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Melissa Hu, MD

Board Certified Facial Plastic Surgeon

It's natural to take steps to look your best
  • Dr. Melissa Hu


Updated: Jun 20, 2018


Changes in the laxity of the skin and soft tissues around the eye can become visible as early as in your 30s. The early appearance of “bags” under the eye or darkening around the eyes is largely due to skin laxity, early soft tissue loss and descent. Topical treatments with medical grade skin care products may address the collagen and help with fine lines and wrinkles. Other treatments such as microneedling also stimulate collagen production and strengthen the skin. When the lower eyelid bags seem to persist despite aggressive skin care, dermal fillers can be used to camouflage the bags and hallows around the eyes, thus providing a smoother contour of the eyelid/cheek junction.


Eyelid surgery is typically recommended when more conservative treatments such as skin care, fillers or neuromodulators (Botox, Dysport) no longer achieve the desired aesthetic result. This typically occurs when skin becomes excessively redundant along the upper eyelids, creating “folds.” When severe, the skin begins to encroach on the eyelashes and impedes your vision. When this happens, upper eyelid surgery may serve not only a cosmetic purpose but also a medical purpose which may be covered by insurance.

The lower eyelid may also begin to develop loose, crepe-y skin. As attachments lose strength, the lower lid fat begins to herniate, the cheek tissues begin to drop and shadows in the tear trough region can become more pronounced.

There are also individuals born with “unfavorable” eyelid anatomy due to fullness in the fat compartments of the upper and/or lower eyelids. These individuals often note fullness and heaviness of the eyes at an earlier age, around their 20s, and need to be assessed for the proper type of eyelid surgery, as it may not be the same as an individual in their 50s or 60s seeking eye rejuvenation surgery.


This happens most often for one of two reasons. One, there may have been pre-existing brow ptosis (low-set brows) that was undiagnosed prior to surgery. In these cases, eyelid surgery alone may bring the brow down even further, creating a heaviness in the upper eyelid as the brow now sits even closer to the eyelid after skin is removed from surgery. Often times, a brow lift is done before or simultaneously with eyelid surgery to adequately treat the heavy and tired eye.

The second cause may be due to inadequate treatment of the upper eyelid fat compartments or thick orbicularis oculi muscle (which underlies the eyelids). These individuals often are younger, 20 – 30 years old, who feel like there upper eyelids are creating a more masculine, heavy or squinted look. In traditional eyelid surgery, excessive skin is removed to address heavy or redundant eyelids. However, skin redundancy is not usually the problem in these younger individuals, and the underlying muscle and fat may need to be addressed to achieve a more open eye.


The approach largely depends on whether the lower eyelids have excessive skin or fat, or a combination of both. When skin laxity is moderate to severe, often an external incision is required to remove the redundant skin. There is no other way to address the excess skin other than through an incision on the skin. The external approach also has more versatility in that it can access the cheek region for combined procedures involving the midface - cheek implants or lift.

An internal approach, “incisionless blepharoplasty” is often restricted to those individuals with good skin texture, strong collagen, but excessive fullness and fat pads of the lower eyelids. If this results in some skin laxity, a small “skin pinch” may be required.

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