the lower eyelids which subsequently creates a tear trough appearance due to the bulge above an otherwise normal tissue area along the infraorbital rim. (lower eyelid socket) Injectable fillers would be contraindicated in this type of lower eyelid anatomy. Conversely you need removal and/or translocation of the lower eyelid fat pads. Some would be removed while a portion would be moved to drape over the infraorbital rim, thus eliminating both the lower eye bulge and the tear trough at the same time. This operation is known as transconjunctival lower blepharoplasty with fat transposition.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 38 years old and have horrible bags under my eyes despite good sleep and a healthy diet. Can you tell me what the best option would be to get rid of them and down time for the surgery?
A: Despite the fact that you are relatively young, your lower eyelids are a contradiction to your age. They show herniated infraorbital fat pads and some excessive skin. Because your pictures show you smiling (which always makes everyone’s lower eyelids have a lot of wrinkles) I can not fully appreciate how much skin laxity is there or to what degree you may have tear troughs present. Thus it is not a question of whether you would benefit by lower blepharoplasties but what type of lower blepharoplasty. Would it be a fat sparing and transpositional one or should the protruding infraorbital fat merely be excised with the skin tightening? I would need to see a picture of you not smiling to make that determination. Regardless of the type of lower blepharoplasty, the recovery is the same. There will be some swelling and bruising and it will take about 10 days or so to become very presentable in public again. It is not painful nor physically limiting just visibly noticeable for this period of time after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am in need of a special type of lower blepharoplasty. I had artefill injected under my eyes and have been having problems with it. Have you ever removed artefill in combinaion with a lower blepharoplasty before?
A: When it comes to lower eyelid procedures, I have seen may different materials placed in the lower eyelid tissues and along the bony orbital rims and orbital floor. I have removed in the past lumps of fat, clumps of artefill/artecoll, goretex strands and Medpor implants while doing lower blepharoplasties. Many of the particulated injections are often in the orbicularis muscles but because they are usually in clumps. Most of the material can be dissected out and removed as part of the lower blepharoplasty procedure. Your case illustrates the potential problems with using particulated fillers in the thin tissues of the lower eyelids. The appeal of a permanent filler is great but every particulated filler with non-resorbable particles has a great propensity for clumping and fibrosis.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in CO2 laser resurfacing and skin under my eyes and also to remove dark spots on my cheeks. Or maybe I need a pinch blepharoplasty instead. I had a lower blepharoplasty three years ago which left my eyes more wrinkled. I was told this procedure would remove the fat and then cut and tighten underneath. Only the fat was removed. I’ve load an up close picture which also shows the spots and a smiling picture you can see how much extra skin is under my left side, which makes me not want to smile as it shows worse when I do.
A: By your description your original lower blepharoplasty sounds like a transconjunctival one in which no skin was removed but only fat from the inside of the lower eyelid. By deflating lower eyelid ‘bags’ (fat), skin wrinkles are often worsened as the skin retracts. This is why many transconjunctival lower blepharoplasties often include a simultaneous skin resurfacing procedure (laser or chemical peel) to avoid this aesthetic problem with fat ‘deflation’. At this point, you need a pinch lower blepharoplasty, as you have surmised, to get rid of the roll of skin and muscle that is just under your lashline. With smiling not all of the extra skin can be completely removed but a significant improvement can be obtained.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I
Am 73 years old. Is blepharoplasty an answer to my swollen, puffy under eye condition? If they can be removed, will they come back?
