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I have seen a few doctors about my lower eyelid bags and have had different advice from each doctor! How can I tell which is the best option for me?

B.C. Shrewsbury, MA

We cannot give you specifics without seeing you in person, but there are a few options for lower eyelid rejuvenation, and they depend on two things – your anatomical problem and your expectations! Lower eyelid aging consists of five components:

  • 1. Development of lower eye lid bags. These are caused by a hereditary pocket of fat under our eyes that protrudes forward, past the orbital rim. Whether in daylight, indoors with artificial light, or in moonlight, light usually shines down from above, causing the upper part of the bag to look lighter in color and creates a shadow under the bag, giving us the “dark circles” one sees in patients with “bags”. Removing this excess fat causes the part below our eyelashes to flatten out and removing the shadow (dark circles) and the appearance of bags.
  • 2. Development of lower lid skin laxity. Skin loosens over time. Some patients get an excessive amount of lower eyelid laxity, others do not. In patients with excessive lower eyelid laxity, the skin excess can be removed via an incision under the eyelashes – these incisions heal exceedingly well and are rarely visible after the wounds have healed, in lighter skinned people and in darker skinned people alike. However, please note that tightening the lower eyelid skin does not change the texture of the eyelid skin, and whatever eyelid skin remains, will have the same texture as it did before the skin tightening.
  • 3. Development of lower eyelid wrinkles. People can develop lower eyelid wrinkles and crow’s feet with or without eyelid bags or skin excess. Good skin care can moisturize the skin and make the wrinkles less noticeable – and so can good makeup. But to remove these wrinkles, one has to treat the surface of the skin with either radiofrequency, lasers or chemical peels.
  • 4. Some patients will develop a downward sag of the lash lines, showing more of the white part of the eyes than is desirable. This too makes the eyes look older. A minor procedure called a canthopexy can tighten the lash line against the globe and return the eye to a more youthful appearance.
  • 5. And finally, some patients complain of a dark discoloration of the lower eyelids. Lower eyelid skin is some of the thinnest we have on our bodies – for example, eyelid skin is approximately 17 thousandths of an inch thick in youth and it thins even further with time, while by comparison, back skin is closer to 150 thousandths thick and you cannot see the underlying fat or blood vessels. Plain and simple, you can see the darker eyelid muscle through this thinner eyelid skin, just as we can see blue veins through the thin skin on the tops of our hands – this darkening is NOT due to skin hyperpigmentation and cannot be improved. The only thing that can make this eyelid darkness less noticeable is good concealing makeup.

In evaluating any patient with lower eyelid complaints, all of the above issues have to be considered and discussed with a patient. If a patient has lower eyelid bags, but no skin laxity, an incision from the inside of the lid, transconjunctival, will be recommended. If a bag is associated with lower eyelid skin excess, or someone has skin excess without a fatty bag, an external incision beneath the lashes will be recommended. A canthopexy may be recommended to raise your lash line if the lash line has drooped and you now see white below your iris. And finally, with any of the above issues, if the skin is wrinkled, resurfacing with chemical peels or lasers, or radiofrequency skin tightening, will be discussed. But the final decision as to which procedures are performed will be a joint decision by the patient and surgeon.

Female in her 50’s, before and after an upper eyelid blepharoplasty to remove excess upper eyelid skin, lower eyelid fat removal and skin excess removal via an incision below the eyelashes, and a TCA peel to remove the periorbital wrinkles.

Male in his early 60’s, before and after a lower lid skin tightening procedure, incision below the lash lines, without fat removal or skin resurfacing. Of course, he also had a brow lift, an upper eyelid blepharoplasty, a rhinoplasty and a chin augmentation as well as Dr. Bunkis’ short scar facelift which is ideal for males with little hair.

If you have any other questions about eyelid rejuvenation, please join us for our next complimentary virtual seminar, tomorrow, on April 8th on YouTube. The topic will be eyelid rejuvenation. Please clink link below to reserve your spot through EventBrite.

If you have any specific questions about cosmetic procedures, your best bet would be to see a qualified plastic surgeon to review your options.

If you would like to contact Dr. Ekstrom or Dr. Bunkis,

For CA, please call 949-888-9700 or visit our websites at:

Or for MA location, call 508-755-4825 or visit

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