Surgery To Remove Bags Under Eyes: Lower blepharoplasty, commonly known as eyelid surgery, is a cosmetic procedure designed to remove bags under the eyes and rejuvenate the eye area. This article covers everything from the procedure details, recovery, and cost to the latest advancements in under-eye bag removal. Whether you’re considering surgery or exploring non-surgical options, this article provides the essential information you need.
In this article, you will learn:
• What causes under-eye bags and how lower blepharoplasty corrects them
• The step-by-step process of the surgery and what to expect during recovery
• How to estimate the cost of your procedure with our free calculator
• The risks and benefits of lower blepharoplasty
• Non-surgical alternatives and how to choose the right option for you
• How to prepare for surgery and select a qualified surgeon
• Post-operative care and long-term results
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Table Of Contents
What Exactly is Surgery To Remove Bags Under Eyes Surgery?
Lower blepharoplasty is a surgical procedure that removes or repositions fat and tightens skin and muscle in the lower eyelid area. This cosmetic surgery addresses under-eye bags, puffiness, and dark circles that create a tired, aged appearance. The procedure can be performed through different approaches, including transconjunctival blepharoplasty (inside the eyelid) or transcutaneous blepharoplasty (external incision).
The primary goal of lower eyelid surgery is to restore a more youthful, refreshed appearance by eliminating the baggy appearance under the eyes. This oculoplastic surgery requires precise technique to avoid complications while achieving natural-looking results. Modern blepharoplasty techniques focus on tissue preservation and redistribution rather than aggressive removal.
Key facts about lower blepharoplasty:
• Typically takes 1-2 hours to complete
• Can be performed under local or general anesthesia
• Addresses both functional and cosmetic concerns
• One of the most common facial plastic surgery procedures
• Can be combined with other facial rejuvenation procedures
What Causes Under Eye Bags and Puffiness?
Under eye bags develop due to multiple anatomical and environmental factors. The primary cause is herniation of orbital fat pads through the thin membrane that normally contains them. As we age, the septum orbitale weakens, allowing fat to protrude forward and create the characteristic puffiness under eyes.
Several factors contribute to under eye bags:
Genetic predisposition plays a significant role in under eye bags development. If your parents had prominent under eye bags, you're more likely to develop them due to inherited facial anatomy characteristics.
Aging process causes natural volume loss and skin laxity. The skin becomes thinner and less elastic while facial bones resorb, creating hollows that accentuate under eye bags.
Lifestyle factors including sleep deprivation, chronic allergies, smoking, and excessive alcohol consumption can worsen under eye appearance. These factors lead to fluid retention and poor circulation.
Sun exposure breaks down collagen and elastin fibers in the skin, accelerating the aging process around the delicate eye area.
Anatomical factors like prominent orbital fat pads, weak orbital septum, and tear trough deformities contribute significantly to under eye bag formation.
How Does Lower Blepharoplasty Work to Remove Eye Bags?
Lower blepharoplasty addresses under eye bags through precise surgical techniques that target the underlying anatomical issues. The procedure works by either removing or repositioning protruding fat, tightening lax muscles, and removing excess skin.
The surgical process typically involves:
Anesthesia administration ensures patient comfort throughout the procedure. Options include local anesthesia with sedation or general anesthesia depending on patient preference and surgeon recommendation.
Surgical approach selection determines whether the surgeon will use a transconjunctival incision (inside the lower lid) or transcutaneous incision (just below the lash line). The approach depends on the specific concerns being addressed.
Fat management is the core of the procedure. The surgeon may remove excess orbital fat, reposition it to fill hollow areas, or use a combination of techniques to create a smooth transition from lower lid to cheek.
Muscle and skin tightening addresses laxity in the orbicularis oculi muscle and removes redundant skin that contributes to a tired appearance.
Incision closure with fine sutures minimizes visible scarring. Transconjunctival approaches typically don't require external sutures.
The procedure fundamentally restores youthful anatomy by reinforcing weakened structures and recontouring the under eye area for a refreshed, natural appearance.
What Are the Different Types of Lower Blepharoplasty Techniques?
Several surgical techniques exist for lower blepharoplasty, each with specific indications and benefits. The appropriate technique depends on individual anatomy, concerns, and desired outcomes.
