Solutions for the Lower Eyelids
Lower Eyelid Fat Bags

Leesburg | Loudoun | Ashburn | Virginia

The development of lower eyelid fat bags can be extremely distressing; and represents one of the most common reasons a patient comes in for a consultation.

Lower eyelid fat bags represent normal fat behind the lower eyelids that begin to push outwards towards the surface.  There is usually a thin barrier that holds the fat bag.  This barrier begins to thin and weaken with age.  Small fat bags are not usually very obvious, but when when they coincide with some of the other aging developments around the lower eyelid with age such as the the loss of volume and camouflage provided by cheek fat, the lower eyelid fat bags can become very obvious.  

The reasons behind the appearance of lower fat bags include:

  • fat pushing outward on the thin barrier that normally holds the fat back
  • The fat bag begins to push and stretch the lower eyelid skin
  • Loss of volume of the upper eyelid and cheek junction exposes the lower orbital bone and eyelid content
Given these findings, the treatment strategy to addressing the dark circles of the lower eyelid are:
  • Add volume to the upper cheek eyelid junction with fillers or fat transfer
  • Forever Young BBL to bleach the dark abnormal pigment of the eyelid skin
  • Surgical removal of excess lower eyelid skin if necessary.

Reasons for the increased visibility of lower eyelid fat bags are 

Weakening and thinning of the barrier that usually holds the lower eyelid fat back

  • There is a normal barrier that usually holds the fat volume that supports your eye begins to thin with age.  Some young patients will have a normally thin barrier.  The more the barrier breaks down, the more the fat will push out on the barrier and show as larger and larger fat bags.

Increased fat content behind the lower eyelids

  • The lower eyelid fat usually supports the eye.  Because all fat has the potential to enlarge with weight gain, increases in lower eyelid fat will eventually push out on the lower eyelid barrier and stretch the skin.  This will show even if you lose the fat.  

Loss of the upper cheek fat volume that normally happens with age exposes the lower orbital bone and fat bags

  • As I have discussed in previous blog questions, there is a normal loss of facial volume with age.  This loss of volume is very obvious in most patients in the upper cheek eyelid junction.  Loss of volume here exposes the lower orbital bone and can be seen as a dark circle.  The loss of volume also exposes any other lower eyelid imperfections like the appearance of lower eyelid fat bags.

The treatment strategy for treating lower eyelid fat bags begins with volume replacement in the upper cheek eyelid junction if possible.  This is followed by lower eyelid surgery if this option is not sufficiently satisfactory.  

Volume Replacement of the upper cheek lower eyelid junction with either cosmetic facial fillers or fat transfer.

  • Volume replacement will camouflage the orbital bone dark circles that affect the lower eyelid.  If the fat bag is not particularly large, volume replacement will be able to partially camouflage the fat bag.
  • If volume replacement is not able to camouflage the fat bag sufficiently ( without making the cheek look abnormally large ), the only other effective treatment is surgical removal of the fat bag.

Surgical Removal of the fat bags from either behind or front of the lower eyelids.

  • Surgical treatment of lower eyelid fat bags is one of the most commonly performed cosmetic surgery procedures.  Surgical removal of the fat bag can be performed from behind the lower eyelid ( mostly for for young patients who do not have a lot of extra eyelid skin that also needs to be addressed and removed ) or from a subciliary incision which is located just below the eyelash ( descriptions below )

Volume loss in the lower eyelid cheek junction is inevitable and is the primary reason for not only the visibility of dark circles of the lower eyelid area but the increasing visibility of the lower eyelid fat bags.

The volume loss is addressed either by injection of facial fillers like Juvederm or Voluma or the addition of fat by fat transfer.  

Facial fillers like Juvederm or Voluma 

Facial fillers can be injected into the area of volume loss.  This simple procedure can often be performed on the same day as your consultation.  The procedure will take about 10 minutes.  There is no down-time.

