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Cosmetic Face Surgery

Lower Eyelid Dark Circles

Lower Eyelid Wrinkles - Lower Eyelid Fat Bags

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One of the most common concerns seen in our office for consultation is dark circles under the eyes.  The reasons for dark circles under the eyes are multi-factorial and include:

  • Loss of volume in the upper cheek eyelid junction which is no longer able to camouflage the underlying orbital bone
  • Increased sun exposure of the lower eyelids as the lower eyelid sits on a shelf on the upper cheek
  • Stretch of the lower eyelid skin as the cheek falls with age causes the lower eyelid skin to wrinkle and darken
Given these findings, the treatment strategy to addressing the dark circles of the lower eyelid are:

  • Add volume to the upper cheek eyelid junction with fillers or fat transfer
  • Forever Young BBL to bleach the dark abnormal pigment of the eyelid skin
  • Surgical removal of excess lower eyelid skin if necessary.

The dark circles under the lower eyelids are the result of many concurrent reasons.  

Loss of volume in the upper cheek eyelid junction 

  • The loss of volume seen in the region of the lower eyelids where it joins the cheek is one of the principle reasons for the development of dark circles.  The fat in this reason normally supports the eyelid and camouflages the visibility of the orbital bones.  Volume is lost as you age beyond your mid-twenties.  As that volume is lost, the remaining cheek tissue will sag, and the combination will expose the orbital bone.  Because the bone is dark and the bone is circular, the resulting visual is a dark circle below the lower lids.

Increased sun exposure of the lower eyelids

  • The lower eyelids are normally supported by the upper cheek.  And the upper cheek acts as a shelf with extra exposure to the sun.  Sun exposure on the cheek reflects light onto the lower eyelid which in turn results in extra tanning of the tissues in this area.  The tanning over time will permanently darken the skin pigment.

Stretch of the lower eyelid skin as the cheek falls with age 

  • An unfortunate fact is that everything falls with age.  The immediate cause is a loss of volume and tissue turgor and the break-down of tissue collagen.  As the volume is lost in the eyelid cheek junction ( see first bullet point ), the tissue around the upper cheek begins to deflate and sag.  The tissue will pull downwards causing the lower eyelid skin to stretch.  The stretched skin is extra skin that folds onto itself causing dark shadowing

Treatment strategies for the dark circles of the lower eyelids revolve around the three reasons for developing dark circles.   These include treatment options for addressing:

  • Loss of volume in the cheek eyelid junction and orbital bone exposure
  • Darkening of the eyelid skin due to excessive sun exposure
  • Excess skin and wrinkles from skin stretch over time and age
Depending on your individual issues, the strategy for addressing your concerns may require treating all 3 findings.  The first step in most patients is to address the volume loss and the skin pigment as these issues are relatively easy to address before considering the treatments for reducing skin excess and wrinkless

Volume loss in the lower eyelid cheek junction is inevitable and is the primary reason for the visibility of dark circles of the lower eyelid area.  

The volume loss is addressed either by injection of facial fillers like Juvederm or Voluma or the addition of fat by fat transfer.  

Facial fillers like Juvederm or Voluma 

Facial fillers can be injected into the area of volume loss.  This simple procedure can often be performed on the same day as your consultation.  The procedure will take about 10 minutes.  There is no down-time.

Fat Transfer

Fat Transfer is more of a surgical procedure.  Fat is obtained by liposuction from the abdomen or thighs.  The fat is processed during the same procedure to remove blood and other fluids from the fat.  The fat is then re-injected into the area that requires volume.  Facial fat transfer will take about 30 minutes.  Most patients will experience swelling and some bruising but will return to work in about one week.

Bleaching of the lower eyelid skin can be obtained by using skin lightening products such as hydroquinone in Obagi Clear or using the Forever Young BBL.  The most effective and most common method we use is the Forever Young BBL.

Forever Young BBL

BBL stands for broad band light, and is the the newest and most advanced version of IPL intense pulsed light therapy.  As the name states, the Forever Young BBL uses a broad range of light waves to capture and treat different skin pigmentations changes more effectively.  In the process, the broad bands of light have been shown to rejuvenate cellular DNA; giving the device its name Forever Young.  