Transconjunctival blepharoplasty involves an incision made inside the lower eyelid, leaving no visible external scar. This approach is ideal for patients who primarily need fat removal or repositioning without significant skin excess. The recovery is typically faster with less swelling and bruising.
Transcutaneous blepharoplasty uses an external incision just below the lash line. This technique allows direct access to address skin laxity, muscle weakness, and fat pads simultaneously. It's preferred for patients with significant skin excess.
Fat repositioning lower blepharoplasty focuses on conserving and repositioning orbital fat rather than removing it. The fat is redistributed into the tear trough area to smooth the transition between lower lid and cheek. This technique addresses hollowing while reducing puffiness.
Arcus marginalis release is an advanced technique that involves releasing the attachment between the orbital bone and soft tissue, allowing better fat redistribution and smoothing of the lid-cheek junction.
Pinch blepharoplasty is a minimal technique that removes only a small amount of excess skin without disturbing the underlying fat. It's suitable for patients with mild skin laxity.
Who is the Ideal Candidate for Lower Eyelid Surgery?
The ideal candidate for lower blepharoplasty is typically between 35-65 years old with specific concerns about under eye appearance. Good candidates have realistic expectations and understand both the benefits and limitations of the procedure.
Characteristics of ideal candidates include:
Good physical health without significant medical conditions that could impair healing. Conditions like uncontrolled hypertension, bleeding disorders, or thyroid eye disease may increase surgical risks.
Specific under eye concerns such as puffiness, bags, or dark circles that are primarily due to fat herniation rather than temporary swelling or allergies.
Non-smokers or willingness to quit smoking before and after surgery, as smoking significantly impairs healing and increases complication risks.
Realistic expectations about what the procedure can achieve. Lower blepharoplasty improves but doesn't completely eliminate under eye concerns.
Stable weight as significant fluctuations can affect results.
Adequate skin elasticity ensures better contouring outcomes, though techniques exist for patients with poor elasticity.
People with certain eye conditions like dry eye syndrome require special consideration and may need modified techniques to avoid exacerbating their condition.
What is the Typical Cost Range for Lower Blepharoplasty?
The cost of lower blepharoplasty varies significantly based on multiple factors. On average, the procedure costs between $3,000-$8,000 in the United States. The final price depends on surgical fees, anesthesia, facility costs, and geographic location.
Cost breakdown for lower blepharoplasty:
Surgeon's fee typically ranges from $2,500-$5,000 based on experience and reputation. Board-certified plastic surgeons and oculoplastic specialists often charge higher fees.
Anesthesia fees range from $500-$1,500 depending on whether local with sedation or general anesthesia is used.
Facility fees for surgical center or hospital use add $800-$2,000 to the total cost.
Geographic variation significantly impacts pricing. Procedures in major metropolitan areas like New York or Los Angeles typically cost 20-30% more than in smaller cities.
Combined procedures like pairing lower blepharoplasty with upper blepharoplasty or facelift increase costs but may provide better overall value.
Additional costs may include medical tests, prescriptions, and post-surgery garments. Most cosmetic surgery is not covered by insurance unless it addresses functional impairments like vision obstruction.
How Does Our Lower Blepharoplasty Cost Calculator Work?
Our lower blepharoplasty cost calculator provides personalized estimates based on multiple clinical and demographic factors. The algorithm considers your specific anatomical concerns, geographic location, and surgeon experience level to generate accurate cost ranges.
The calculator processes several key inputs:
Demographic information including age and gender helps tailor recommendations since surgical approaches may vary by these factors.
Medical history assessment identifies conditions that might affect surgical risk or technique selection, potentially influencing costs.
Clinical factors like under eye bag severity, skin type, and previous treatments help determine surgical complexity.
Geographic location adjusts cost estimates based on regional pricing variations for cosmetic procedures.
Surgeon experience level accounts for fee differences between newly trained surgeons and established experts.
The calculator algorithm weights these factors based on their impact on final costs, with surgical complexity and geographic location having the strongest influence. The result is a personalized cost range that reflects your specific circumstances rather than generic averages.
What Factors Influence the Final Cost of Lower Blepharoplasty?
Multiple elements contribute to the final cost of lower blepharoplasty, explaining the wide price variation among patients. Understanding these factors helps patients make informed decisions about their procedure.
Primary cost factors include:
Procedure complexity significantly impacts cost. Simple fat removal costs less than complex fat repositioning with extensive skin tightening.