Fat Transfer

Fat Transfer is more of a surgical procedure.  Fat is obtained by liposuction from the abdomen or thighs.  The fat is processed during the same procedure to remove blood and other fluids from the fat.  The fat is then re-injected into the area that requires volume.  Facial fat transfer will take about 30 minutes.  Most patients will experience swelling and some bruising but will return to work in about one week.

Bleaching of the lower eyelid skin can be obtained by using skin lightening products such as hydroquinone in Obagi Clear or using the Forever Young BBL.  The most effective and most common method we use is the Forever Young BBL.

Forever Young BBL

BBL stands for broad band light, and is the the newest and most advanced version of IPL intense pulsed light therapy.  As the name states, the Forever Young BBL uses a broad range of light waves to capture and treat different skin pigmentations changes more effectively.  In the process, the broad bands of light have been shown to rejuvenate cellular DNA; giving the device its name Forever Young.  

The Forever Young BBL can be used for the eyes, face in general, neck, chest, or any other area.  Treatment for the eyelids takes only 5-10 minutes with no downtime.  The treatment may need to be repeated once or twice for optimal results.  Results after treatment can be visualized after 1-2 weeks.

Hydroquinone Products

Hydroquinone is a popular bleaching agent that works to bleach the pigment from skin melanin.  While effective, it is not as effective as a BBL treatment.  In addition, the results will take weeks to months to achieve.  We suggest it mostly as part of a maintenance regimen or for patients not ready for a BBL treatment.

The procedure is most commonly performed under local anesthesia without general anesthesia in the office if you are not having any other procedures.  Patients with more complicated procedures or are having multiple concurrent procedures will benefit from general anesthesia at the hospital or surgery center.

  • The procedure begins with the injection of an anesthetic to numb up the area as well as to reduce the degree of bruising.

  • If you are having fat bag removal without the need for skin removal, you will sometimes have a transconjunctival procedure which uses a incision on the inside surface of the eyelid and benefits from no scar on the surface skin.  Usually, only young patients less than 30-40 years old will be able to benefit from this technique.

  • If you are having a fat bag removal with skin removal, you will need a subciliary incision.  The incision is placed nearly invisibly below the lower eyelash.
  • The skin excess is lifted and removed

  • Once the superficial skin is removed, it is easy to visualize the excess and protruding fat.  The fat is conservatively removed.  Aggressive removal gives the appearance of hollowing.

  • Once the extra fat is removed, the skin is closed with a combination of absorbable sutures and sutures that need to be removed depending on the situation

There are two types of lower eyelid surgery; the TRANSCONJUNCTIVAL technique and the SUBCILIARY technique.  

The goals of the upper eyelid surgery are to reduce the appearance of fullness and heaviness caused by the development of extra eyelid skin, lower eyelid fat bags, and reduce the contribution of forehead droop if necessary.  

The procedure is most commonly performed under local anesthesia without general anesthesia in the office if you are not having any other procedures.  Patients with more complicated procedures or are having multiple concurrent procedures will benefit from general anesthesia at the hospital or surgery center.

  • The procedure begins with the injection of an anesthetic to numb up the area as well as to reduce the degree of bruising.

  • If you are having fat bag removal without the need for skin removal, you will sometimes have a transconjunctival procedure which uses a incision on the inside surface of the eyelid and benefits from no scar on the surface skin.  Usually, only young patients less than 30-40 years old will be able to benefit from this technique.

  • If you are having a fat bag removal with skin removal, you will need a subciliary incision.  The incision is placed nearly invisibly below the lower eyelash.
  • The skin excess is lifted and removed

  • Once the superficial skin is removed, it is easy to visualize the excess and protruding fat.  The fat is conservatively removed.  Aggressive removal gives the appearance of hollowing.

