Blepharoplasty, upper and/or lower eyelid surgery, consistently ranks among the top cosmetic surgery procedures in the US: an indicator of the fact that, where visible aging is concerned, the eyes are a key source of angst. If you've noticed your upper eyelids looking heavier, eye bags developing under your eyes, or dark circles that won't budge, you're not alone, and the causes are more specific than you might think.

While Dara covered neck and shoulder tension and its potential effect on sags and bags on Substack, she also wanted to include a more skin- and eye-area-focused perspective to round out our deep dive into it all. She could think of no better point of view to get than that of Dr. Macrene Alexiades, the brilliant New York dermatologist.

Dr. Macrene Alexiades has long been an Ayla inspiration for many reasons, starting with her list of accomplishments. She has a BA, MD, and PhD in genetics from Harvard, where she was a Fulbright scholar; a bustling dermatology practice on Park Avenue and in the Hamptons; an associate clinical professorship at Yale School of Medicine; extensive publications; and a phenomenal line of skincare products called Macrene Actives. 

Here, she discusses why the upper eyelid tends to sag, why the lower eyelid tends to bag, and what can be done about it all, from topical skincare to dermatological treatments to surgery. 

Topics covered in this interview:

- Why the upper eyelid shows sagging and other signs of aging
- How to treat the upper lid with topical skincare
- How to treat this area with in-office treatments, from Botox to PRF to surgical treatments 
- Why the lower lid shows bags, discoloration, and different signs of aging
- How to treat the lower lid with topical skincare
- Options for in-office treatments to address concerns around the lower lid, from hyaluronic acid filler in the tear trough to carboxytherapy to surgical treatments

Why the upper eyelid sags: causes and contributing factors

Dara Kennedy: Why does the upper eyelid area tend to get droopy?

DR. MACRENE ALEXIADES:
The upper eyelid is one of the most anatomically complex and mechanically stressed regions of the face. A few converging forces drive drooping here:
Genetics and structure. The upper lid is governed by the levator palpebrae muscle and its aponeurosis — a fibrous sheet that attaches to the tarsal plate and lifts the lid. Some people are born with a weaker levator or a lower-set attachment, which predisposes them to hooding even in their twenties and thirties. This is the "clown eye" or heavy-lid look that many patients describe — and it is largely structural and hereditary.
Skin laxity and collagen loss. The eyelid skin is the thinnest on the body — roughly 0.5mm — and has virtually no subcutaneous fat beneath it. It therefore loses collagen and elastin faster than any other facial zone. From our mid-thirties onward, collagen synthesis declines and existing fibers cross-link and fragment, causing the skin to thin, crinkle, and drape over the orbital rim.
Brow ptosis and volume descent. Critically — and this is something I emphasize to every patient — what looks like an upper lid problem is often a brow problem. The brow descends with age due to loss of the deep fat compartments that hold it aloft, weakening of the frontalis muscle, and skin laxity. As the brow drops, it pushes tissue onto the lid, creating the appearance of hooding even when the lid itself hasn't changed. This is why a surgical upper bleph without addressing brow position can sometimes worsen the periorbital appearance — you remove skin but the root cause remains.

Dara: Why is this trending in younger patients? 

DR. MACRENE: There are a few factors. Social media and the front-facing camera create an exaggerated awareness of asymmetry and lid heaviness. Filters have essentially trained an entire generation to prefer a more open, awake-looking eye. In addition, surgeons have become more aggressive in their marketing. The clinical indication used to be functional — lids so ptotic they impair the visual field, which genuinely warrants intervention. Now we are seeing purely cosmetic indications in patients in their late twenties and thirties. I would caution anyone in that age bracket to be thoughtful: the upper bleph removes skin permanently, and if performed too early or too aggressively, it can result in lagophthalmos — the inability to fully close the eye — which is a serious, sight-threatening complication I am seeing with increasing frequency in younger patients who underwent blepharoplasty.