Surgeon expertise and reputation commands higher fees. Board-certified plastic surgeons with specialized experience in blepharoplasty typically charge more but may deliver superior results.
Geographic practice location causes substantial price variation. Surgeons in metropolitan areas with higher overhead costs typically charge 20-40% more than those in smaller cities.
Surgical facility type affects costs. Hospital-based procedures are generally more expensive than those performed in accredited office-based surgical suites.
Anesthesia type influences pricing. General anesthesia costs more than local anesthesia with sedation.
Combined procedures increase total costs but may offer savings compared to separate surgeries.
Revision surgery typically costs more than primary blepharoplasty due to increased complexity.
Pre-operative testing, post-operative care, and prescription medications represent additional costs that patients should factor into their budget.
What Does the Lower Blepharoplasty Procedure Process Involve?
The lower blepharoplasty procedure follows a structured process from initial consultation through full recovery. Understanding each step helps patients prepare mentally and physically for the experience.
Initial consultation involves comprehensive assessment of under eye concerns, medical history review, discussion of expectations, and development of a surgical plan. The surgeon evaluates skin quality, fat distribution, muscle tone, and asymmetry.
Pre-operative preparation includes medical clearance if needed, cessation of certain medications and supplements that increase bleeding risk, and arranging for post-operative assistance.
Surgical day process begins with anesthesia administration. The procedure itself takes 1-3 hours depending on technique complexity. Patients spend time in recovery before being discharged with a companion.
Immediate post-operative period involves managing swelling and discomfort with cold compresses, head elevation, and prescribed medications. Vision may be temporarily blurry due to ointments and swelling.
First week recovery focuses on healing with limited activities. Stitches are typically removed around days 5-7 if external incisions were used.
Long-term recovery sees gradual improvement over several months as residual swelling resolves and final contours emerge.
Follow-up appointments monitor healing progress and address any concerns throughout the recovery journey.
What is the Recovery Timeline After Lower Eyelid Surgery?
Recovery from lower blepharoplasty follows a predictable pattern, though individual healing rates vary. Understanding the typical timeline helps patients plan their downtime and set appropriate expectations.
First 48 hours post-surgery involve the most significant swelling and bruising. Patients should apply cold compresses frequently and keep their head elevated. Mild discomfort is managed with prescribed or over-the-counter pain medication.
Days 3-7 see gradual reduction in swelling and bruising. Many patients feel comfortable returning to sedentary work around day 5-7, though some visible signs of surgery remain.
Weeks 2-3 bring significant improvement with most bruising resolved and swelling substantially reduced. Light exercise can typically resume, though strenuous activities should still be avoided.
Months 1-3 represent continued refinement as residual swelling resolves and incision lines mature. Final contours become increasingly apparent during this period.
Months 3-6 reveal the near-final results with complete resolution of swelling and natural-looking outcomes.
One year marks complete healing with stabilized results and barely visible incision lines.
Factors like surgical technique, individual healing capacity, and adherence to post-operative instructions influence the exact recovery timeline.
What Results Can You Realistically Expect from Lower Blepharoplasty?
Realistic expectations are crucial for satisfaction with lower blepharoplasty outcomes. While the procedure produces significant improvement, it doesn't achieve perfection or completely stop the aging process.
Typical results include:
Reduction of under eye bags by 70-90% through removal or repositioning of protruding fat pads.
Improved smoothness in the transition from lower eyelid to cheek area, reducing the appearance of hollows and shadows.
Minimal visible scarring with proper technique. Transconjunctival approaches leave no visible scars, while transcutaneous incisions typically heal to fine lines concealed along the lash line.
Natural-looking rejuvenation that refreshes rather than radically alters appearance when performed by a skilled surgeon.
Long-lasting results with fat removal being permanent. The aging process continues, but patients typically maintain improvement for 10-15 years or longer.
Enhanced self-confidence from improved facial harmony and more rested appearance.
It's important to understand that lower blepharoplasty doesn't eliminate dark circles caused by pigmentation or thin skin, though it may improve their appearance by addressing underlying structural issues.
What Are the Potential Risks and Complications of Lower Blepharoplasty?
Like any surgical procedure, lower blepharoplasty carries potential risks and complications. Understanding these helps patients make informed decisions and recognize when to seek medical attention.
