Why Would an Aesthetic Physician Choose Eye Bag Surgery? Dr. Hsin-Hung Chen Explains the Key to Treating Under-eye Bag and Tear Troughs
When a physician who is familiar with dermal fillers, neuromodulators, and other minimally invasive aesthetic treatments develops under-eye bags, would they continue using injectable treatments—or choose lower blepharoplasty?
The patient featured in this case is an aesthetic physician.
Because of his medical background and familiarity with the benefits and limitations of different aesthetic procedures, he understood that not every under-eye shadow or hollow can be corrected with fillers alone.
After a comprehensive assessment, we decided to address the underlying structure of the lower eyelid by treating the protruding fat pads and improving the uneven transition between the under-eye bags and tear troughs.
Video Case｜Why Did an Aesthetic Physician Choose Lower Blepharoplasty?
This video documents the patient’s lower blepharoplasty experience and postoperative recovery.
What makes this case meaningful is not simply that a physician underwent eye bag surgery. It demonstrates that even someone who is highly familiar with injectable treatments may still choose surgery when the main concern is caused by structural under-eye bags.
Injectable treatments and surgery do not necessarily replace one another. They are designed to address different types and levels of concern.
Why Can’t Some Under-Eye Bags Be Corrected With Fillers Alone?
When people notice shadows or hollows beneath their eyes, they often assume that tear trough filler will solve the problem.
However, under-eye bags and tear troughs are not the same condition, even they usually should be treated at the same time.
Under-eye bags are commonly associated with protruding lower eyelid fat, changes in the surrounding support structures, and varying degrees of skin laxity. A tear trough is the depression located beneath the eye bag.
When both are present, they can create a “bulge above and hollow below” appearance. This difference in height creates a visible shadow, making the face appear tired even after adequate rest.
If the primary concern is mild volume loss or a shallow tear trough, injectable treatment may be considered following a medical assessment. However, when prominent fat pads are already present, repeatedly filling the hollow beneath them may not address the underlying problem. In some cases, adding more volume can make the lower eyelid appear heavier or puffier.
Before selecting a treatment, it is therefore important to determine whether the under-eye concern is primarily caused by:
Protruding lower eyelid fat
A tear trough or under-eye hollow
Lower eyelid skin laxity
Changes in structural support
A combination of several factors
Identifying the actual cause of the tired appearance allows us to choose a treatment that is more appropriate for the patient’s anatomy.
Before and After｜Clinical Case Record
Suggested image caption:
Preoperative and postoperative clinical photographs following lower blepharoplasty. Before surgery, protruding lower eyelid fat and a visible transition between the eye bags and tear troughs can be observed. After surgery and recovery, the under-eye contour appears smoother, with improvement in the shadow created by the original bulge and hollow.
During the preoperative assessment, I was not only looking at the size of the eye bags. I also considered the location of the protruding fat, the depth of the tear trough, the condition of the lower eyelid skin, and the transition between the lower eyelid and midface.
The purpose of lower blepharoplasty is not to remove as much fat as possible. The goal is to adjust the protruding tissue appropriately while maintaining a natural and balanced under-eye contour.
Excessive fat removal may result in a hollow or sunken appearance, which can make the eyes look more tired. On the other hand, insufficient correction may leave the original eye bag contour visible.
Achieving an appropriate balance between reducing the bulge and preserving natural under-eye volume is therefore an important part of surgical planning.
Case image disclaimer:
This case is shared with the patient’s consent. The photographs are individual clinical records provided for educational purposes and treatment explanation only. Treatment plans, recovery, and outcomes vary according to each patient’s anatomy, skin condition, healing response, and other individual factors. An in-person medical assessment is required.
Lower Blepharoplasty Is More Than Simply Removing Fat
Lower blepharoplasty is sometimes described as a procedure that “removes excess under-eye fat.”
