Undereye bags can result from a number of issues, but one of the most common reasons is the presence of excess orbital fat within the lower eyelid that protrudes or herniates into the cheek. All of us have multiple orbital fat compartments that serve to cushion and lubricate the movement of the eye, but as a result of age or genetics for some of us this lower eyelid fat, which normally resides below the eye and behind the cheek, begins to bulge forward, or pseudoherniate, thus creating a visible eye bag and a tear trough below it.
Protrusion of the eyelid fat will typically accentuate the hollowing that naturally occurs below the eyes and along the cheeks with age, as it creates a convexity above this depressed area below the orbit and eyes. When the amount of fat is minimal but there exists a significant volume deficit or hollowing in the infraorbital area and tear troughs, then adding volume by way of filler injections or fat grafting are viable options that can produce significant improvement. Volume may also be replenished with newer options such as Juvelook or platelet-rich plasma (PRP) and platelet-rich fibrin (PRF).
For patients with a significant amount of lower eyelid fat, the lid-cheek contour can only be fully improved by addressing the lower eyelid fat, either by repositioning or by removal during a lower blepharoplasty surgery. The traditional surgery involved making an incision through the lower eyelid skin (subciliary approach) and orbicularis muscle to expose the orbital fat, with a subsequent removal of various portions of fat, muscle and skin. Some of the marked disadvantages of this approach included a hollow appearance to the lower eyelids with advancing age, lid malposition as involutional volume changes occurred or as cicatricial scarring forces caused the lower eyelid to evert with a resultant ectropian. Even in the best outcomes, a visible scar remained along the lower lash border.
For these factors many contemporary surgeons choose to approach the lower eyelid via a transconjunctival approach (an incision made in the back of the eyelid along the pink conjunctiva, where it is completely hidden) so as to obviate the appearance of a scar. Since the anterior lamella of the eyelid is not violated, this approach has also significantly minimized the risk of eyelid malposition and eyelid retraction post surgery. Another generational paradigm change has been that of volume preservation versus simple excision and removal of fat. Studying the anatomic changes that occur with aging has taught us that we lose fat volume in our face as we age. For this reason most contemporary surgeons have transitioned to repositioning this precious fat volume into an area that needs it, namely the tear trough. By reducing volume in an area with excess, the eyebag, and instead applying it to an area of hollowing, the tear trough, the lid-cheek contour becomes smooth and a youthful appearance is restored.
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