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A woman had eye bag surgery three years ago. Unfortunately, her lower eyelid has descended and her under eye area is hollow. She wants to know how to correct this area. Dr. Amiya Prasad explains that lower eyelid surgery addresses fat pockets or herniated fat. However, when those fat pockets are addressed, often surgeons overlook the adjacent area of the eyelid called the eyelid-cheek junction or not pay attention to the cheek area or the submalar area. As a cosmetic oculofacial cosmetic surgeon, Dr. Prasad performs eyelid and facelift surgery as well as cheek implants so he really looks at the eyes from the perspective of the whole face. During lower eyelid surgery, he explains to his patients that there is often concurrent volumetric loss in the eyelid-cheek area and the cheek area. A few years ago, Dr. Prasad wrote a book called “The Fine Art of Looking Younger” where he explained the basic philosophy about genetic and age-related changes where there is often descent or laxity. In this woman’s case, the position of her lower eyelid relative to her iris or pupil is slightly lower. The factors that are required for stability of the lower eyelid position needs to be addressed. This includes the lateral canthal tendon that attaches the outer corner of the eye to the bone, and the orbicularis oculi muscle which supports the lower eyelid. Depending on the type of surgery she had, whether or not she had skin removal or if it was done from the inside, there may be some loss of support in the middle part of the inside of the eyelid called the middle lamella. When the lower eyelid sags in the middle, it may be an indication of that laxity of the support structures under the eyelid. Dr. Prasad says it is important to do a physical exam to really understand what the patient’s eyelid tone is. He does a snap test where he pulls the eyelid down and lets it snap up to see what the eyelid tone is. Laxity may be part of the situation with her lower eyelid. If she had skin removal, there may be some degree of a skin shortage. In terms of problems like hollowing, there is often an involution or a loss of volume in between the rim of the eyelid and the cheek. In Dr. Prasad’s practice, he discusses options for enhancing that area of the rim using a hyaluronic acid filler like Restylane and combining that with platelet-rich plasma (PRP). Platelet-rich plasma is derived from the patient’s own blood and it is used to stimulate blood supply, collagen and even increase fat volume in the layers of the skin. From Dr. Prasad’s perspective, regenerative medicine is an important part of his surgical procedures, and is also independent of surgical procedures such as in hair loss treatment. He really appreciates the importance of the healthy fat layer under the skin and people lose that as they get older, and because of genetics. In addition, Dr. Prasad advises patients to also address volume in the submalar or cheek area so that there’s continuity and a contour that is very smooth. He has seen patients who have had filler done along the rim or in the tear trough and it looks like their eyes are puffy and he ends up dissolving it or adding volume to create continuity. He always thinks of the eyelid and cheek as one unit and looks at it from different angles. In the absence of a physical exam, Dr. Prasad thinks it’s best for her to move forward with meeting with either her original surgeon or other doctors who specialize in treating volume. At the same time, she should consider options related to the lower eyelid. The lower eyelid is deceptively complex and support structures have to be in perfect balance to get a really nice almond shape. To learn more about the causes of lower eyelids drooping after eye bag surgery and how they can be corrected, please visit our website: http://prasadcosmeticsurgery.com/pras...