From a plastic surgeon’s perspective, however, removing more fat does not necessarily produce a better result. Surgical planning should include an assessment of:
The location and degree of fat protrusion
The transition between the eye bags and tear troughs
The amount of lower eyelid skin laxity
Lower eyelid tone and structural support
The relationship between the lower eyelid and midface
Whether other periorbital rejuvenation procedures should be considered
The goal is not to eliminate every trace of under-eye fat. It is to create a smoother transition between areas of protrusion and depression while preserving a natural appearance and the patient’s individual features.
Transconjunctival or External Lower Blepharoplasty?
Lower blepharoplasty is generally performed through either a transconjunctival or external approach. The appropriate technique should not be determined by age alone.
Transconjunctival Lower Blepharoplasty
The incision is made inside the lower eyelid, leaving no external skin incision. This approach is often considered for patients whose primary concern is protruding lower eyelid fat without significant skin laxity.
External Lower Blepharoplasty
The incision is generally placed close to the lower lash line. Depending on the patient’s condition, this approach may allow the surgeon to address protruding fat, excess skin, and certain lower eyelid support concerns at the same time.
It may be considered when more noticeable skin laxity is present or when a more comprehensive adjustment of the lower eyelid is required.
The most suitable approach depends on the degree of fat protrusion, skin elasticity, lower eyelid tone, previous treatments, and the patient’s individual needs. It cannot be determined solely by age or photographs.
How Can Patients Support a Smooth Recovery After Eye Bag Surgery?
A certain degree of swelling and bruising is expected after lower blepharoplasty. The extent and duration of these changes vary among individuals and may be influenced by the surgical approach, healing response, lifestyle, and postoperative care.
Patients should follow their surgeon’s specific postoperative instructions, which may include:
Applying cold compresses and following the recommended postoperative care plan
Keeping the head appropriately elevated while resting or sleeping
Avoiding rubbing the eyes, bending forward, straining, and strenuous exercise
Temporarily avoiding alcohol and highly irritating foods
Attending scheduled follow-up appointments
Avoiding unapproved massage, pressure, or unverified methods intended to reduce swelling
Contacting the medical team immediately if unusual pain, significant visual changes, or rapidly increasing swelling on one side occurs
The goal of postoperative care is not to force the swelling to disappear as quickly as possible. It is to allow the tissues to heal gradually in a safe and stable condition.
Dr. Chen’s Perspective: Identify the Problem Before Choosing the Treatment
I do not believe that every under-eye concern requires surgery. I also do not believe that every eye bag or tear trough can be treated with injectables alone.
For mild volume loss or early signs of periorbital aging, nonsurgical treatment may be sufficient after an appropriate medical assessment. However, when protruding fat, skin laxity, or a significant difference between the eye bag and tear trough is present, the underlying structure of the lower eyelid should be carefully evaluated.
Even an aesthetic physician who is highly familiar with injectable treatments may choose surgery when faced with structural under-eye bags.
The most important question is not which treatment is currently more popular. It is what is actually causing the concern—and which option is appropriate for the patient’s individual anatomy and expectations.
About the Author｜Dr. Hsin-Hung Chen
Dr. Hsin-Hung Chen is a board-certified plastic surgeon and former Director of the Aesthetic Medical Center at Chang Gung Memorial Hospital. He currently provides medical services at Jeunesse Clinic in Taipei, Jeunesse Clinic in Taichung, and Javaya Clinic in Taipei.
With extensive clinical experience in plastic and aesthetic surgery, Dr. Chen focuses on periorbital rejuvenation, facial contouring, minimally invasive injectable treatments, and energy-based procedures.
His approach considers the relationship between under-eye bags, tear troughs, skin laxity, and the overall facial contour. Through comprehensive assessment and thorough communication, he develops individualized treatment plans based on each patient’s anatomy, concerns, and personal needs.
Medical information notice:
This article is intended for general education regarding under-eye bags, lower blepharoplasty, and periorbital rejuvenation. Every patient has different anatomy, skin condition, treatment needs, and healing responses. All medical and surgical procedures involve potential risks. The appropriate treatment should only be determined after an in-person consultation, medical assessment, and discussion with a qualified physician.
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