Skincare for the Upper Eyelid: What Works and What Doesn’t

Dara: Can you give us a general overview of skincare options for the upper eyelid?

DR. MACRENE: I want to be direct about what skincare can and cannot do in this zone. It cannot lift a drooping levator muscle, restore lost brow volume, or reverse significant structural hooding. What it can do — meaningfully — is address the skin quality component, slow the progression of laxity, and optimize the appearance of the area in a way that for many patients in their thirties and forties is genuinely sufficient as a standalone approach, and essential as a foundation for anyone who has had or is planning a procedural intervention.

The priorities for the upper lid skin are:

Collagen and elastin stimulation. This requires ingredients that penetrate and signal dermal activity; retinoids, peptides, and growth factors are the evidence-based options. My MACRENE Actives High Performance Eye Cream was formulated specifically for the periorbital zone, with a peptide and growth factor complex that stimulates collagen synthesis without the irritation that makes most active ingredients intolerable on this thin skin. The upper lid skin cannot tolerate the same concentrations used on the cheek or forehead, which is why formulation matters enormously here.
Antioxidant protection. UV and oxidative stress are the primary accelerants of collagen degradation around the eye. A stable, bioavailable vitamin C complex applied in the morning is protective.
Hydration and barrier integrity. Thin skin dehydrates rapidly, and dehydration accentuates crepiness and the visual weight of hooding. Hyaluronic acid, ceramides, and squalane in the eye formulation help maintain the skin's water content and plumpness.
What skincare cannot do: it cannot address brow ptosis, levator laxity, or significant fat herniation. For those anatomical issues, you need procedural intervention.

Dara: What do you suggest as a skincare routine to help with upper eyelid drooping and other signs of aging around the eyes?

DR. MACRENE:
The upper lid skin is the thinnest on the body — roughly 0.5mm — which means it loses collagen and elastin faster than any other facial zone, dehydrates rapidly, and cannot tolerate the concentration of actives used elsewhere on the face. I cover the full anatomical and procedural complexity of this zone in detail in the Periorbital Chapter of my textbook, Alexiades's Cosmetic Dermatologic Surgery, which I would direct anyone seeking a deeper clinical grounding to consult. Formulation is therefore not a cosmetic detail but a clinical necessity — and this is the foundational principle behind both the MACRENE Actives High Performance Eye Cream and the High Performance Eye Mask, where every active is calibrated for the specific biology and tolerance threshold of periorbital skin.

• Daily protocol: High Performance Eye Cream. The cornerstone of the upper lid regimen is consistent daily delivery of collagen-stimulating, firming, and protective actives. The Eye Cream's anti-wrinkle and firming complex — peptides, hyaluronic acids, proline, and organic plant sterols — works to reduce the appearance of fine lines, target elasticity, and progressively support the structural integrity of the thinning upper lid dermis. Skin barrier actives, including olive and coconut derivatives, Helianthus annuus, and squalane, fortify the eyelid's barrier function, which is chronically compromised in this zone by its thinness and constant mechanical movement. Hydrators — jojoba, sodium lactate, Oryza sativa, and glycerin — maintain even moisture levels, critical for the upper lid where dehydration accentuates crepiness and the visual weight of hooding. The brightening complex of arginine, aspartic acid, alanine, and gluconolactone addresses the uneven pigmentation and dullness that develops on the upper lid skin over time, evening and illuminating the overall tone of the periorbital zone.
  
