Blepharoplasty or Filler in the Tear Trough?

Thank you for your photo. I'm sorry to hear about the resut your aunt had with eyelid surgery. Too often, surgeons remove too much skin and fat from the eyelid. Yes, it can be repaired. A link to my eyelid surgery before and after gallery can be found below 

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.
Some under eyelid 'bags' involve redundant muscle tissue which must be removed and/or repositioned, usually in patients who are in their sixties or older. This is performed through an under-eyelid (sub-ciliary) incision which is extended laterally into the 'crow's feet' area.

As mentioned above, it is very important to preserve (or restore) soft tissue volume in the lower lid. When I review with eyelid surgery patients some photographs from their twenties, in most cases we find that years ago there was no visible demarcation between lid and cheek, but instead a smooth, gently convex curve extending downward from the lower lid margin.
In patients who have developed deep 'tear troughs' at the junction of the lower lid and cheek, adjacent to the side of the nose, the meticulous grafting of fat harvested from the patient's abdomen, hips or thighs can build this area back up and nicely restore a more youthful contour. In some blepharoplasty patients this depression or 'hollow' extends horizontally across the entire junction of the lower lid and cheek, and this must be corrected to obtain the ideal postoperative result.
In select patients, lower lid rejuvenation may consist of conservative reduction (not removal) of the lower lid fat pads or 'bags', in combination with structural fat grafting of the 'tear trough' hollow immediately below. As with all aesthetic surgical procedures, it is absolutely essential to customize the surgical plan to the specific needs of every patient.

Web reference: http://www.michaellawmd.com/gallery/eye_rejuv1.html

I think surgery is the better choice for you and here's why:

You have an abundance of fat that can be used to reposition over the hollow areas under your eyes and in your tear troughs. This method avoids the over-hollowing some patients experience. The fillers are fine but do not last very long and have a high risk of bruising (so does surgery but at least it's a one time thing). Just make sure you see a surgeon who is not overly aggressive about fat removal and more conservative in the approach, preferably to reposition the fat.

Fillers can help disguise the bags but have a risk of irregularities. You note that your aunt has a hollowed out look, and this is the reason that I would recommend not removing fat from your lower eyelids, but rather transferring fat to fill out the tear trough grooves (the grooves between the lower eyelids and the cheeks). This has the combined benefit of getting rid of the puffiness, putting the fat to good use to fill out the grooves between your lower eyelids and cheeks, and preserving volume. We all lose volume with age, and this can be made worse by removing fat, eventually causing a hollowed out look.

This procedure of fat transfer can be accomplished with a transconjuntival approach (an incision inside the lower eyelid) or an open approach (an incision on the outside of the lower eyelid). Discuss the above with your plastic surgeon. If you choose to have fillers, make sure that the doctor doing the filler is very experienced as the lower eyelids are one of the most demanding areas.

There are many valid arguments for each type of approach to rejuvenating the eyes in lower lid Blepharoplasty. You are young and it is clear that the herniated fat that your lower eyelids exhibit is genetic in origin. You are definitely a candidate for filler in this area but, you are also a fantastic candidate for a conservative transconjunctival Blepharoplasty of the lower lids. If you have dermal filler placed in the lower lids, you will need to have the procedure repeated every 7-9 months to maintain your appearance.
In your case, a transconjunctival Blepharoplasty is extremely safe and when performed appropriately, will give you results that are superior to dermal fillers of the eyes and will last for years. At your age, and based on your photos, you will likely need little if any manipulation of the lower lid skin following fat removal or fat repositioning, which really decreases the incidence of postoperative lower lid Blepharoplasty complications. A good and thorough consultation with a surgeon experienced in both dermal fillers and Blepharoplasty will be your best bet.

