As much as any sign of aging, patients in Toronto and across Canada notice how their lower eyelids can make them look tired, sad and old. It would be nice if there were one simple answer for these problems, but the reality is there are several causes and several treatments to choose from in Toronto. Let’s look at what bothers you the most, and what your options are. And, remember, everyone is different in their concerns, as only you can decide what’s best for you once you know what it’s all about.

First off, puffy bags of the lower eyelids are due to fat pouches pushing through the retaining wall, or septum, of the lower eyelid. This can occur as a familial trait or with the laxity of tissues associated with aging. Ideal treatment is removal of the excess fat through a lower blepharoplasty procedure. This can be done from behind the eyelid or through a fine incision hidden by your eyelashes. Once removed, the fat never comes back, so you look better for life. Sometimes, instead of removing all the excess fat, some is transposed or placed into the “tear trough” that frequently forms just beneath the fat pads. This can level the trough out and improve overall contour of the lower eyelid. In other patients, fillers such as hyaluronic acid (for example, Juvéderm and Restylane) can be used in the tear trough either alone or in combination with blepharoplasty to improve the contour. Used alone, the injection is an office procedure and the filler can last from one to three years. Occasionally fat or other materials may also be considered as tear trough fillers.

If wrinkling of the lower eyelids is a concern, this is partially addressed by removing the excess, lax skin of the eyelid as a part of the blepharoplasty procedure. But the surgeon cannot try to “pull up” too much eyelid skin to remove wrinkles or it can pull the eyelid down. We say, “The eyelid cannot hold up the cheek.” Wrinkles themselves can be improved with chemical peels such as trichloroacetic acid – Jessner’s solution or laser resurfacing. Crows’ feet laterally can be diminished with Botox, and sometimes fillers.

By improving the lower eyelid contour, the dark shadows are usually improved. However, in patients with darker pigmentation or congestion from allergies causing shadowing, makeup and medical treatment of allergies may be required as well.

In this very complex region, what is most important is to identify clearly to your surgeon what your concerns are, and together you can choose the most appropriate options for you.