The Forever Young BBL can be used for the eyes, face in general, neck, chest, or any other area.  Treatment for the eyelids takes only 5-10 minutes with no downtime.  The treatment may need to be repeated once or twice for optimal results.  Results after treatment can be visualized after 1-2 weeks.

Hydroquinone Products

Hydroquinone is a popular bleaching agent that works to bleach the pigment from skin melanin.  While effective, it is not as effective as a BBL treatment.  In addition, the results will take weeks to months to achieve.  We suggest it mostly as part of a maintenance regimen or for patients not ready for a BBL treatment.

There are delicate structures around the undereye, including eye muscles and the eyeball itself. The surgery requires a delicate, precise approach to smooth the undereye area and make it appear less puffy.

Several surgical approaches exist for lower eyelid surgery. The approach usually depends on your goals for your undereye area and your anatomy.

Prior to the procedure, a surgeon will mark your eyelids. This will help the surgeon know where to make incisions. They’ll usually have you sit up so they can see your eye bags better.

The procedure may be performed under general or local anesthesia. General anesthesia is when a patient is completely asleep and unaware of what is happening during the procedure. Local anesthesia allows a patient to be awake, but the eye area has been numbed so they don’t feel what the surgeon is doing.

If you’re having multiple procedures, a doctor will likely recommend general anesthesia. If you’re having just lower eyelid surgery, a doctor may recommend local anesthesia. A benefit of this is that a doctor can test eye muscle movements to reduce the risks for this side effect.

While the incision sites may vary, a doctor will make cuts into the lower eyelid. Your doctor will then remove excess skin and fat and suture or sew the skin back together to create a smoother, lifted appearance.

Blepharoplasty is the technical name for surgical eyelid surgery. Cosmetic lower eyelid surgery is one of the most common cosmetic surgeries performed by Dr. Chang. The surgery removes fatty tissue under the eye, along with skin to produce a brighter, fresher look.

There are a number of techniques Dr. Chang uses  depending on what is required.

The subciliary lower eyelid blepharoplasty

The subciliary lower eyelid blepharoplasty is performed by making an inconspicuous incision just below the lower eyelashes. The eyelashes partly hide the eventual scar. In addition, the abundant moisture natural to the the lower eyelid margin helps produce nearly invisible scars.  

Once the incision is created, the skin and eyelid muscles are elevated to expose the excess orbital fat below them. The excess orbital fat is very conservatively removed so as to not produce a hollowed out appearance. The excess skin is then removed. The skin incision is closed with absorbable sutures that may need to be removed in 5-10 days.  

The transconjunctival lower eyelid blepharoplasty

The transconjunctival lower eyelid blepharoplasty is performed by making a very inconspicuous incision “behind” the lower eyelid. This technique is only appropriate for patients with fat bags but very little skin excess. The incision behind the eyelid allows exposure and removal of the fat but does not allow removal of the skin. Some skin tightening can be provided with the skin resurfacing laser.  

General information

Patients are given the choice to have the procedure in the office with local anesthesia and valium or at the surgery center for general anesthesia.  The procedure will take about 1-1.5 hours.  Patients will recover at home and return for a follow-up in a few days.  

Lower eyelid aging is a normal part of aging. For some people genetics, sun exposure, and gravity can cause more severe aging and produce fatty bags and wrinkles. Other cause are:

Weakening and thinning of the barrier that usually holds the lower eyelid fat back

  • There is a normal barrier that holds the fat volume that supports your eye, but this begins to thin with age. Some young patients will have a normally thin barrier. The more the barrier breaks down, the more the fat will push out on the barrier and show as larger fat bags.

Increased fat content behind the lower eyelids

  • The lower eyelid fat usually supports the eye.  Because all fat has the potential to enlarge with weight gain, increases in lower eyelid fat will eventually push out on the lower eyelid barrier and stretch the skin.  This will show even if you lose the fat.  

