Lower blepharoplasty - with or without fat transfer? (Photo)

Your questions are perceptive. Your anatomy is typical: some bulging
of the orbital fat combined with a tear trough line that is caused in part by
the insertion of the orbicularis muscle along the orbital rim and the tight
arcus marginalis. The best results can be achieved by a lower lid
blepharoplasty. I would use a transconjuctival approach and release the arcus
marginalis and the orbicularis insertion. I would make a decision
intraoperatively whether to simply reposition the fat, allowing it to flow over
the orbital rim or (likely) also remove a small amount. Then I would harvest
some fat from your abdomen with a fine cannula, and place some fat into the
tear trough area under direct vision. Fat grafting alone will help some but not
completely correct the problem. Your question about anesthesia is a
good one. This is an easy area to anesthetize with local anesthesia, but it
does require some experience to obtain effective complete local anesthesia.
I often perform this surgery in the office with light oral sedation. Many
surgeons will do this procedure only in the operating room using deep sedation
or general anesthesia, but in my hands, the results are equivalent either
way. Many patients are comfortable with light oral sedation, but some prefer
deeper levels of sedation, which requires an anesthesiologist.

Yes, hyaluronic acid fillers, specifically, Restylane can filler your under eye hollow and provide a result that is actually better than what can be achieved with surgery.  While the result is not permanent, it is generally quite good for 12 months before a top off is beneficial.  So I strongly recommend considering this option.  Provided you are getting a result you like, there is no reason you can continue to get fillers as need.  If you reach a point that the filler is no longer getting the job done, surgery remains an option.  Generally fat grafting is not a very good option.  It tends to make lumps and bumps and is impossible to adjust without more surgery.

 We have performed  a lower blepharoplasty on many physicians in our practice and for patient safety and comfort, we place them under general anesthesia by a board certified physician anesthesiologist. A lower blepharoplasty is not a clinic procedure, it is a invasive surgical procedure only performed  in an operating room. In the state of Washington,  all surgery such as this must be performed a certified AND licensed outpatient surgery Center. The fat pads of the lower lids have very deep proprioceptive nerve fibers that do not numb up to the lidocaine, so teasing the fat is very painful under local . Electric cautery is also used to stop any bleeding of the fat inside the orbital septum.