• Intensive treatment: High Performance Eye Mask. Used two to three times per week, the High Performance Eye Mask functions as a concentrated amplifier of the daily regimen. Developed from my 25 years of dermatologic and genetics research, it delivers the patented MA37™ formulation via plant-based biocellulose patches specifically designed to rapidly infuse actives into the skin — the occlusive nature of the biocellulose dramatically increases penetration and efficacy in skin that is otherwise too thin to hold actives at the surface long enough for full biological effect. For the upper lid, the mask's peptide complex drives collagen and elastin synthesis to firm and smooth the delicate periorbital skin, while plant-derived antioxidants and polyphenols neutralize the UV and environmental oxidative damage that are the primary accelerants of collagen degradation in this zone. The DNA repair actives address oxidative damage at the cellular level — supporting long-term skin integrity in a way that goes beyond surface treatment. Hyaluronic acids deliver multi-depth hydration that plumps fine lines and restores moisture to skin that dehydrates faster than anywhere else on the face. I recommend the mask to patients preparing for an event, or in the days following an in-office procedure — whether radiofrequency, plasma fibroblast, or PRF — where its active payload supports and extends the regenerative response the procedure has initiated.

In-Office Treatments for Upper Eyelid Sagging: A Dermatologist’s Guide

Dara: There’s no one I’d trust more to outline the possibilities available for in-office treatment of the upper eyelid. What are the best options out there? 

DR. MACRENE:

Neuromodulators (Botox/Dysport). A brow lift with neuromodulator — specifically, relaxing the depressor muscles (orbicularis, corrugator, procerus) while preserving frontalis activity — can produce a 2–4mm brow elevation that meaningfully opens the upper lid. This is my first-line recommendation for patients in their thirties and early forties with brow ptosis contributing to hooding. Results last three to four months. It requires precise injection by an experienced injector; placed incorrectly, it can worsen lid heaviness.
Radiofrequency and ultrasound (Thermage, Ultherapy/Sofwave). These energy-based devices deliver heat to the deep dermis and SMAS layer, stimulating neocollagenesis and causing immediate tissue tightening. For the brow and upper lid, Thermage FLX with the eye tip and Sofwave are my preferred modalities. They are not surgical in their magnitude, but for a patient with mild to moderate laxity who is not ready for surgery, they provide a real and measurable improvement over a series of treatments.
Platelet-Rich Fibrin (PRF). One of the most exciting additions to my in-office protocol is PRF — platelet-rich fibrin — which I have been using extensively in the periorbital zone and for which I have developed one of the largest published case series to date, with a manuscript currently in preparation. PRF is derived from the patient's own blood: a simple blood draw is centrifuged to concentrate the platelets and fibrin, which are then injected into the periorbital tissue. Unlike PRP (platelet-rich plasma), which has been used in aesthetics for years, PRF releases growth factors — including PDGF, TGF-β, VEGF, and IGF — in a slower, more sustained manner due to its fibrin matrix, producing a more prolonged biological stimulus. Around the eyes specifically, PRF addresses multiple concerns simultaneously: it stimulates collagen and elastin synthesis to thicken and firm the thin lower lid skin, improves vascularity and microcirculation to reduce the vascular component of dark circles, and provides subtle biostimulatory volume that softens the tear trough without the risk of the Tyndall effect seen with some hyaluronic acid fillers. The published literature supports its efficacy for periorbital rejuvenation, and in my own growing case series, I have observed consistent improvements in skin quality, pigmentation, and contour that are both clinically meaningful and durable — with the added advantage of using the patient's own biological material, making adverse reactions exceptionally rare.
Plasma fibroblast (Plexr/NeoGen). This is a non-surgical option that creates controlled micro-trauma to the skin surface, stimulating fibroblast activity and causing skin contraction. It can reduce mild to moderate upper lid skin excess. The downside is significant downtime — crusting for 7–10 days — and in darker skin tones, a real risk of post-inflammatory hyperpigmentation.