Common risks include:
Temporary side effects like swelling, bruising, dryness, and sensitivity to light are expected and typically resolve within 1-3 weeks.
Asymmetry may occur as a normal variation or due to uneven healing. Minor asymmetry is common and often resolves as swelling subsides.
More significant complications include hematoma (collection of blood under the skin), infection, and unfavorable scarring.
Eye-specific risks include ectropion (lower lid pulling away from the eye), entropion (lid turning inward), scleral show (white of eye visible below iris), and dry eye syndrome.
Visual changes though rare, can include temporary or permanent blurring or double vision.
Unsatisfactory aesthetic outcomes like overcorrection, undercorrection, or contour irregularities may require revision surgery.
Choosing an experienced, board-certified surgeon significantly reduces complication risks. Thorough pre-operative evaluation and careful surgical technique help minimize potential issues.
How Does Lower Blepharoplasty Compare to Non-Surgical Alternatives?
Several non-surgical treatments address under eye concerns with less downtime than surgical blepharoplasty. Understanding the alternatives helps patients choose the approach that best matches their goals and tolerance for intervention.
Dermal fillers can camouflage tear trough deformities and mild hollowing by adding volume to the under eye area. Results last 9-18 months with minimal downtime but don't address fat herniation or significant skin laxity.
Laser resurfacing improves skin quality, texture, and pigmentation but doesn't address underlying fat pads or significant skin excess.
Radiofrequency treatments like Thermage stimulate collagen production to mildly tighten skin with minimal downtime but provide subtle results compared to surgery.
Chemical peels improve skin texture and pigmentation but don't address structural issues causing under eye bags.
Kybella (deoxycholic acid) is FDA-approved for submental fat reduction but used off-label for under eye fat with variable results and significant swelling during recovery.
Platelet-rich plasma (PRP) therapy uses growth factors from the patient's own blood to improve skin quality with minimal downtime.
Non-surgical treatments work best for mild concerns or as maintenance after surgical blepharoplasty. They typically require repeated treatments to maintain results.
What Should You Look for in a Blepharoplasty Surgeon?
Choosing the right surgeon is the most important decision in the blepharoplasty process. A qualified specialist with appropriate training and experience significantly impacts both safety outcomes and aesthetic results.
Key qualifications to seek:
Board certification in plastic surgery, oculoplastic surgery, or facial plastic surgery indicates completed rigorous training and meets standards of expertise.
Specialized experience in eyelid surgery specifically, not just general cosmetic surgery. Ask how many lower blepharoplasty procedures the surgeon performs annually.
Before-and-after photos of actual patients demonstrating consistent, natural-looking results for concerns similar to yours.
Good communication and comfort level with the surgeon during consultation. They should listen to your concerns and provide clear, realistic explanations.
Hospital privileges to perform blepharoplasty, indicating their credentials have been reviewed by other physicians.
Transparent pricing with detailed breakdown of all costs associated with the procedure.
Avoid surgeons who pressure you into additional procedures or promise unrealistic results. Trustworthy specialists provide balanced information about both benefits and limitations.
How to Prepare for Lower Blepharoplasty Surgery?
Proper preparation optimizes safety and results while minimizing complications. Following pre-operative instructions carefully contributes to smoother surgery and recovery.
Essential preparation steps include:
Medical clearance if you have underlying health conditions. Your surgeon may require clearance from your primary care physician or specialists.
Medication adjustments as directed by your surgeon. Typically, this involves discontinuing blood-thinning medications, supplements, and herbs 2-3 weeks before surgery.
Smoking cessation at least 4-6 weeks before surgery and throughout recovery to promote proper healing.
Arranging support for the first 24-48 hours after surgery, including transportation home and assistance with initial recovery.
Pre-operative purchases like cold compresses, prescribed medications, saline eye drops, and comfortable sleeping arrangements with extra pillows for head elevation.
Practical preparations like filling prescriptions, preparing recovery space, and arranging time off work (typically 7-10 days for sedentary jobs).
Mental preparation through realistic expectation setting and understanding the recovery process.
Following these preparation steps systematically reduces anxiety and creates optimal conditions for successful surgery and smooth recovery.
What is the Long-Term Maintenance Required After Lower Blepharoplasty?
