Three Questions That Guide Treatment
When I assess someone's lower eyelids, I ask myself three questions. The answers tell me which treatments will help and in what combination:
- Is there excess or loose skin? If yes, we can tighten it with laser or remove it surgically.
- Are there eye bags? If yes — meaning actual bulging of fat beneath the eye — the most effective treatment is blepharoplasty surgery to remove or reposition that fat.
- Is there volume loss or hollowing? If yes, we can restore volume with fat grafts or fillers.
Most patients have more than one of these concerns, which is why I often recommend a combination approach.
Lower Blepharoplasty: Removing Eye Bags
Lower blepharoplasty is a surgical procedure that addresses the fat pads beneath the eye. These fat pads can bulge forward with age, creating the appearance of bags.
The procedure can be performed through an incision just below the lashes (external approach) or from inside the eyelid (transconjunctival approach), leaving no visible scar. I carefully remove or reposition the excess fat to create a smoother contour.
What it treats: Eye bags caused by bulging fat.
What it doesn't treat: Loose or crepey skin, volume loss, or fine lines extending beyond the eyelid.
Recovery: Bruising and swelling typically last 1-2 weeks. Most patients return to normal activities within 10-14 days.
Laser Skin Resurfacing: Tightening Loose Skin
Laser resurfacing uses controlled energy to create microscopic channels in the skin. As these heal, the skin contracts and tightens. The laser essentially "drills" tiny holes in the skin, leaving gaps of normal tissue between them. This normal tissue then contracts, pulling everything tighter.
The key advantage of laser over surgery for skin tightening is its reach. A lower blepharoplasty only removes skin from the eyelid itself — roughly the area between the lashes and the lower lid margin. But loose skin often extends beyond this: into the crow's feet area, down onto the upper cheek.
With laser, I can treat a wider area — going across into the crow's feet and down towards the cheek — addressing skin that surgery alone cannot reach.
What it treats: Loose, crepey skin; fine lines and wrinkles; skin texture.
What it doesn't treat: Eye bags (bulging fat) or volume loss.
Recovery: This is the most significant factor to consider. Laser burns the skin — that's how it works — and the recovery reflects this. The skin will be red for several weeks and pink for several months. Most patients see the pinkness resolve by 6-9 months. You can wear makeup during this time to conceal it.
Fat Grafting: Restoring Lost Volume
As we age, we lose fat from around the eyes. This creates a hollow, sunken appearance that can make someone look tired or gaunt. Fat grafting restores this lost volume by transferring fat from another part of your body (usually the abdomen or thighs) into the under-eye area.
Here's what happens with fat grafting: I harvest fat cells and inject them carefully into the hollow areas. These fat cells need to establish their own blood supply to survive. On average, about 50% of the transferred cells will successfully "take" and become permanent. The others don't pick up a blood supply, so your body recognises them as dead cells and gradually absorbs them through the immune system.
Because of this, I typically overfill slightly to account for the expected loss. Over the following months, the fat settles into its final volume.
What it treats: Hollowing, tear troughs, sunken appearance, volume loss.
What it doesn't treat: Eye bags or loose skin.
Recovery: Usually just some puffiness and mild swelling that gradually resolves over weeks to months.
Why Combination Treatment Often Works Best
Each treatment addresses a different aspect of lower eyelid ageing:
- Blepharoplasty removes the bags
- Laser tightens the skin
- Fat grafts restore the volume
When performed together, these treatments have an incremental effect on each other — the combination produces better results than any single treatment alone.
For someone with loose skin, some hollowing, and mild puffiness, I might recommend all three. For someone with just loose skin extending into the crow's feet area, laser alone might be sufficient. For someone with prominent bags but good skin quality, blepharoplasty alone could be the answer.
The right approach depends entirely on what's happening in your particular case — which is why a thorough assessment is essential before recommending any treatment.
The Laser Recovery Reality
I want to be clear about laser recovery because it's often underestimated. When I tell patients the skin will be red and then pink for months, some worry this will be unacceptable. In practice, most patients find that by their six-week follow-up, they're looking "just a little bit pink rather than very red."
If you have a history of rosacea, this is worth discussing. Laser treats the small blood vessels involved in rosacea, but it also stimulates new blood vessel formation, which can temporarily increase redness. The end result is usually an improvement, but the journey there involves more redness than someone without rosacea would experience.
The bottom line: don't underestimate laser recovery. It's not a quick fix. But for the right candidate, the long-term results are excellent and permanent.
Frequently Asked Questions
No. Laser tightens loose skin but cannot remove the fat pads that cause eye bags. If you have actual bags (bulging fat), you need a blepharoplasty to remove or reposition the excess fat.
The skin will be red for several weeks and pink for several months — typically 6-9 months before all pinkness resolves. You can wear makeup to conceal the colour during healing.
About 50% of transferred fat cells survive long-term by establishing a blood supply. The surgeon typically overfills slightly to account for this. Results can be very long-lasting once the fat has settled.
Yes. Combining lower blepharoplasty, fat grafting, and laser often produces the best results because each treatment addresses a different aspect of ageing around the eyes.
Lower blepharoplasty only removes skin from the eyelid itself. Laser can treat skin beyond the lid margin — into the crow's feet area and down onto the cheek — tightening loose skin that surgery alone cannot reach.