A true awakening: Procedures to eliminate undereye bags

There has been a growing trend in treatments for the appearance of the undereye area. This increasing popularity can be attributed to several factors, including the prevalence of social media and selfies, as well as the rise in the availability of weight loss medications. Additionally, this new aesthetic shift is not limited to one type of patient, gender or age group, making it a unique area for plastic surgery.

One of the most common aesthetic concerns raised about the appearance of the undereye area is the issue of "undereye bags." A more prevalent appearance of these pockets of skin can be attributed to a variety of factors, including age, lack of sleep, dehydration and simple genetics. This was once thought to be a concern that was not easily addressed, but advancements and new innovations have offered more opportunities for surgeons to tackle the issue and achieve remarkable, immediate results for their patients.

To learn more about undereye bags and potential procedures to address their appearance, we reached out to ASPS Member Surgeons Laura Devgan, MD, and Karen Horton, MD, MSc, FACS, along with Emily Sespaniak, NP, who is the aesthetic injector at Dr. Horton's practice.

The aesthetic focus on undereye bags

As the focus on our faces increases in a digital age where we are frequently on camera, more patients are requesting options to improve the look of their undereye area.

"Undereye bags are one of the most common aesthetic concerns I see across all age groups and genders," said Dr. Devgan. "The lower eyelid area is particularly unforgiving – volume loss, fat herniation and thinning skin can lead to a tired, aged or puffy appearance that doesn't reflect how a patient feels. Because the eyes are such a focal point of facial expression, even minor changes in this area can have a profound impact on one's overall look and confidence."

Popular procedures to address undereye bags

While the appearance of the undereye area may be a common concern among patients, there is no single go-to method for treating this area.

"Treatment is highly individualized and depends on the underlying cause, whether it's fat protrusion, hollowness, pigmentation or skin laxity," said Dr. Devgan.

In terms of surgical procedures, several options are available for patients to address these aesthetic concerns.

"Surgically, lower lid 'pinch' blepharoplasty that only removes skin but leaves muscle and fat pads alone is my go-to technique," said Dr. Horton. "An incision is made just below the lash line in the subciliary region, a strip of skin is removed, which helps to redrape excess skin upwards."

According to the 2024 ASPS Plastic Surgery Statistics Report, blepharoplasty was the fifth most popular cosmetic surgery procedure, and it's easy to see why, given its impact on a patient's appearance.

"Surgically, lower blepharoplasty is the gold standard for true undereye bags caused by fat herniation, often combined with fat grafting to smooth contour irregularities," said Dr. Devgan.

There are also many minimally invasive options available for patients interested in improving the appearance of their undereye area.

"Nonsurgically, tear trough filler using hyaluronic acid can camouflage mild volume loss and transition zones," said Dr. Devgan. "For patients with crepey skin or mild laxity, erbium laser resurfacing or microinfusion microneedling with PRP can stimulate collagen and improve skin texture."

However, there are very real restrictions on what nonsurgical treatments can do to address undereye bags in patients.

"Nonsurgically, the options for treating true undereye bags are limited," said Sespaniak. "In some rare cases, dermal filler can be strategically placed in the mid-cheek to help mask undereye bags, but most of these cases are best addressed surgically with a lower lid blepharoplasty with or without fat excision or repositioning."

There are plenty of procedures to address undereye bags, but there are a few that should be avoided.

"Patients should be cautious about overfilling the undereye area with injectable fillers, particularly if their concern is true fat herniation rather than hollowing," said Dr. Devgan. "In those cases, filler can worsen puffiness or lead to the Tyndall effect, where the skin takes on a bluish hue. Similarly, aggressive resurfacing without anatomical support can cause lower lid retraction. The undereye area demands finesse and restraint – less is often more."

Undereye filler is something that should be approached with caution, and many injectors avoid recommending it as an option to patients altogether.

"It often results in a puffy look that persists even after post-filler swelling resolves," said Sespaniak. "There are occasionally some patients who will notice a slight improvement in the undereye area when filler is carefully placed in the mid-cheek, but this is definitely on a case-by-case basis."

Best practices for patients considering undereye bag removal

There are a few key steps patients pursuing undereye procedures and treatments can take to set themselves up for success.

The first and most important step to take when considering any plastic surgery procedure, whether invasive or noninvasive, is to ensure that you are seeing a board-certified plastic surgeon.

"Do your homework, see a board-certified plastic surgeon who ideally has additional fellowship training in aesthetic surgery of the eyelids, ask to see lots of results, and if they don't feel comfortable operating, trust that they are not the surgeon for you," said Dr. Horton.

Always schedule a consultation with a potential surgeon to make sure that they are the right fit for you and your unique goals.

"I would recommend scheduling a few different consultations to find the best fit for you, as a patient," said Dr. Horton. "Eyelid surgery is a big commitment. Don't turn to social media like TikTok for referrals, where surgery risks may be minimized and marketing is heavy."

Next, it's essential to come prepared with any relevant photos, target results and personal medical information.

"Begin with a consultation that includes a structural and skin quality assessment," said Dr. Devgan. "Photos from your 20s or 30s can also help guide treatment toward restoring your natural anatomy, rather than reshaping it."

You may be tempted to pick a treatment without considering your long-term plans and maintenance of results. Yet, hurrying a decision may not be the best option for excellent long-term results.

"I always advise patients to avoid rushing into overdone treatments, especially with injectables," said Dr. Devgan. "Layering subtle interventions over time yields the most natural and durable results."

This type of procedure offers immediate and amazing results, but it's essential to practice good skincare and self-care habits both before and after the treatment to maintain the results.

"Remember, quality sleep, sun protection and topical skincare remain critical tools in long-term maintenance," said Dr. Devgan.

Establishing these self-care routines can set your beauty regimen up for success now and well into the future.

"For patients concerned with the appearance of their undereye area, nightly use of a retinol-based eye cream to stimulate collagen and target fine lines is advised," said Sespaniak. "In addition, protecting the skin of the delicate eye area is essential. Keeping the eyelids moisturized and protected from the sun will help minimize the effects of aging. There are some great eye products available now that triple as an eye cream, mineral sunscreen and concealer. Invest in one of these and use it daily. Good sleep and good hydration are also key!"

The increasing focus on the appearance of the eyes and the prevalence of undereye bags mean that treatment options are continually growing. Patients can now address these aesthetic concerns with the assistance of board-certified plastic surgeons through both surgical and nonsurgical means, offering numerous paths forward to a brighter undereye and a more youthful appearance.

To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area.