While lower blepharoplasty provides long-lasting results, proper maintenance helps preserve outcomes and support continued eye area health. A comprehensive maintenance approach addresses both surgical results and ongoing aging.
Essential maintenance practices include:
Sun protection with broad-spectrum sunscreen (SPF 30+), sunglasses, and hats to prevent UV damage that accelerates aging and worsens pigmentation.
Skincare regimen including gentle cleansing, moisturizing, and products with retinoids, vitamin C, peptides, and other proven ingredients that support skin health.
Healthy lifestyle with adequate sleep, balanced nutrition, hydration, and avoiding smoking to support overall skin quality and slow aging.
Non-surgical treatments like occasional filler touch-ups or laser treatments can address new concerns as they develop without additional surgery.
Regular follow-ups with your surgeon during the first year and periodically afterward to monitor results and address any concerns.
Eye health awareness including addressing allergies, dry eye, or other conditions that might affect the eye area appearance.
While the fat removed during blepharoplasty doesn't return, continued aging, weight fluctuations, and lifestyle factors will gradually change appearance over time.
How Does Lower Blepharoplasty Impact Vision and Eye Function?
Most patients experience temporary visual changes after lower blepharoplasty, but permanent vision impairment is extremely rare when performed by a qualified surgeon. Understanding typical visual experiences during recovery helps alleviate concerns.
Common temporary visual effects include:
Blurred vision from ointments, eye drops, and swelling typically resolves within days to a week.
Light sensitivity may increase temporarily during early recovery.
Dry eye symptoms are common as swelling temporarily affects tear production and distribution. These typically resolve as swelling decreases.
Tearing may increase initially due to temporary changes in eyelid position or swelling affecting tear drainage.
Rare but more serious visual complications include:
Diplopia (double vision) from temporary muscle swelling or, rarely, muscle injury.
Lagophthalmos (inability to fully close eyelids) if too much skin was removed, potentially leading to exposure keratitis.
Ectropion (eyelid turning outward) affecting tear distribution and eye protection.
Choosing an experienced surgeon who conserves adequate tissue and uses precise techniques minimizes risks to vision and eye function. Most patients return to normal visual function within 1-2 weeks.
What Are the Latest Advancements in Lower Blepharoplasty Techniques?
Blepharoplasty techniques continue evolving with advancements that improve safety, precision, and outcomes. Modern approaches focus on tissue conservation and natural-looking rejuvenation rather than aggressive removal.
Recent innovations include:
Fat preservation and repositioning techniques that maintain orbital volume while eliminating puffiness, creating more natural results with reduced hollowing risk.
Laser-assisted blepharoplasty using CO2 or erbium lasers for precise tissue removal and skin resurfacing in the same procedure.
Endoscopic approaches providing enhanced visualization for complex cases though not typically needed for standard lower blepharoplasty.
Suture suspension techniques that provide support to repositioned tissues without requiring external incisions.
Combination therapies integrating blepharoplasty with fat grafting, laser resurfacing, or other modalities for comprehensive periorbital rejuvenation.
Improved anesthesia protocols allowing more comfortable procedures with faster recovery.
These advancements contribute to more predictable outcomes, reduced complication rates, and enhanced patient satisfaction. Surgeons who stay current with these techniques typically offer state-of-the-art care.
How Does Age Affect Lower Blepharoplasty Timing and Technique?
Age influences both the ideal timing for lower blepharoplasty and the surgical approach selected. Different age groups present distinct anatomical considerations that affect surgical planning.
Younger patients (30s-40s) typically have better skin elasticity and primarily require fat management with minimal skin removal. Transconjunctival approaches often work well for this group.
Middle-aged patients (40s-60s) commonly need combined approaches addressing fat, muscle, and moderate skin laxity. Both transconjunctival and transcutaneous techniques may be appropriate depending on specific concerns.
Older patients (60+) often present with significant skin excess, muscle laxity, and volume loss requiring more comprehensive techniques that may include canthal support.
Considerations by age group:
Skin quality generally decreases with age, affecting incision planning and closure techniques.
Healing capacity may be slower in older patients, extending recovery time.
Comorbidity prevalence increases with age, potentially affecting anesthesia choices and risk profile.
Volume loss patterns become more pronounced with aging, influencing decisions about fat removal versus repositioning.