A: Lower eye bags are caused by the progression herniation of fat that comes out from under the eyeball. Many people will eventually get them as they age although some people will actually have the opposite effect…loss of fat and deep set eyes with hollowing as they age. A lower blepharoplasty procedure will remove the protruding fat, a little bit of lower eyelid skin and tighten the corners to reduce the risk of a drooping lower eyelid after surgery. Age is not an issue when it comes to having this eyelid procedure only one’s health is. Most lower blepharoplasty procedures need to be done under anesthesia as it is very difficult to keep the eyelid still when you can see what is happening right in front of your field of vision.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I have very thin skin under my eyes and they are puffy 🙁 I always look so tired and worn out) Just curious if surgery could correct this ?! 🙂
A: The puffiness under your eyes is a common problem and is due to intraorbital fat that is now sticking out. This is a typical development that occurs as we age. Normally the fat around the eyeball is contained behind the eyelids by certain supportive tissues. As we age these tissues weaken and the fat begins to protrude against the lower eyelid. This creates the classic lower eyelid puffiness or bags that many people have. With time these lower eyelid bags can become quite pronounced. Because fat has a high content of water, this is why these eye bags may be bigger in the morning or after eating foods with high salt contents. While some people have these bags naturally even as early as their teens, most people develop them to varying degrees after the age of 40 or so. This fat removal is a common component of most lower eyelid blepharoplasty procedures, If one does not have any or too much loose skin, the fat can be removed from inside the eyelid. (transconjunctival lower blepharoplasty) When loose and sagging skin needs to be removed and tightened as well, an external transcutaneous lower blepharoplasty technique is used. (traditional method) Both techniques can result in a significant change that removes that tired look.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to know the cost for under eye surgery to remove bags. I don’t believe I need lid surgery.
A: Thank you for your inquiry. Your question as posed is contradictory. The removal of eyelid bags is a form of eyelid surgery that, if done in isolation, is accomplished through an incision inside the eyelid without outward skin removal or an imperceptible scar along the lashline. This is known as a transconjunctival lower blepharoplasty. While this type of lower eyelid procedure does not remove skin it is often combined with adjunctive lower eyelid skin tightening techniques such as chemical or laser peels. When excess skin as well as herniated fat exists, the removal of skin and fat is done through an external incision. This is known as a transcutaneous lower blepharoplasty.
I believe you were likely referring to the desire for transconjunctival lower blepharoplasty when you made the statement that ‘I don’t believe I need lid surgery’. That cost is usually in the range of $ 3,500 to $4,000 for both lower bags. If skin removal is needed this wil, raise the cost to about $ 4,000 to $ 4,500.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, can excess skin be removed and remaining skin lifted up and under the eye? Can the outer corners of the eyes be lifted for “sad eyes” at this same time? How is this done? I have tired and sad looking eyes that need some help as they make me look so bad. The outer part of my eyes has always been turned down since I was young and I have never liked it.
A: Traditional lower blepharoplasty or eyelid tuck techniques can remove fat that causes bags and to tighten loose skin under the eyes. At the same time, the outer corner of the eye can be changed. The position of the corner of the eye is controlled by a tendon that attaches it to the inside of the bony socket of the eye. This tendinous position can be changed to raise the corner of the eye, known as a cantopexy procedure, making it either level to the inside of the eye or higher if one desires more of an upward tilt to the eye. This can be done at the same time as a lower blepharoplasty (or an upper blepharoplasty) through the same incision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, A friend of mine just had her upper and lower eyelids done. She said that on her lower eyelid, besides removing fat and pinching some skin out, that she also had her cheek muscles repositioned. Is it true that cheek muscle can be lifted with a lower eyelid procedure? If so, what is the cosmetic benefit for doing so?
A: What you are referring to is known as lifting the sagging cheek at the same time as a lower blepharoplasty. Some call this a midface lift or malar resuspension. It is not a true muscle lifting procedure but rather that of sagging cheek fat and skin. As the midface ages, the cheek tissues will slide off the cheek bone particularly if the cheek bone is naturally flat or not that prominent. This creates malar pads that can be seen as an additional fold of tissue below the lower eyelids. This sagging cheek tissue can be lifted through a standard open lower eyelid incision for a full lower blepharoplasty. This is convenient since both the lower eyelid and cheek issue can be addressed through the same incision. The operation you describing that your friend had was a more limited blepharoplasty known as a pinch lower blepharoplasty. Through this limited approach it would not be possible to do a true midface lift or malar resuspension.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 72 years old and in excellent health… exercise, good diet, etc. When I was around age 45 I had a blepharoplasty operation as I had developed large bags under my eyes. The surgery was to remove fatty tissue from my eyelids. It did me a world of good, as I was quite self-conscious of my appearance. Those bags have gradually come back and I am, again, very self-conscious of them. I look relatively young except for this excess fatty tissue. I can hardly imagine how I would look now had I not had the first operation! My question is how could this fat come back since I haven’t really gained any significant weight. Can they be removed again and do you think that it would be covered by Medicare? Thank you for your help.
