Lower Transconjunctival Bleph +/- Filler? Second Opinion? (photo)

I am 35 and am bothered by lower eyelid puffiness. More often, I am having people tell me I look tired when I've had a full night's sleep. I have talked to an oculoplastics surgeon who recommended removal of the lower medial fat pads only. I am concerned this will result in a hollow underneath my eyes as I age. Should wait to have a transcutanous bleph and just have filler done in the mid cheek area to smooth out this puffiness or have it done now to prevent more sagging of the undereye area?

Doctor Answers (7)

Re-position of Lower lid fat pads prevents later hollowing

+1

From the limited photos you provided you have two options that I would recommend.

1. Transconjunctival fat pad adjustment either with a conservative removal or releasing the restraining membrane (arcus marginalis) and allowing the fat pad to be redistributed to blend in with your cheek fat. If done conservatively I do not think you would be at increased risk for any abnormal hollowing.

2. Use of fillers beneath the fat pad to camouflage the bulging fat (this would only be temporary solution


Orange County Plastic Surgeon
5.0 out of 5 stars 45 reviews

Lower Blepharoplasty

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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 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.

Michael Law, MD
Raleigh-Durham Plastic Surgeon
4.5 out of 5 stars 40 reviews

Treatment of tear troughs

+1

I think you could get what you want from just placing a filler in the groove or trough. You will need to discuss which filler with your surgeon. I think if you just take out the fat you will end up skeletonizing the area leaving you with a hollowed out appearance.
 
My response to your question/post does not represent formal medical advice or constitute a doctor patient relationship. You need to consult with i.e. personally see a board certified plastic surgeon in order to receive a formal evaluation and develop a doctor patient relationship.

Aaron Stone, MD
Los Angeles Plastic Surgeon

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Lower eyelid transconjunctival blepharoplasty with fat augmentation.

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Lower eyelid transconjunctival blepharoplasty with fat augmentation will kill 2 birds with one stone. The fat is removed from the "mountain" and placed next to the bone in the "valley". No fillers or secondary procedure. See an experienced surgeon who is familiar with this technique so you do not end up with bumps!

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Thanks for the photo. I would first do the transconj including 2 of the 3 fat compartments. Allow 2 to 3 months healing than use a filler if needed. 

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TC Bleph

+1

A transconjunctival bleph is usually the best for young patients with lower eyelid fat. I do not like fillers in the lower lids, removing the fat is usually the best treatment.

William B. Rosenblatt, MD
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Please post better photo.

+1

From the photo you posted, it seems to me that using fillers or fat grafting would give you a more natural result right now. Photo does not replace the need for a good hands on exam, and it may be your surgeon is correct, and that I will come to the same conclusion if I examined you in person.

Get a second opinion. Not all surgeons are comfortable with fillers.

An ASOPRS trained Oculoplastics surgeon near you is available on ASOPRS dot org.

A.J. Amadi, MD
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These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.