Basil Pakeman, MD

You seem to have a condition which is referred to as hypertropic orbicularis. The orbicularis muscle it is used primary in eyelid closure and blinking. The upper portion of your orbicularis in your lower eyelids have become larged and therefore it gives a role to appearance. This may often be mistaken for excess fat while it is redundant muscles. A traditional blepharoplasty surgery will not resolve this issue..

The simplest way to address your hypertrophic orbicularis is with Botox injection to minimize the muscle contracture which would help to decrease its hypertrophic appearance. This must be done by someone who have extensive experience treating this condition.

In severe case surgical option may be viable in which some of the muscle is resected out. One must be cautious, not to resect too much of the muscle because it may increase the chance of an ectropion. This will result in the eyelids turning outward. With proper technique, an ectropian can be avoided with excellent results.

The simple solution for your condition is just the use of Botox and you should see significant improvement in one to two weeks. You may need repeated treatments in the future to maintain the appearance of a smoother and flatter eyelid.

You seem concerned about the difference or asymmetry between the right and left eyelids and eyebrows. In viewing your photos, your left eyelid is drooping, and the left brow is raised. This is a sign of eyelid ptosis with a compensation to open the eye wider by lifting the brow on your left side in a attempt to raise the lid higher

Eyelid Ptosis is a condition where the eyelid margin sits lower in relationship to the pupil. The eyelid crease on the left side is higher than the one on the right side. This is an indication the muscle that opens the left eye is sitting higher or it has become slightly detached. This condition can be acquired or it can be congenital.

Symmetry eyelid can be attained with ptosis surgery of the left eyelid to match the right eyelid. The surgery involved tightening up of the muscle that open the eyelid, the levator muscle. This will help to raise the eyelid and lower the eyebrow on the left side.

You have quite prominent eyes, and they sit anterior cheer to your cheekbone, which is referred to as a negative vector. There is skin excess and excess fat pockets. You have three issues for the best results all three should be addressed.
Let’s start with a blepharoplasty to remove the excess orbit fat. The negative vector of the cheekbone can be addressed with fat grafting, fillers, or a Cheek implant. This will help to make the cheek look more prominent and lessen the effects of the negative vector for more harmonious look. The eyes would be align with the cheek or sit slightly posterior to the cheek. The final step would be to address the skin excess. This can be done by skin excision or skin tightening. Skin tightening can be accomplished with a CO2 laser thereby the skin is not cut. The skin excess can also be removed by cutting the excess skin.
In cutting the excess skin, great care must be taken not to excise too much skin This can lead to a mal-position of the lower eyelids due to lack of support by the lateral canthal tendon. .

Your primary concern seem to be the creepy skin appearance of your lower eyelids. Your lower eyelid fat pads do not seem to be a concern in the photos. A pinch blepharoplasty may be a good option for you since In the photos, the orbital fat pockets does not seem to be herniating forward. In a traditional blepharoplasty, we remove both fat and skin. The skin laxity can be addressed with pinch blepharoplasty or less invasive option is treatment with a CO2 laser to tighten the skin.

I can certainly understand your dilemma, whether a facelift (smas lift or deep plain lift ) with fat grafting or a blepharoplasty is an option to help improve the hollowness and volume loss of your lower eyelids. All these choices are all viable options that would improve the appearance of the lower eyelid. The question becomes how I get the best result with the least amount of surgery.

Your choice of a deep plain facelift with fat transfer Is a good and reasonable choice. This will help to improve the eyelid appearance and possibly avoid a blepharoplasty If not needed. This will allow to see the result without a blepharoplasty, and if you’re happy with the results, End of story! If you feel that you need further improvement, then a blepharoplasty can be done later. They also the possibility you can do all three at the same time. Your approach is logical and reasonable.