A: Bags that develop from the lower eyelids is a common problem that occurs largely in aging eyes and occasionally in younger people due to genetics. The bags are due to fat which is sticking out from underneath the eyeball. One can think of it as a hernia. Our eyeballs are surrounded for their protection by fat. This fat is held in place underneath the eyeball by a special tissue that runs from below the lashline (tarsus) of the lower eyelid down to the rim of the lower eye socket. As we age this tissue becomes weak and the fat is no longer held back and begins to stick out. (bags) For some people, they have a congenital weakness of this tissue and they may have bags as early as their teen years. Once this protruding fat is removed, it is still possible later in life for it to ‘return’. This is really just more fat that is coming out from around the eyeball as the supporting tissues become weaker. Like the first surgery, further fat can be removed by additional lower blepharoplasty surgery.
Lower eyelid surgery is never covered by insurance because it does not interfere with one’s vision. Only the upper eyelid can create that medical problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q : I had my lower eyelids tucked (blepharoplasty) over 6 months ago. While my lower lids look much better, I have had a problem with dry eyes and tearing since the surgery. It was really bad right after and has gotten somewhat better. It is almost painful to be out in direct sunlight and my eyes really tear if there is any wind. My lower eyelid also doesn’t look right. I think I show more whites of the eye than before and it looks pulled down. My doctor keeps saying to give it more time and it will get better. But it has been some time now since surgery and I just don’t see it happening. What do you suggest? By the way I am a women who is 58 and I still have to work!
A: One of the potential, although fortunately uncommon, risks of lower blepharoplasty surgery is ectropion. This sounds like exactly what you have.
The lower eyelid, unlike the upper, is like a clothesline strung out between the inner and outer eye socket bones. The eyelid is attached to the bone by tendons called the canthal tendons. This clothesline effect keeps the lower eyelid snugged up against the eyeball just at the lower edge of the iris. By being tight up against the eyeball, it is protected from drying out and being irritated. Any slight change, even one millimeter, between the eyelid and the eyeball (out or down) will cause eye symptoms of dryness, irritation, and tearing. Manipulation of the lower eyelid through surgery can disrupt this relationship if the eyelid and the lateral canthal tendon are snugged back up properly as part of the operation.
While small amounts of ectropion may correct itself with the passage of time and upward massage, six months with this degree of symptoms indicates another approach is necessary. Performing a canthopexy or canthoplasty (tendon tightening and eyelid re-suspension) and retightening of the outside eye corner can provide an immediate solution to this very irritating problem. Once the lower eyelid is back tight against the eyeball, it will not only look better and more natural but the eye is protected once again.
Dr. Barry Eppley
Q : I am writing because I am bothered by bags under my eyes. Since I was a teenager these bags have been there but are now much more prominent as I have gotten older. I don’t expect my eyes to be perfect but I shouldn’t look this way at only 38. I have tried every cream out there and nothing seems to make them better. Is there a plastic surgery for this problem?
A: Lower eye bags are the result of herniated eye fat. Most of the time they appear as a result of aging. But some people have it appear much sooner in life, even during their teenage years. One occurs as a result of weakening of a lower eyelid membrane with age, teenage eyebags are the result of a congenital weakness in the same membrane.
To understand lower eye bags, one must know that our eyeball sits in a bed of surrounding fat for padding and protection. The lower eyelid is like a gate in which fat underneath the eye is held back by a membrane between the lower eyelid margin down to the lower edge of the eye socket bone. When this membrane is weak, eye fat can protrude through like a hernia through an abdominal wall defect. This is easy to demonstrate by closing your eye and pressing on the eyeball. You will see that the tissues underneath the eye bulge out as you press in. This is eye fat being pushing out.
Lower eyebags can only be removed by lower blepharoplasty surgery. No topical treatments or other external treatments will cause the fat to go away. If there is no significant extra skin which is common in younger patients, the fat can be removed through an incision from inside the lower eyelid. (trasnconjunctival blepharoplasty). If there is extra skin from aging, the fat and skin are removed through an incision right underneath the lashline. (external lower blepharoplasty)
Dr. Barry Eppley