They’re the main focal point when others look at our face. They’re also where we start to observe the first signs of aging. Because we can’t hide aging eyes behind our Tom Fords forever, it’s a good thing we have a bevy options to brighten, tighten and rejuvenate.

Nonsurgical Options

Line Smoothers
Neurotoxins can temporarily soften and prevent future lines from forming around the eyes. “Botox injections every three to four months can help crow’s-feet, open the eye area and shape the brows,” says Fresno, CA dermatologist Kathleen Behr, MD. “Each patient is unique and placement is key to achieving good results.”

According to West Palm Beach, FL dermatologist Kenneth R. Beer, MD, a little neurotoxin can deliver an instant nonsurgical browlift. “We use a little bit of botulinum toxin to reposition the brows, and a lot of times it also helps with eyelid drooping. Other times we have to refer people for surgery, but between the lasers, neurotoxins and fillers, we have so much to offer people who aren’t ready to go under the knife.”

Skin Plumpers
For hollowness around the eyes, filler can help restore some youthful volume to the area. “When patients come in with hollowness, there are special injection techniques that can be used with a micro-syringe full of filler, and that works pretty nicely,” says Dr. Beer. “For eyelid hooding, sometimes we can get some benefit from fillers placed high to push up the brow.” Results should be retouched at anywhere from six to 12 months, depending on the filler used.

“Fillers can be used off-label in the tear trough, but must be placed by an advanced skill injector,” adds La Jolla, CA plastic surgeon Robert Singer, MD. “What appear to be under-eye bags can also be the result of bad filler placement. Some people end up having to undergo surgery because of inadequate improvement from nonsurgical procedures.”

Energy-Based Treatments
Lasers and other skin-perfecting treatments can also help with volume loss, discoloration and skin texture. “Lasers do two things,” says Dr. Beer. “They will help create new collagen and tighten existing collagen. They also resurface new skin growing in.”

“Microneedling is a great option for those who want to help stimulate collagen production in their skin,” explains Boston facial plastic surgeon Jaimie DeRosa, MD. Many doctors combine radio frequency with microneedling. “In tissue studies, Profound RF around the periorbital region has been shown to increase elastin within the skin, as well as hyaluronic acid and collagen.” Dr. Behr says other energy devices often used for under-eye tightening are Ultherapy, which employs ultrasound energy, and ThermiSmooth, which gently heats deep layers of skin using radio-frequency energy.

According to Chatham, NJ oculoplastic surgeon Baljeet Purewal, MD, there are claims that dark circles caused by pigmentation in the skin can be improved with chemical peels or microneedling with platelet-rich fibrin. “These treatments are often combined with a skin-care regimen that includes a brightening topical cream,” she says. Dr. Singer notes that the benefits of nonsurgical eyelid treatments all have significant limitations and that while dark circles can typically be improved, they cannot usually be eliminated.

Concerned about lines around her eyes and what she called a “sunken- in look,” this 43-year-old patient opted for an injectable treatment. Dr. Beer injected the neurotoxin Jeuveau to treat lines around the eyes, and the hyaluronic acid filler Belotero Balance in the tear troughs, off-label, using micro-injections.

Surgical Options

Blepharoplasty
Upper
An upper blepharoplasty can reposition fat and muscle and reduce excess skin to correct the drooping and puffiness, making eyes look more open and alert. It can be done in the office and takes about one hour, with results lasting 10 to 15 years.

Lower
The best surgical solution for persistent under-eye bags is a lower blepharoplasty. Typically, a small amount of fat and muscle is removed, and slack skin is tightened up. “The partial removal or repositioning of lower eyelid fat bags is performed either through the inside of the lower eyelid—the transconjunctival approach—or directly,” says Eugene, OR plastic surgeon Mark Jewell, MD. Lake Oswego, OR facial plastic surgeon Mark A. Petroff, MD adds, “A lower blepharoplasty will eliminate the shadowy look by getting rid of the fat bulge under the eye.”

Festoons
Festoons, aka malar bags, are genetic conditions that present as puffy bags below the lower eyelids and above the cheeks, and can look similar to dark circles. This results in an older-looking appearance, which New York plastic surgeon Mokhtar Asaadi, MD says occurs due to a loss of underlying muscle tone. “Everyone thinks festoons are caused by fluid collection, but in 80 percent of patients with malar bags, it’s also because of the lower lid muscle laxity. You must also address the orbicularis muscle.”

To treat the bags, he first evaluates the cause: “If excess fat is a contributing factor, then the fat deposits underneath the skin must be surgically removed. If the cause is lax muscles, then the ligaments of the surrounding eye muscles must be released and the eye muscles need to be tightened to reduce puffiness.”

Combination Procedures
No two eye concerns are the same, and many patients may need both upper and lower eyelid surgery to get a bright-eyed result. “The ultimate goal is to create a more youthful-looking eye that has a natural crease that fits their anatomy. And everyone’s anatomy is different. There’s not one eye procedure that fits all,” Dr. Petroff says.

This 68-year-old patient was concerned about upper eyelid drooping and under-eye fullness. Denver facial plastic surgeon Brent J. Smith, MD treated her with an upper and lower blepharoplasty.

Wanting to refresh “tired-looking” eyes, this 50-year-old patient sought Dr. Asaadi for a combination surgery. Dr. Asaadi performed a bilateral upper and lower blepharoplasty with festoon correction.