Dr. Barbour's Answer: That depends on two issues: The first is about addressing what is causing the bags and the second has to do with your own idea of what is acceptable as a result. Sometimes a nice little improvement is improvement enough or can allow you to delay surgery.
The bags under the eyes are usually genetically determined, but other factors such as allergies, sun damage, repeated rubbing of the eyes or pulling at the lids to insert contact lenses can create or exacerbate the situation. Additionally, sometimes what people call “bags” are just some fine wrinkles under the eyes and not really bags at all. Let’s go over what contributes to the appearance of bags.
Loss of skin elasticity.
A protrusion of fat at the lower lids above the bone (the orbital rim)
Bulking up of the muscle at the lower lids (which sometimes can look like fat on casual observation).
“Festoons” which are right at or under the cheekbone.
A false protrusion of the lower lid that is actually a result of lack of volume under the lower lid.
Any combination of the above.
So you can see that your first step is to have the situation evaluated by a physician who is well trained and experienced in the anatomy around the eye. Then the two of you can decide how to proceed. If there is truly excess fat at the lower lids, the only precise way to address it is surgically, however even in these cases sometimes a non-surgical approach can help cosmetically.
Wrinkles at the lower lids can be tightened up with lasers or, to a lesser extent, radiofrequency (RF) devices. Both will also stimulate collagen formation at this very thin skin and make it more durable. Peels can help somewhat, but don’t expect them to perform miracles.
Sometimes it’s not so much that the bags are out as much as what’s around them is in, and this is where some carefully placed fillers can make an absolutely amazing difference. Again, if this route is the way to go make sure your doctor is an expert around the eyes. This is a challenging area for the most skilled physicians and should not be approached cavalierly or without a great deal of experience with the eyelid anatomy and with several types of fillers.
Occasionally, the appearance of a bag can actually be caused by the overuse of a muscle that encircles the lids. This can be helped surgically, however with some time and patience it often will improve with tiny amounts of a neuromodulator (BoTox, Dysport or Xeomin) over time. This is not for everyone with this condition and the lids must be thoroughly evaluated prior to its use there.