As far as surgical options are concerned:

Upper blepharoplasty. When the anatomy genuinely warrants it — significant functional impairment or skin excess that no non-surgical approach will address — surgery remains the gold standard. I simply advocate for appropriate patient selection and conservative tissue removal.
Suture Brow Lift. For patients with brow ptosis as the primary driver of upper lid hooding — which, as I noted earlier, is far more common than patients realize — the suture brow lift offers a minimally invasive surgical solution that bridges the gap between neuromodulator treatments and a full surgical brow lift, as documented in the Skin Laxity Chapter of Alexiades’s Cosmetic Dermatologic Surgery. The procedure involves the placement of permanent or long-lasting sutures through small puncture incisions, repositioning and suspending the brow at a higher, more youthful position without the extended downtime, scarring, or recovery associated with traditional open brow lift surgery. It is particularly well suited to patients in their forties and fifties who have significant brow descent contributing to upper lid heaviness but who are not ready for or do not want a full surgical approach. The results are immediate, the recovery is measured in days rather than weeks, and when combined with neuromodulator treatment to maintain the depressor muscles in a relaxed state, the longevity of the lift is meaningfully extended. For the right patient — one whose upper lid heaviness is driven primarily by brow position rather than true skin excess — the suture brow lift can be a more anatomically precise and less invasive solution than an upper blepharoplasty, which removes skin but does not address the brow descent that may be the root cause of the problem.

What causes eye bags, puffiness, and dark circles under the eyes

Dara: What causes signs of aging like sagging and bags underneath the eyes?

DR. MACRENE: 

The lower eyelid is a different anatomical problem from the upper. As detailed in Alexiades’s Cosmetic Dermatologic Surgery, the primary drivers are:

Orbital fat herniation. The eye sits in the orbit cushioned by fat pads. The orbital septum — a fibrous membrane — holds this fat in place. With age (and sometimes from birth, in genetically predisposed patients), the septum weakens and the fat prolapses forward, creating the classic "bag" — a convex bulge in the lower lid. This is not a fluid problem, it is a structural fat problem, and no topical ingredient will eliminate a true fat bag. I want patients to understand this clearly, because there is enormous misinformation about "de-puffing" eye creams dissolving orbital fat herniation. They cannot.
Volume loss in the cheek and tear trough. The tear trough — the groove between the lower lid and the cheek — deepens as the malar fat pad descends and cheek volume is lost. This creates a hollow or shadow that reads as "under-eye darkness" and accentuates the transition between any residual fat pad above and the deflated cheek below. The V-shaped deformity that results is one of the most aging features of the mid-face.
Skin laxity and festoons. The lower lid skin, like the upper, thins and loses elasticity. In some patients, the orbicularis muscle itself weakens and redundant skin and muscle form "festoons" — malar mounds that drape across the cheekbone. These are notoriously difficult to treat, even surgically.
Lymphatic congestion and fluid. True morning puffiness — the kind that resolves within an hour of waking — is largely lymphatic and vascular in origin. Fluid accumulates in the loose areolar tissue of the lower lid during recumbency. This is transient and genuinely responsive to topical actives, lifestyle factors (sleep position, sodium intake, alcohol), and lymphatic drainage techniques.
Pigmentation. The darkness of the under-eye is frequently multifactorial: shadowing from volume loss, post-inflammatory hyperpigmentation (especially in skin of color), and vascular show-through — visible blood vessels beneath the very thin lower lid skin. These require different approaches from structural bags.

Skincare for the lower eyelid: what’s most effective

Dara: Can you give us a general overview of the best skincare options for the lower eyelid?

DR. MACRENE:
For the under-eye, skincare is most powerful for the vascular, pigmentary, and skin-quality components — and genuinely effective for those. For structural fat herniation, it manages the overall appearance without addressing the root anatomy.
Key actives for the lower lid:
•    Peptides and growth factors for collagen stimulation and skin thickening — thickening the skin over time reduces the vascular show-through that contributes to dark circles and makes the fat herniation less visible. This is a real, if modest, benefit. My High Performance Eye Cream contains palmitoyl tripeptide-5, EGF, and a proprietary growth factor blend targeted at this mechanism.
•    Caffeine and flavonoids for vasoconstriction and lymphatic decongestion — these genuinely address transient morning puffiness by constricting the microvasculature and supporting lymphatic clearance. The effect is real but temporary, lasting a few hours.
•    Vitamin K and tranexamic acid for the vascular pigmentation component — there is reasonable evidence for vitamin K's role in reducing periorbital vascular leakage that contributes to dark circles, and tranexamic acid addresses the melanin component of pigmentation.
•    Retinoids (low concentration) — carefully formulated retinol or retinaldehyde in the lower lid zone can stimulate collagen and mildly thicken the dermis over time. Concentration must be calibrated; irritation in this area causes rubbing, which worsens laxity.
•    Physical approaches — sleeping on your back with the head slightly elevated meaningfully reduces fluid accumulation. Cold compresses and gentle lymphatic massage (inward to outward, downward from the lid) in the morning can accelerate clearance of overnight edema.

