The treatment for under eye bags depends on what is causing the “bags.” Said another way, “under eye bags” is a non-specific term that is often used to describe several cosmetic concerns. These concerns include: 1) under eye hollows; 2) under eye wrinkles; 3) puffy under eyes; and/or 4) under eye dark circles. One or more of these concerns may contribute to the appearance of an “under eye bag.” Let’s talk about each of these concerns in order.
First, we need to distinguish between temporary and permanent hollows.
Temporary hollows – as the name implies – are temporary. Often these are caused by, e.g., allergies or loss of sleep. Temporary hollows will resolve with appropriate supportive care such as allergy medication or sleep.
Permanent under eye hollows are generally caused by having insufficient tissue volume in the under-eye area relative to the underlying bone structure. Common reasons why some people have insufficient volume include genetics, aging, and weight loss. Hollows may also be due to separation of the cheek muscles.
Permanent under eye hollows can often be addressed with fat grafting or a low-density non-hydrophilic injectable filler (e.g., Volbella®). The main difference between the two approaches is that fat grafting is considered a permanent solution while filler is considered a moderate-term solution.
Fat grafting involves taking a small amount of your own fat with a liposuction cannula. This fat is then placed in under eye area with a blunt tipped cannula. You can read more about fat grafting here.
Filler, such as Volbella® is considered a moderate term solution. This is because the clinical studies monitored results for 12 months. Thus, the FDA approval is for correction lasting 12 months.
However, many of my patients report that the results last much longer. Note, the type and amount of filler selected for placement into this area is critical. The wrong filler or too much filler can cause puffiness, make the area look worse, and even make the skin appear blue.
There are two main approaches for fixing under eye wrinkles. Which approach used generally depends on whether the under-eye wrinkles are caused by muscle movement, extra skin, or both.
Under eye wrinkles caused by muscle movement.
If the under-eye wrinkles are caused by muscle movement – e.g., when you smile – then a neurotoxin such as Botox® or Dysport® may address this concern.
There are two important considerations when using neurotoxin to address under eye wrinkles.
First, most often, people complain of crow’s feet causing their under eye wrinkles. Once injected neurotoxins generally take effect 7–10 days after they are injected and work for 90–120 days. This means that reinjection is required 3–4 times per year to maintain the effect in most people. In some cases, there are also “crinkles” under the colored part of the eye (the iris). These “crinkles” can be injected superficially with 1–2 units of neurotoxin. Because only a small dose is possible in this area without affecting the smile, I’ve observed that the effects generally last about 8 weeks.
Second, people commonly request that only the crow’s feet be treated with neurotoxin. While this can be done, it’s generally optimal to also treat the frontalis (forehead) and glabella (11 lines). This is because the muscles of the upper face are interconnected. This means that only injecting the crow’s feet can cause compensatory effects – i.e., an overactive frontalis and glabella muscle. This can produce unintended facial expression imbalance. Thus, while there are certainly patients that I inject only one or two areas, the general rule of thumb is that if one area is to be injected, all areas should probably be injected.
Under eye wrinkles caused by extra skin.
If the under eye wrinkles are caused by extra skin, then the extra skin needs to be removed. The gold standard for removing extra skin below the under eye is a lower blepharoplasty. You can learn more about a lower blepharoplasty here. In brief, a skin-only lower blepharoplasty is a surgery that removes a very small strip of extra skin under the eye. The scar for this surgery is often imperceptible within 6–12 months of surgery.
While a blepharoplasty is the gold standard for addressing extra undereye skin, more conservative treatments may be an option. These conservative treatments include chemical peels and/or Ellacor.
A chemical peel removes the top layer of skin – in effect, a chemical peel creates a skin injury. This injury promotes the production of collagen, hyaluronic acid, elastin, and other grown factors that, in turn, can produce the appearance of tighter skin.
Ellacor is an in-office procedure that removes microcores of skin over the entire lower face. Although the undereye area is not specifically treated with facial Ellacor, I’ve consistently seen an improved under eye appearance in patients treated with Ellacor.
Under eye wrinkles caused by extra skin AND muscle movements.
Sometimes, under eye wrinkles are caused by both muscle movement and extra skin. In this case, standard lower blepharoplasty preoperative planning together with Botox often addresses both concerns. Specifically, neurotoxin is commonly placed in the forehead, crow’s feet, and glabella (or “11 lines” between the brows) before a lower blepharoplasty. This is because neurotoxin prevents these muscles from moving, pulling on incision sites, and widening the scar. While the lower blepharoplasty is considered permanent (subject to the natural aging process), neurotoxin must generally be injected every 90–120 days to maintain effect.
Note, for a more conservative approach, under eye wrinkles caused by both muscle movement and extra skin can sometimes also be addressed by neurotoxin together with chemical peels and/or Ellacor.
First, we need to distinguish between temporary and permanent puffy under eyes.
Temporary puffy under eyes – as the name implies – are temporary. Often these are caused by allergies and will resolve with appropriate supportive care such as allergy medication. Sometimes, puffy under eyes are caused by the incorrect placement, type, or amount of filler. If the filler is a hyaluronic acid filler, a natural enzyme – hyaluronidase – can be used to dissolve the filler.
The source of permanent under eye puffiness is most often related to the lower eyelid fat pads. Puffiness is often caused by big fat pads. The natural anatomy of the under eye is comprised of three fat pads, muscle that overlays each fat pad, and then skin over the muscle. Less often, puffiness is caused by the muscle over the fat pad being herniated – i.e., the muscle has a hole it that allows the fat pads to pass through and tent the skin up.
The gold standard to address permanent under eye puffiness is a transconjunctival lower blepharoplasty. You can learn more about this procedure here. However, in brief, the surgery can removal some or all the fat pads and/or repair the broken muscle.
The optimal approach to address under eye dark circles depends on the cause of the under eye dark circles. Common causes include: 1) genetic predisposition for increased melanin production in the under eye area; 2) thinning skin making underlying muscle more visible; 3) and medical conditions such as eczema, melasma, or certain thyroid disorders.
If the cause is genetics, oral medication and/or topical ointments approaches are generally discussed with the patient as a first line of treatment. Treatments may include oral tranexamic, topical tranexamic acid, and/or topical retinoic acid. The literature suggests that these medications can help chaperone melanin production. Overtime, this can help normalize facial coloration to produce a more even skin tone.
If the cause for dark circles is thinning skin, fat grafting or a low-density non-hydrophilic injectable filler (e.g. Volbella®) may be an option to create a barrier between the skin and underlying structures. Depending on how thin the skin is, some patients may not be a candidate for under eye filler.
Fat grafting involves taking a small amount of fat out of the body with a liposuction cannula and then placing it into the under-eye area with a blunt cannula. You can read more about fat grafting here.
Alternatively, a low-density non-hydrophilic injectable filler – such as Volbella ® – may be used. Note, the type and amount of filler selected for placement into this area is critical. The wrong filler or too much filler can cause puffiness, make the area look worse, and even make the skin appear blue.
If the cause for dark circles is a medical condition such as eczema or a thyroid disorders, the treatment most often starts with addressing the underlying medical condition.
Contact Us To Schedule Your Consultation
