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Should I do a filler for my lower lids or a Lower Transconjunctival Bleph? (photo)

Ever since I quickly lost weight after my last pregnancy (2 yrs ago), my bags got really noticeable and they don't go away anymore. People tell me I look tired even when I've had 9 hours of sleep. Which way is the way to go? I went in for a couple of consultations so far. I am not afraid of surgery, just afraid to be left with lower hollows if fat pad are removed. What are your thoughts?

Doctor Answers (8)

You have a significant lower eyelid fat prolapse, so transconjunctival blepharoplasty is needed. How to avoid hollowing...

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As a cosmetic oculofacial plastic surgeon, I deal with this question every day. Puffy bags under the eyes transcend age, gender and ethnicity. People can be young or older when puffy bags appear. The cause of puffy bags under the eyes is the fat that is normally around the eye pushes forward, which is called lower eyelid fat prolapse. Several MRI studies have also shown that people who have puffy bags have an increase of fat around the eyes. Typically, this is a genetic trait and within the same family.

When fat is prolapsed and is pushing forward, there are different degrees that the fat can manifest. In the past few years, the approach to lower eyelid fat prolapse has provided people options such as a filler or surgery. In my practice, I help patients understand that there’s a certain level of fat prolapse where fillers can be added in the tear trough area to try to camouflage it. Unfortunately, a lot of nonsurgical physicians try to help their patients by adding fillers to meet the projection of the fat pocket resulting in fat pockets that look worse. A lot of patients come to us to dissolve these fillers.

From the photo you submitted, I think that your lower fat prolapse is significant enough to require surgery. The approach that I would suggest is a procedure called transconjunctival blepharoplasty. It’s a way of addressing the fat pockets by ressectioning and repositioning from the inside of the eyelid thereby avoiding any external incision. The patient will look as if they never had bags under their eyes.

Hollowing is often seen when the lower eyelid is pulled down as complication of lower eyelid blepharoplasty whether it’s from the transconjunctival or transcutaneous approach. When the eyelid is pulled down, the patient looks very hollow. Hollowing is also often perceived not because of the fat pockets were removed too aggressively, but because the patient noticed the eye bags as the dominant issue, and may not have noticed the hollowing earlier. I happen to be boarded in facial cosmetic surgery and I do facelifts, cheek implants and other facial rejuvenation procedures. By these procedures, I understand that the eyelid-cheek area is a very important area. As we get older or if we are very lean, the area called the malar fat pad will become thin. The space where the eyelid and cheek junction called the orbital rim can diminish in volume or efface and this is called the V-deformity thereby making the person look relatively hollowed.

I explain to my patients and show them prior to the surgery that after the fat procedure is done, we can address any concern about hollowing using fillers such as Restylane as well as platelet-rich plasma. We have been very successful in using a combination of hyaluronic acid such as restylane and platelet-rich plasma. Platelet-rich plasma is using the growth factors of the patient’s own blood by doing a blood draw, spinning the blood and concentrating the plasma to have a higher level of platelets. Platelet-rich plasma includes vascular endothelial growth factor that improve the skin quality and wound healing.

At this point, I would recommend that you find a qualified and experienced surgeon, look at the results, and be comfortable with the personality of the doctor. Then you can move forward with the transconjunctival blepharoplasty. I hope that was helpful, I wish you the best of luck, and thank you for your question.


New York Oculoplastic Surgeon
4.5 out of 5 stars 34 reviews

Trans-conjunctival lower blepharoplasty

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When herniated fat bags are present on the lower lids, a trans-conjunctival approach for a conservative fat removal on the lower lids is the best choice. We do not recommend fillers in the eyelids since they are temporary.

William Portuese, MD
Seattle Facial Plastic Surgeon
5.0 out of 5 stars 60 reviews

Should I do a filler for my lower lids or a Lower Transconjunctival Bleph?

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Or maybe both options. Best to seek ONLY IN PERSON evaluations from boarded surgeons in your city/state..//

Darryl J. Blinski, MD
Miami Plastic Surgeon
4.5 out of 5 stars 64 reviews

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Filler for my lower lids or a Lower Transconjunctival Bleph?

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Most expert experienced artistic plastic surgeons have a variety of procedures at their disposal to produce excellent cosmetic results in the appropriately selected patient: temporary fillers, micro-fat grafts, and blepharoplasties. There is no one best procedure. Each has benefits and  potential drawbacks.

Following the advice of anyone who would presume to tell you what to do based on limited 2 dimensional photos without taking a full medical history, examining you, feeling and assessing your tissue tone, discussing your desired outcome and fully informing you about the pros and cons of each option would not be in your best interest. Find a plastic surgeon that you are comfortable with and one that you trust and listen to his or her
advice. The surgeon should be certified by the American Board of Plastic Surgery and ideally a member of the American Society for Aesthetic Plastic Surgery (ASAPS). You should discuss your concerns with that surgeon in person.

Robert Singer, MD FACS

La Jolla, California

Robert Singer, MD
La Jolla Plastic Surgeon
4.5 out of 5 stars 15 reviews

Depends on the cheeks

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The appearance of the lower lids in your case is related to the shadow cast from overhead lights onto the unmasked bags. If you lost a lot of weight, deflation of your cheeks may be the predominant cause. Either liposculpture (fat grafting) to the cheek area and/or Belotero (hyaluronic acid filler) to the tear trough would be a good option. The advantage of fat grafts is it is permanent, although only about 50% of what is injected goes on to survive in the grafted area. For areas where the skin is very thin, such as the eyelids, Belotero is a better option. It is however temporary and lasts about 6 months. 

Conservative transconjunctival lower blepharoplasty to remove just a bit of fat is also a reasonable option, provided the excision is conservative. One can also move the fat from the bulging area to the depressed area to smooth out the contour instead of excising the fat.

All the best,

John Park, M.D.

John Park, MD
Irvine Oculoplastic Surgeon
5.0 out of 5 stars 1 review

You have some prolapsed orbital fat which creates a dark shadow in the tear trough.

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The fat does not have to be removed - and an excellent option is a fat reposition blepharoplasty where the fat is moved down into the tear trough to create a smooth cheek to eyelid transition. Not all surgeons do this surgery, so make sure you go to one who does.  You could also use some fillers which will help to mask the fat until you ready to have a surgery done.     

John J. Martin, Jr., MD
Coral Gables Oculoplastic Surgeon
4.5 out of 5 stars 12 reviews

Lower lid bags

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While I don't know your age, nor can see you in 3-dimension as I would in person, it looks like you are young and your skin and lids are rather youthful without a lot of excess skin. You may benefit from a trans-conjunctival blepharoplasty where the fat is removed from inside the eyelid. This surgery works well in young people who still have good skin tone. If you do chose to go for fillers around the eyes, research your doctor very carefully. Fillers around the eyes are too often overdone, giving the whole area a puffy appearance. Less is more. 

Andrea Nowonty Hass, MD
Palm Beach Oculoplastic Surgeon
5.0 out of 5 stars 1 review

You should be afraid of surgery.

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There is no questions based on the photos that fillers are the way to go.  You will need to do some careful research to find a sophisticated injector in your area who can help you.  Fortunately you are in a community with excellent medical resources.  This is not a place to have the technician at the spa do the service. Take your time and find the right injector.

Kenneth D. Steinsapir, MD
Los Angeles Oculoplastic Surgeon
5.0 out of 5 stars 18 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.