There's no specific age limit for lower blepharoplasty—physiological age and specific concerns matter more than chronological age in determining candidacy and technique selection.
Can Lower Blepharoplasty Be Combined with Other Facial Procedures?
Lower blepharoplasty is frequently combined with other facial rejuvenation procedures to address multiple concerns in a single surgical session. Combination approaches often provide more harmonious results than isolated procedures.
Common combination procedures include:
Upper blepharoplasty addresses drooping upper eyelids that often accompany under eye concerns, providing comprehensive periorbital rejuvenation.
Facelift or mid-facelift improves cheek and jawline contours that influence the lower eyelid-cheek transition zone.
Brow lift corrects forehead aging and eyebrow position that affects overall eye appearance.
Fat grafting adds volume to areas like the cheeks, temples, or lips to address age-related volume loss.
Laser resurfacing improves skin texture, fine lines, and pigmentation around the eyes and throughout the face.
Injectable treatments like Botox or fillers can refine results by addressing dynamic wrinkles or volume concerns not fully corrected by surgery.
Combination procedures require careful planning to ensure safety and optimize outcomes. They typically involve increased cost and recovery time but may provide better overall value than staged procedures.
Frequently Asked Questions About Lower Blepharoplasty
How long do lower blepharoplasty results last?
Lower blepharoplasty results are considered permanent for the fat that is removed, as these fat pads do not regenerate. However, the natural aging process continues, and patients will gradually develop new changes in the eye area over time. Most patients enjoy significant improvement for 10-15 years or longer, with some aspects of the procedure providing lifelong benefits.
Is lower blepharoplasty painful?
Most patients report minimal pain during and after lower blepharoplasty. The procedure is performed under anesthesia, so you won't feel pain during surgery. During recovery, most discomfort is manageable with prescribed or over-the-counter pain medication. Patients typically describe the sensation as tightness, swelling, and mild discomfort rather than sharp pain.
When can I wear makeup after lower blepharoplasty?
Most surgeons allow makeup application 7-10 days after surgery, once incisions have sufficiently healed and any external sutures have been removed. It's important to use clean applicators and gentle products initially to avoid irritation or infection. Many surgeons recommend mineral-based makeup during the early recovery period.
Will insurance cover lower blepharoplasty?
Insurance typically does not cover lower blepharoplasty when performed for cosmetic reasons. However, if the procedure addresses functional impairments like significant vision obstruction documented through visual field testing, insurance coverage may be possible. Each insurance provider has specific criteria for coverage determination.
Can lower blepharoplasty correct dark circles?
Lower blepharoplasty can improve the appearance of dark circles caused by shadowing from protruding fat pads or tear trough deformities. However, it does not directly address dark circles caused by pigmentation or extremely thin skin that reveals underlying blood vessels. Combining blepharoplasty with other treatments like chemical peels or laser therapy may better address pigmentation-related dark circles.
What is the difference between lower and upper blepharoplasty?
Lower blepharoplasty focuses on removing or repositioning fat pads and tightening skin beneath the eyes, while upper blepharoplasty addresses excess skin, fat, and muscle in the upper eyelids that can create a heavy, hooded appearance. The techniques, incisions, and recovery considerations differ between these procedures, though they are often performed together.
How soon can I exercise after lower blepharoplasty?
Most surgeons recommend avoiding strenuous exercise for 2-3 weeks after lower blepharoplasty. Light walking can typically resume within a few days. Activities that increase blood pressure or heart rate can worsen swelling and bruising during the initial recovery period. Your surgeon will provide specific guidelines based on your healing progress.
Recommended Affiliate Products and Brands
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- Recovery Products: Promote specialized post-surgery kits from companies like Embrace Scar Therapy and Sylapore for optimal healing
- Sun Protection: Affiliate partnerships with EltaMD, Colorescience, and SkinCeuticals for broad-spectrum sunscreens crucial for maintaining results
- Nutritional Supplements: Collaborate with brands like Vital Proteins for collagen supplements and PhysIQ for targeted nutritional support
- Home Devices: Partner with NuFACE for microcurrent devices and CurrentBody for LED therapy masks that enhance and maintain results
- Cosmetic Camouflage: Affiliate with Dermablend and Cover FX for corrective makeup products used during recovery
- Professional Treatments: Establish referral relationships with medical spas for complementary non-surgical treatments like laser therapy and chemical peels
