Question: I have puffiness under my eyes. It’s been getting worse with age. I am a happy person, but people often think I look sad or tired. I tried Botox and laser, but neither worked. Are there options that can make me look more rested and awake?

Answer: Puffy or tired-looking eyes are a common concern as the face ages. There are several options ranging from surgery to minimal invasive treatments, depending on the cause. Treatment of this area can be tricky and requires a detailed understanding of lower eyelid/upper cheek anatomy, as well as a high degree of technical skill.

1. Volume loss of the upper edge of the cheek can give the appearance of hollowing under the eyes. This volume loss can be due to diminishing fat and or bone along the upper edge of the cheek where it meets the lower eyelid. Restoration of volume is typically done with injectable fillers. Treatment options include Bellafill – the filler that last 5 years – as well as Restylane, Juvederm, or RHA collection. Sometimes the volume loss is not restricted to the lower eyelid alone but also extends to the upper cheek. A keen aesthetic eye is necessary for the latter which requires injection of fillers to both the lower lid hollow as well as the upper cheek in order to maintain a natural, balanced appearance to the face.
2. I am seeing an increasing number of patients who have had filler injections by generic injectors from other offices and have complaints of persistent lower lid puffiness. Some also have a bluish discoloration under the eyes or over the upper cheek. When the filler used is a hyaluronic acid (HA) filler such as Restylane, Juvederm, or Voluma, success can be achieved by dissolving with Hyelenex or Vitrase. It is important to note, however, that the greater cross-linking present in an HA filler, the lower the likelihood that filler will completely dissolve. When treating the lower eyelid/upper cheek, seeking a Master Injector can be key to a successful outcome.
3. Puffiness under the eyes can also be due to protruding fat. As the eyes age, the ligaments and fascia that support the fat surrounding the eyeball loosen and result in fat bulging outward in the lower lid zone. Treatment involves the removal of excess fat to make the lower lid more flush with the cheek area beneath it.
4. Another cause of puffiness around the eyes can be excess skin and/or poor skin elasticity. In some cases, treatment with Botox or lasers can be beneficial. In others, removal of excess skin is required.

Treatment of the delicate eyelid area can be quite complex. Some patients fit into one of the above categories whereas others have multifactorial causes of aging, requiring more than one treatment approach. A detailed consultation with a board-certified Facial Plastic Surgeon who specializes in the rejuvenation of the upper face is the first step.