  • Once the extra fat is removed, the skin is closed with a combination of absorbable sutures and sutures that need to be removed depending on the situation

Facelift or Mini-Facelift – for lower facial droop and jowling

Forehead lift- for brow droop 

Upper eyelid surgery- Extra skin and fat of the upper eyelids

Fat transfer or Facial fillers-  for facial volume

Forever Young BBL – For dark skin pigment, sun spots, age spots

Profractional Laser Peel – For fine lines and textural changes of the skin

Micropeel – For fine lines and textural changes of the skin

Botox- for the dynamic wrinkles of the forehead, glabella, and crows feet

More often than not, lower eyelid surgery is performed without general anesthesia if it is performed as the only procedure.  

The procedure is most commonly performed under local awake anesthesia.  A long acting ( 6 hours ) is injected directly into the eyelid.  Most patients are also given a valium-type drug to help them relax.  

The best plastic surgeon near you should have the following qualifications

  • In practice for at least 3 years
  • Performs at least 1 upper eyelid surgery per week
  • Is a board certified plastic surgeon ( as opposed to a ENT, opthalmologist, or dermatologist )
  • Look at reviews in google

Complications of lower eyelid surgery are fortunately rare.  The most worrisome complications are the removal of too much lower eyelid skin and blindness.  I thankfully have never seen either of these in my own practice.  And short of journal reports, I have never known of any patient to have experienced blindness.

The more common and realistic complications include:

  • residual fine lines and extra skin.  As a conservative surgeon, I would much rather leave a little bit of aging than to remove too much skin and have your eyelid pull down.
  • residual fat protrusion .  Conservative rather excessive removal of the fat bags is often prudent to avoid complications of looking hollowed out.
  • Milia and small cysts along the suture line.  This complication is unfortunately very common.  They resemble pimples and are easily removed in 3 to 6 months and usually without extra charges.  

Subciliary incision technique:

Most patients will have a subciliary incision technique because of the need to address both the removal of extra skin as well as the removal of the lower eyelid fat pockets.  This incision is placed just below the lower eyelid eyelashes.  The scar is red at first but easily hidden with make-up for first 3-6 months.  After about 3 months, the scar will begin to whiten and lighten.

Transconjunctival lower eyelid technique:

Some patients will benefit from a transconjunctival technique which is directed at removal of the lower eyelid fat bags but not skin removal.  The incision is behind the surface of the eyelid so there is not external visible scar.

 

The recovery from  lower eyelid surgery is mostly cosmetic as opposed to functional.  That is, most patients are capable of work from a pain and discomfort standpoint in 2-3 days.  But because of the visibility of bruising most patients will not return to work for 7-10 days.  

  • Patients can work from home nearly immediately.  
  • Bruising will take up to 2 weeks to resolve.
  • Sunglasses hide a lot.
  • Patients can use make-up in 7-10 days 

Bruising of the lower eyelids can be dramatic.  The bruising will show as a dark blue in the first week and as a yellow green in the second week after surgery.  Make-up can be used to cover up any bruising once the sutures are removed in 7 to 10 days.  

Candidates for lower eyelid surgery will complain of the following:

  • fat bags are beginning to show
  • skin excess is visible and beginning to fold and wrinkle
  • dark shadows begin to show from the loss of fat volume along the lower orbital rim at the eyelid upper cheek junction.  This volume loss exposes the lower orbital rim bone
  • the lower eyelid appears to lengthen.  This is also because of the loss of fat volume along the lower orbital rim.  The extra tissue in the cheek then begins to pull down and stretch the lower eyelids.

For my patients:

  • First follow up visit is usually 1 to 2 days after surgery.  Out of town patients and some patients who are more comfortable can skip this appointment and replace it with a text image of your eyes from home.
  • Ice the eyes for the first 2-3 days to reduce bruising and swelling
  • Avoid any physical activities for 3-7 days to reduce bruising and swelling
  • Suture removal appointment in 7-10 days

Lower eyelid blepharoplasty is the medical term for lower eyelid surgery

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