Dara: What do you suggest as a skincare routine to help with signs of aging around the lower lid, like bags, discoloration, and puffiness?

DR. MACRENE ALEXIADES: For the lower lid, skincare is most powerful for the vascular, pigmentary, fluid, and skin-quality components of under-eye aging — and it is genuinely effective for all of those. For structural orbital fat herniation, it manages the overall appearance without addressing the underlying anatomy. As I detail in the Periorbital Chapter of Alexiades's Cosmetic Dermatologic Surgery, understanding which anatomical layer and which biological mechanism is the primary driver is what separates a targeted, effective treatment plan from a scattershot one — and this principle applies equally to the selection and use of topical actives as it does to procedural choices.
The MACRENE actives High Performance Eye Cream and High Performance Eye Mask form the clinical backbone of the topical protocol here, with each category of active directly matched to the specific and layered biology of the lower lid.

Daily protocol — High Performance Eye Cream. The anti-wrinkle and firming complex — peptides, hyaluronic acids, proline, and organic plant sterols — progressively thickens and firms the lower lid dermis over time, which matters structurally: a thicker, more elastic skin over the lower lid reduces the vascular show-through that contributes significantly to dark circles and makes any underlying fat herniation visually less prominent. The de-puffing complex of organic Coffea robusta, natural caffeines, and organic yerba mate tea directly targets the lymphatic drainage and vasoconstriction mechanisms that drive under-eye swelling — producing a real and visible decongesting effect that is meaningful for daily appearance. The anti-redness actives — organic Theobroma cacao, Rosmarinus officinalis, and bisabolol — reduce the blue and red vascular discoloration that underlies so much of what patients identify as under-eye darkness. The brightening complex of arginine, aspartic acid, alanine, and gluconolactone addresses the pigmentary component — lightening brown blotches and evening the overall tone of the lower lid, which is particularly relevant in skin of color where post-inflammatory hyperpigmentation compounds the dark circle picture. Barrier actives and hydrators — squalane, olive and coconut derivatives, jojoba, glycerin, and Oryza sativa — complete the formulation by maintaining the skin's moisture barrier, without which no active ingredient can function optimally in this perpetually stressed tissue.

Intensive treatment — High Performance Eye Mask. The lower lid is where the Eye Mask's occlusive biocellulose delivery format is perhaps most clinically impactful. The loose areolar tissue of the lower lid accumulates fluid overnight, leaving the skin in a state of low-grade chronic congestion that compromises both appearance and the tissue's ability to absorb and utilize actives effectively. The mask's sustained-contact environment allows the full MA37™ formulation — peptides, hyaluronic acids, DNA repair actives, plant-derived antioxidants and polyphenols, brighteners, dark circle reducers, plant-derived caffeine, and microbiome rebalancers — to penetrate deeply and work simultaneously across every mechanism that topical treatment can reach. The plant-derived caffeine component is particularly impactful in the morning application, driving lymphatic clearance and vasoconstriction in tissue that is at its most congested after a night of recumbency. The microbiome rebalancing actives address the chronic low-grade inflammation of the periorbital zone — an underappreciated driver of both puffiness and pigmentation — by restoring the microbial equilibrium that supports barrier function and quiets inflammatory signaling. Used two to three times per week alongside the daily Eye Cream, and particularly as a post-procedure complement following PRF injections, RF microneedling, or carboxytherapy, the Eye Mask represents the most complete and intensive topical approach available to a patient managing the full complexity of lower lid aging.