Loss of the upper cheek fat volume that normally happens with age exposes the lower orbital bone and fat bags

  • There is a normal loss of facial volume with age.  This loss of volume is very obvious in most patients in the upper cheek eyelid junction.  Loss of volume here exposes the lower orbital bone and can be seen as a dark circle. The loss of volume also exposes any other lower eyelid imperfections like the appearance of lower eyelid fat bags.

Someone who wants to:

  • Reduce the visability of wrinkles
  • Remove any skin excess
  • Reduce the appearance of fat bags
  • Reduce the appearance of dark circles

It is important to be healthy, ideally a non-smoker, not overweight and to have a realistic expectation of what can be achieved.

After surgery you should rest at home and let yourself heal. Dr. Chang will send you home with a detailed recovery plan. There are a number of different things to expect:

  • There will be bruising for 2-3 weeks
  • Final results should not be expected for 3-6 months
  • Most patients will return to work in 1-2 weeks with make-up
  • Sutures are removed in 7-10 days if they have not absorbed
  • Avoid strenuous exercise for 2-4 weeks
  • Apply the prescribed opthalmic ointment 3x per day until gone
  • Pain is negligible
  • Scarring will be minimal and hidden in the natural skin folds and creases

As with any surgery, there are associated risks. Only you can decide whether a lower eyelid surgery can achieve your goals and if the recovery and risks are acceptable to you. Complications are rare but can include:

  • Local bleeding or prolonged bruising
  • Ectropion ( pulling down of the eyelid )
  • Milia ( small cysts along the suture line )
  • Residual skin or fat
  • Infection particularly from the absorbable sutures
  • Loss of sensation although rare
  • Widened or thickened scar
  • Asymmetry (unevenness between two sides)
  • Delayed wound healing with skin or tissue necrosis
  • Extra skin at the ends of the incisions
  • Under-correction
  • Over-correction

Unsatisfactory results may require additional procedures. Patients will generally be responsible for any associated facility fees. 

If dark circles are caused by shadowing due to the fatty bags they can be significantly reduced. Dark circles caused by pigmentation will need other procedures such as laser treatment or chemical peels.

Wrinkles will reduce due to the excess skin being removed and tightened but wrinkles around the eyes (crow’s feet) will not be reduced by lower eyelid surgery.


The cost of lower eyelid surgery partially depend on the exact technique and whether the procedure is performed under local anesthesia or general anesthesia.  

There are a number of surgical and non-surgical procedures that can be combined with lower eyelid surgery:

  • Canthopexy (lower eyelid)
  • Upper eyelid surgery
  • Forehead lift
  • Mini Facelift
  • Botox and Fillers
  • BBL Laser treatment for pigmentation
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Lower Eyelid in Northern Virginia

Dr. Phillip Chang Plastic Surgeon in Loudoun VA

Dr. Phillip Chang is a leading plastic surgeon in Loudoun County who specializes in surgical and nonsurgical cosmetic procedures for the breast, body, face, and skin. He is board certified in plastic surgery by the American Board of Plastic Surgery and is the founder of Aesthetica Cosmetic Surgery & Laser Center in Leesburg, VA. Dr. Chang is dedicated to providing high-quality service that concentrates on the unique needs and concerns of his patients. He believes combining attentive care and minimally invasive techniques is the best avenue for achieving beautiful, natural-looking results. Dr. Chang is thrilled to be serving the greater northwest area of Washington, D.C. with top cosmetic care that is dependable and trustworthy.

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We are based in Leesburg, VA. Located as part of the Lansdowne medical complex, you have access to our 24-7 state-of-the-art facility as well as access to Lansdowne hospital. We are based directly across the road from INOVA hospital. There is ample parking, elevators to bring you to our third floor offices, and welcoming staff to sign you in.

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Aesthetica has received numerous awards from the Loudoun County Chamber of Commerce, New Beauty, Best of Loudoun, Posh 7 Top Picks, and Dr. Chang is internationally known for his lectures and advances in precise surgical technique as demonstrated through his unique mini-facelift procedure.

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