I have very puffy bags under my eyes and very noticeable crow's-feet. I will be 45 in...
Plastic surgeons' thinking regarding the best treatment of lower eyelid bags has, in many instances, changed. We now understand that eyelid fat disappears with age, and this may cause the eyes to have a "hollowed out" appearance. Also the cheek pads tend to fall to a lower position. Many surgeons are now performing lifts below the eyes (cheek lift or midfacial procedures), and fat-sparing lower eyelid surgery (instead of removing fat, the fat bulges are used to fill in hollow areas below the eye). The crow's-feet are still a problem. Some of these procedures help the crow's-feet area slightly. Many patients still find that they need Botox if they want the wrinkles greatly reduced in the crow's-feet area.
A very common aging change in the lower eyelids is the development of 'bags', which are in most cases due to an outward bulging of the fat pads behind the lower lids. These 'bags' of fat can be improved by conservative removal through an invisible incision on the inside of the lower lid (trans-conjunctival approach) in patients that do not require skin excision, or through the under-eyelash (sub-ciliary approach) in patients that are having some excess lower lid skin removed.
As with skin removal, I believe that the reduction (NOT total removal) of lower lid fat pads should be conservative. Excessive removal of lower lid fat pads results in a hollowed-out appearance that makes blepharoplasty patients look tired or even ill. I see quite a number of eyelid surgery patients who require structural fat grafting of the lower lids to improve that very problem following an over-aggressive lower blepharoplasty in the past.
In some case lower lid 'bags' can be improved by repairing or reinforcing the soft tissues that normally hold them back. Additionally, excessive lower lid fat can sometimes be mobilized and transposed inferiorly to fill in periorbital hollows or depressions such as the 'tear trough' at the medial junction of the lower lid and cheek.