As a facial plastic surgeon, the under-eye area is one of the most common concerns patients bring to my practice. Patients often point to their lower eyelids and ask for a single cream, laser, injection, or surgery to “fix it.”
However, clinical experience and facial anatomy dictate that the under-eye doesn’t just age in one way; it ages through three distinct processes. Because the causes are multifaceted, treating them with a single approach often leads to unnatural or underwhelming results.
Based on my clinical experience and supported by plastic surgery literature, the safest and most effective way to comprehensively rejuvenate the under-eye and upper cheek is through a multimodal approach. Here is a deep dive into what happens to our underyes as we age, and our philosophy for how to provide lasting rejuvenation for this area.
Process 1: The “Bags” (Orbital Fat Pseudoherniation)
Within the eye socket, the eyeball is cushioned by orbital fat. This fat is held in place by a thin, fibrous wall called the orbital septum. As we age, the septum weakens. Without that strong barrier, the orbital fat begins to bulge forward (pseudoherniation), creating what we commonly call under-eye “bags.”
To address the bulging fat, I prefer a transconjunctival lower eyelid blepharoplasty.
- Instead of cutting through the skin and muscle on the outside of the eyelid, an incision is made purely on the inside of the eyelid (the conjunctiva) to remove or reposition the excess fat.
- According to multiple scientific studies, the transconjunctival approach significantly reduces the risk of postoperative complications compared to the traditional “transcutaneous” (through the skin) approach. [Asaria 2023, Shao 2014] Because it leaves the critical support muscle (the orbicularis oculi) intact, it drastically lowers the risk of ectropion (the eyelid pulling down), changing the shape of the eye, causing tearing, leaving visible scarring, or inducing chronic dry eye. [Baylis 1989]
Process 2: The “Dark Circles” (Tear Trough Volume Loss)
Just below the under-eye bags sits the upper cheek. In our youth, thick malar fat pads create a seamless, smooth transition from the lower eyelid to the cheek. Over time, these fat pads deflate and descend due to gravity. This leaves a volume deficiency in the tear trough, creating a visible depression or shadow that patients often interpret as “dark circles.”
You cannot fix a volume deficit by simply removing tissue above it; you must replace the lost volume.
- During the blepharoplasty, we perform fat grafting or fat transposition. This involves taking the patient’s own fat (either the bulging orbital fat we are already accessing, or fat harvested from elsewhere) and meticulously laying it into the tear trough depression.
- This is a critical step to bridge the gap and restore the youthful, flush junction between the under-eye and the upper cheek.
Process 3: Crepey Skin and Wrinkles (Collagen Loss)
The skin of the lower eyelid is the thinnest skin on the human body. As it loses collagen and elastin over time, it loses its snap, resulting in a crepe-paper texture and fine wrinkles.
Historically, surgeons would simply cut away the excess skin. However, excising lower eyelid skin carries a high risk of making the eyelid weaker, pulling the eyelid downward (ectropion) and causing severe dry eye and problems with tearing. Instead, I prefer to address the skin through powerful resurfacing.
- How it works: CO2 laser and Phenol/Croton Oil peel are the most powerful resurfacing agents currently available. By applying these methods to the lower eyelid skin, we induce massive collagen remodeling.
- The Impact: It dramatically tightens the skin and erases deep wrinkles without a single external incision. This preserves the anatomical shape of the eye, avoids visible scarring, and completely bypasses the risks associated with surgical skin excision.
The Bottom Line
Under-eye aging is a combination of bulging fat, lost cheek volume, and deteriorating skin quality. By combining a transconjunctival blepharoplasty, targeted fat grafting, and a powerful resurfacing treatment, we can comprehensively address all three issues simultaneously. This yields a dramatic, natural result with the highest margin of safety.
Works Cited
Asaria J. Transconjunctival Lower Eyelid Blepharoplasty with Volume Augmentation for Correction of the Lower Eyelid and Cheek Junction. Facial Plast Surg. 2023 Feb;39(1):20-27.
Shao C, Fu Y, Lu L, Chen J, Shen Q, Zhu H, Fan X. Dynamic changes of tear fluid after cosmetic transcutaneous lower blepharoplasty measured by optical coherence tomography. Am J Ophthalmol. 2014 Jul;158(1):55-63.e1.
Baylis HI, Long JA, Groth MJ. Transconjunctival lower eyelid blepharoplasty. Technique and complications. Ophthalmology. 1989 Jul;96(7):1027-32. doi: 10.1016/s0161-6420(89)32787-4. PMID: 2771349.
Disclaimer: This blog does not constitute medical advice and no doctor-patient relationship is formed by reading it. Prior results do not guarantee a similar outcome. Additional facts or future developments may affect subjects contained within this blog post. Before acting or relying upon any information within this newsletter, seek the advice of a medical doctor.