Severe bilateral palpebral edema with xanthelasma

Patient description

54yo smoker without any prior medical conditions, manual worker

Case description

The patient wants to get rid of his puffy lower eyelids.

He doesn't complain of his upper eyelids, nor of his eyebrow ptosis (I strongly recommended a bilateral direct excision brow lift).

I've prescribed an extensive lab work but I haven't found any patent easy-to-think-of metabolic anomaly that could explain such a severe bilateral eyelid edema.

Thyroid function's normal, ASATs are 4 times normal value though. And FIB-4 is a bit above normal. Minor hypoglobulinemia.

Auto-immune panel is normal.

The only other diagnosis to rule out is hereditary angioedema but I'm gonna leave this to Internal Medicine to who I'm also referring the patient.

Surgically, does any of you have any experience on how to get rid of those puffy lower eyelids ?

I was thinking of a sub-ciliary skin incision, followed by a pre-orbicularis undermining, skin defatting. Then defatted eyelid skin repositioning (like a graft) with very conservative excision of the excess + lateral canthopexy to anticipate retraction

What do you think ?