Physical adjuncts. No skincare section for the lower lid is complete without noting that sleeping on your back with the head slightly elevated meaningfully reduces overnight fluid accumulation. Cold compresses and gentle lymphatic massage — moving inward to outward, then downward away from the lid margin — in the morning accelerate clearance and prime the tissue to receive topical actives more effectively. These are not substitutes for a well-formulated product regimen, but they are genuinely additive to it.

In-office Treatments for Eye Bags, Dark Circles, and Tear Trough Hollowing: a Dermatologist’s Guide

DARA: There’s also no one I’d trust more to outline the possibilities available for in-office treatment of the lower eyelid. Can you guide us through the options?

DR. MACRENE:
Hyaluronic acid filler in the tear trough. For volume loss and tear trough hollowing — not for fat herniation — a small amount of a soft, hydrophilic HA filler placed deep to the orbicularis in the tear trough can restore the smooth contour from lid to cheek and eliminate the shadow that reads as darkness. This is one of the most transformative minimally invasive procedures I perform. It requires an injector deeply familiar with the vascular anatomy of this zone — the angular artery runs through this territory — and absolutely must be performed conservatively. Overfilled tear troughs look worse than unfilled ones.
Radiofrequency microneedling (Morpheus8, Matrix Pro). RF microneedling delivers heat to the deep dermis and subdermis, stimulating collagen and causing skin tightening in the lower lid. Matrix Pro has specific protocols for the under-eye zone that target the vascular component of dark circles as well. For festoons and lower lid laxity without significant fat herniation, this is my preferred energy-based approach.
Carboxytherapy. Injection of CO₂ gas into the periorbital tissue stimulates circulation and collagen production and has reasonable evidence for reducing dark circles, particularly the vascular subtype. It is underutilized in the United States relative to Europe and South America.
Chemical peels and laser resurfacing. For the pigmentary component of dark circles and for surface skin texture, fractional resurfacing (Fraxel, CO₂) and medium-depth peels address the dermal pigmentation and induce neocollagenesis. These require careful skin-type assessment.
Lower blepharoplasty. When orbital fat herniation is the primary driver, transconjunctival blepharoplasty — fat repositioning or removal through an incision inside the lid, leaving no external scar — is the definitive treatment. Fat repositioning into the tear trough, rather than pure excision, gives the most natural result. I would caution against aggressive fat removal, which can leave patients with a skeletonized, hollowed appearance that is difficult to correct.

Dara: We frequently receive customer questions and photos like this one: “As I move through my 40s, my ‘clown eyes’ feel like the elephant in the room.” For those reading this who might be feeling similarly and wondering where to begin, what do you suggest?

DR. MACRENE: I would want to know more about what specifically troubles her. If it is brow heaviness and the sensation of visual weight on the lids, a brow lift protocol with neuromodulator plus an energy-based treatment is a reasonable, non-surgical starting point. If it is the tear trough shadow beneath, filler may be the more targeted answer. The goal is always to understand which anatomical layer is the primary driver — and meet it there. Surgery is not the only answer, and for many patients in their forties, it is not yet the right one.

Dara: As always, enormous thanks for being so generous with your time and advice. This will help so many people!

References:
Alexiades M. Cosmetic Dermatologic Surgery. Wolters Kluwer, 2020.
Alexiades, M, Friedman, D, and Schallen, KP. Bipolar Fractional Radiofrequency Microneedling Treatment Using Multiple Depths in One Insertion: A Novel Approach to the Treatment of Wrinkles, Lasers in Surgery and Medicine, 2025.

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We love Dr. Macrene's ability to advise her clients on both dermatological treatments and topical skincare. For more from Dr. Macrene Alexiades on dermatological procedures and daily skincare, check out this interview.