Web reference: http://www.renudc.com/blepharoplasty.html

In the lower eyelid including there can be the appearance of a tear trough depression and dark circles with facial ageing. Beneath the skin there are layers of fat in the face and loss of some of this fat with time is very common, in some people as a consequence of their genetics and anatomy this can become apparent as a tear trough depression. Rejuvenation of this area can be both non-surgical or surgical depending on the individual changes in the eyelid. The lower eyelid and tear trough area is a challenging area to rejuvenate and requires thorough understanding of the underlying anatomy. In the past surgery and lower blepharoplasty was the mainstay of treatment however this can lead to a hollowed out appearance if too much soft tissue is removed.
In a person with isolated tear trough depression and relative your non-surgical correction of the depression with a filler is a good option. The technique is challenging and requires skill to perform both effectively and safely. Although some products can produce unfavourable results the use of a filler placed deeply beneath the skin can result in a natural rejuvenation. As a non-surgical technique the filler is temporary and dissolves with time. There are fine blood vessels that surround the eye and there are rare risks of the procedure that include damage to the vision. Care is required with this procedure and surgical techniques are important to avoid these rare complications. I use a cannula technique to maximize safety in this area.
In some patients surgical correction may be a better option for a more permanent technique is volume restoration with fat transfer. The fat will survive long-term providing permanent fill of the tear trough.
In a person with combined tear trough and bags, the orbital fat has resulted in bags and to give a smoother rejuvenation lower blepharoplasty is required with the procedure.

Fat transfer, fat grafting, fat injections, and structural fat grafting are basically the same.  This involves taking live fat cells, protecting and processing them, and re-injecting or placing them in an area where more fat or bulk is needed.  Some special terms are used for marketing purposes, but it is all fat grating. There is a greater possibility of irregularity of result with fat than with fillers.  That is because it is difficult to place very tiny strands of fat under the very thin skin in the tear trough area, and therefore slight lumpiness is sometimes seen and is not desirable.  However, there is a way to combine fat grafting with blepharoplasty where the fat in injected underneath the skin into the bulk of the orbicularis muscle of the lower lid.  My best advice to is go to a board-certified plastic surgeon who has experience with lower lid conservative blepharoplasty, talk to some of his patients, fully understand his surgical plan, and make sure that he/she understands your goals for the surgery,

Thank you for your email. I do see the depression beneath your lower eyelid called the Tear Trough and the puffiness of the lower eyelid above the depression. Some call this Dark Circles under the Eyes.

This is best treated with the Transconjunctival Blepharoplasty with Arcus Release and Fat Grafting. See the link below for a detailed explanation of the correction of Dark Circles under the Eyes.

Filler injections into the lower eyelid are dangerous in inexperienced hanbds and can often make the problem worse.

Web reference: http://drseckel.com/surgical-procedures/result-oriented-removal-of-dark-circles-under-the-eyes/

I would agree with Dr. Aldea. The decision comes down to a topographic decision. Is the prominent orbital fat the problem or the sagging cheek fat creating a depression? In my opinion, it appears that the prominent orbital fat is the main culprit. Conservative removal of the fat should be a realitvely simple and long term solution. This can be done through a concealed incision behind the eyelid. The Restylane could be injected at a later date if the cheek fat is also responsible.

I think you would do best with a careful, minimal, precise lower lid fat removal via a Transconjunctival Blepharoplasty. That would reduce the baggy fat pseudo herniation of the lower lids.

Once the swelling has disappeared, I would re-asses and if needed, add Restylane to the tear troughs to fill the nasojugal line depression.

Dr. P. Aldea

You are asking a very important question that deserve a careful answer.   Fillers are a good way to improve the lower lid appearance by filling the dark circles that start by the nose, the so called tear trough area. This can be done safely and effectively by a technique that I describe in a blog on my web site today in response to your question and other questions that I have received recently. In your situation you present with an eyelid bag which is the orbital fat protruding through eyelid soft tissues. The best and most permanent solution is to conservatively remove the excess fat or use the fat to fill in the tear trough during a surgical procedure. Fillers, if done properly could give you an improvement but could not completely resulve the problem. If you didn't have the bulging fat you would have been a perfect candidate for fillers. 

Web reference: http://www.betterplasticsurgery.com/news