Can my Lower Eyelid Hollows and Fat Pads Be Treated with Fillers? (photo)

I have had a problem with dark circles since I was young. I am 53 now and the circles have developed into hollows. I also have round-ish fat pads below the outside corner of my lids and small oblong fat pads just above the "tear trough". The fat pads don't seem to project beyond the under-eye hollow. Can my problem be fixed with fillers or do I need an Arcus Marginalis Release surgery? Also, what do you think of platelet rich plasma as a filler?

Doctor Answers (8)

Lower Eyelid rejuvenation

+3
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.
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.


Raleigh-Durham Plastic Surgeon
4.5 out of 5 stars 37 reviews

Your best options are surgical treatment for your fat pads, and platelet-rich plasma will help with hollowing and skin health

+2

The photos you submitted are very clear about your skin type and the fat pockets you were referring to. The one towards the inner aspect, that’s called the medial and central fat pocket and the outer one is called the lateral fat pocket. In my practice, many people come in just like you in terms of your skin type and your issues.

Fat pockets are herniated fat which means the fat behind the eyelid has pushed forward and created a bulge. Instead of an Arcus Marginalis Release Surgery, I would perform a transconjunctival blepharoplasty to address these fat pockets. This procedure involves resecting or reducing the fat pockets and doing some repositioning from the inside of the eyelid. This way, there’s no external incision or scar.

We’ve actually had a lot of success in my practice in improving the quality of the skin using platelet-rich plasma. Platelet-rich plasma works by stimulating the body’s collagen, blood supply and blood flow to the area that needs improvement. I have a lot of experience with this, not only on the face, but also in our division for hairloss where we use platelet-rich plasma with ACell to treat hairloss. Platelet-rich plasma is often used for athletic injuries and sports medicine.

What we do routinely for someone like you is at the time of lower lid blepharoplasty, we also inject platelet-rich plasma to help the area of the skin that has been affected by age, environment and other causes but it doesn’t change ethnic skin color. Anybody who has dark skin and has had dark circles since they were young are still going to have dark circles. The thing that makes dark circles look worse is poor skin quality, so what we work on is improving it. In addition, we see how the person responds to the platelet-rich plasma by observing how that the skin quality, lines and overall luster of the skin improves. We can actually inject platelet-rich plasma again after several months to further enhance the benefit. Like lifting weights, two people can lift the same weight but they’ll have different responses. Therefore, the patient’s response to platelet-rich plasma can be variable from individual to individual.

In our practice, we also have a skin care product line. We take the next step of maintenance to protect, improve and hydrate the skin. With this, we do things that are less invasive than surgery but we complement the surgery to maximize the appearance of the eyes. I hope that was helpful to you, and thanks for your question.

Amiya Prasad, MD
New York Oculoplastic Surgeon
5.0 out of 5 stars 20 reviews

Fillers do a good job of camouflaging hollows in the lower lid region.

+2

The photograph demonstrates lower lids with some fat herniation. Ideally a lower blepharoplasty with repositioning rather than excision of the herniated fat can do much to eliminate shadowing and restore some periorbital volume. If an operation is not desired fillers can do much to improve the appearance.

Vincent N. Zubowicz, MD
Atlanta Plastic Surgeon
4.5 out of 5 stars 7 reviews

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Lower eyelid issues

+2

If you ahve fat bags then they probably need a conservative removal. The arcus can be released to blend the lower lid better. Sometimes filler can be used to soften this area. I do not think uch of PRP.  Best to be seen in person for proper evaluation.

Steven Wallach, MD
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Herniated fat pads on the lower lids

+2

 The photo shows herniation of fat in all 3 compartments of the lower lids. The best solution for this problem is a trans-conjunctival blepharoplasty. A conservative removal of fat in all 3 compartments we'll remove the fat bags and the shadows cast below them to rejuvenate the lower lids. Look for a surgeon who is well-versed in a trans-conjunctival approach for best results

William Portuese, MD
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Lower lid hollows, fillers, fat injections

+2

sheluma you have touched on most of the means to correct hollow lower eyelids.  in your question.  The answer really depends on your goals and expectations.  If you would like to have the least expensive easiest procedure done as that would improve your lower eyelids all of them injectable fillers such as Juvaderm or Restylene are appropriate with the understanding that they are temporary and are not without risks or complications. Release and repositioning of the orbital fat and SOOF to correct the shadowing of the lower eyelids is the most permanent and complete approach with the greatest amount of control and consistency, however, it is the most surgical approach.  Fat injections and platelet rich plasma can also be used but have been found to have less consistent results.

Edward Farrior, MD
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Lower blepharoplasty vs. fillers.

+2

Lower blepharoplasty vs. fillers is a common question. Fillers are temporary and worth a try if the difference between the hollow and the bulge is small--otherwise a blepharoplasty with fat reposition is best.

Toby Mayer, MD
Beverly Hills Facial Plastic Surgeon
5.0 out of 5 stars 14 reviews

Taking a picture of you looking up greatly exaggerates how bad those lower eyelid fat pads look.

+2

Fillers are amazing.  Very likely you can get help with this service.  The key is treatment by an injector who knows what he or she is doing.  You need to do your homework and look for someone in your area with a significant practice of filling the lower eyelid hollows and making people happy.  Unfortunately, it is an art form.

Kenneth D. Steinsapir, MD
Los Angeles Oculoplastic Surgeon
5.0 out of 5 stars 14 reviews

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.