Eyelid Surgery or Fillers First for Tired-looking Eyes?

I am a 43-year-old female that over the last 6 - 8 months have seen a noticeable change in my eyes. Puffiness, drooping eyelids and heavier lines under my eye, some days hollow-looking, other days puffy. I always look tired one way or another Should I look to an surgical eye lift or go with a more tame approach, such as Radiesse, Juvederm etc.? I look as if I aged 3-5 years in this period of time.

Doctor Answers 10

Eyelid Surgery vs Fillers for Tired Eyes

Thank you for your question.

First, if you chose Filer Injection, only Restylane, not Juvederm or Radiesse should be used around the eyes, and then only in small amounts, 0.6 cc and ONLY by an expert in Eyelid Surgery who has experience. Many patients have suffered complications from Filler Injection in the eyelid area, including visible grey lumps and blindness has been reported, but rarely.

Fillers are used to camouflage the deep depression or dark circle under the lower eyelid called the Nasojugal Fold which in time can become part of the Tear Trough Deformity.

Fillers are temporary and need to be repeated.

If you have puffiness, loose skin and a deep depression under the lower eyelid, a Blepharoplasty with Arcus Marginalis Release and Fat Grafting is a more accurate and permanent solution (see below.)

Blepharoplasty or dermal fillers for eyes

Normal changes to the lower eyelids can really make us look older quicker. Injections to the lower eyelids are fine for subtle changes such as small amounts of "pooching" of the fat pockets or hollowing (dark circles and shadows) of the lower eye in younger individuals. For significant changes to the lower lid, a formal surgical procedure is likely going to make you happier than fillers and the outcome will last considerably longer. You can always try a quick dermal filler fix, but, at some point you should sit down with a surgeon you trust to thoroughly discuss your long term options.

Philip S. Schoenfeld, MD, FACS
Chevy Chase Facial Plastic Surgeon
4.5 out of 5 stars 20 reviews

Best Eyelid Technique Depends on Surgeon

Without photos and an exam it is not possible to give you an expert opinion. What you need to concentrate on is finding the best plastic surgeon and not the technique. Looking at photos is just a single way to judge a plastic surgeon's talents but certainly not the best way. There is no average amount to show or look at. Expert Eyelid surgeons include Board Certified Plastic Surgeons, Facial Plastic Surgeons (ENT), and ophthalmology. There is no such thing as a "eyelid fellowship". The most critical decision to be made in achieving the best plastic surgical result is picking the most experienced and talented, that is the best, plastic surgeon possible. Too often, patients choose a physician based on a catchy ad, the brand name of a technique, the basis of one or two before and after photos, or their web site’s search engine ranking. These criteria will not find the most experienced and talented plastic surgeon. See the below link on how I would research the identity of the best plastic surgeon for your eyelid surgery.

Larry S. Nichter, MD, MS, FACS
Orange County Plastic Surgeon
5.0 out of 5 stars 102 reviews

Rejuvenation of the lower eyelids - What are my options

You would be a candidate for a  lower eyelid  blepharoplasty if you have herniation of orbital fat causing bags of the lower lids with lack of soft tissue fullness.  These features can be corrected with a lower eyelid blepharoplasty with fat repositioning.  An accurate diagnosis of the problem is essential.  .  If the condition is only lose skin then you may want to consider SmartSkin or  SmartXide microablative fractionated CO2 laser resurfacing.   A consult would be needed to advise you which procedure would meet your expectations.  Other choices would include soft tissue fillers such as Juvederm.

Jeffrey Zwiren, MD
Atlanta Plastic Surgeon
4.5 out of 5 stars 14 reviews

Options for tired looking eyes

The puffiness around the eyes is caused by fluid retention in the upper and lower lids located in the fat pads underneath the muscle of the eyes. This tends to shift with the time of day and time of the month. Make sure that all allergies are addressed as well as a low-salt diet. We do not recommend any of the fillers injected into the eyelids. If this happens to be injected into the orbital septum it will stay swollen for several years in duration.

William Portuese, MD
Seattle Facial Plastic Surgeon
4.5 out of 5 stars 107 reviews

Fillers vs. Eye Lid Surgery

The correct choice depends upon your particular situation,

A depression or hollowness beneath the lower eyelids, often referred to as the "tear trough" deformity, can give a tired look. In this case a filler such as one of the hyaluronic acid products, (Restylane or Juvederm), or even micro fat grafts can fill in these areas and create a smoother contour. I tend to prefer the softer products for the eyelid region. These are short term solutions. The fillers resorb over time.

On the other hand, if you are developing loose excess skin and the fat pockets around the eyes are beginning to protrude creating the "bags" under the eyes, eyelid surgery may be needed to resupport the tissues and smooth the contours. The eyelid surgery is a longer term solution.

Obtain a consultation with a board certified surgeon who performs frequent eyelid surgery and who has a good reputation. He or she can recommend the best choice for you.

James H. Schmidt, MD (retired)
Sarasota Plastic Surgeon
5.0 out of 5 stars 7 reviews

Try Juvederm/Restylane for Tired Eyes

The tired eye look is usually from a deep tear trough. If you are not sure about surgery then buy some time by getting Juvederm/Restylane in the nasojugal groove (tear trough) and you will look better. However that is good for only six months. Surgery might be the long lasting solution.


Tanveer Janjua, MD
Bedminster Facial Plastic Surgeon
5.0 out of 5 stars 63 reviews

Fill or surgery for tired lower lids, or both?

Aging in the lower lids often does not follow a continuum and can be modulated by inherited lid characteristics. This can also be true of the amount of fatty tissue in the neck. At 43, you are on the early side of surgical rejuvenation of the lower lid, though the best assessment will determine the condition of the skin of the lid, and the degree to which the fat in the lid is prominent. I believe that the first signs of aging tend to be a loss of the fat under the skin where lid joins the cheek, the 'tear trough' zone. If your skin is in good shape, fillers, especially fat, can be an excellent non-surgical choice to fill and restore the area. Be sure to have only the most skilled provide fill in the lid and around the eye as this is not an area for amateurs to treat and note that this is an 'off label' place for fillers so be certain you understand what will be done and who will do it.

The inherited puffy eye is another matter and surgery may be beneficial to control the puffy look, to repair, remove, or reposition fat as needed. Still, depending on where you are on the aging curve at age 43, a fill of some type may also compliment the result. A board certified plastic surgeon in your area is a place to start.

Best of luck,


Peter E. Johnson, MD
Chicago Plastic Surgeon
4.0 out of 5 stars 38 reviews

Surgery or fillers for tired eyes

A definitive recommendation can only be made after an in person consultation with a plastic surgeon but you have identified some key questions. We can look tired or older around the eyes because the lids are droopy, or because we look puffy or hollowed out. Fillers are generally not used in the eyelids, but can be useful in the areas around the eyes such as high in the cheek or along the arch of the brow. If a "hollowed out" appearance is the problem, fillers may be just the thing. Extra skin can only be treated with surgery. Sometimes a combination of both is best. Make sure that the medical provider you see in consultation is able to do both surgery and fillers. You will receive the best evaluation and recommendation when the doctor has a full complement of procedures to offer.

Elizabeth Slass Lee, MD
Bay Area Plastic Surgeon
5.0 out of 5 stars 48 reviews

Blepharoplasty or fillers...or both.

A proper evaluation by a surgeon (i.e., someone who can also operate on the eyelids and not just inject patients) would be a good place to start. Some patients, for example, really need a lower blepharoplasty--eyelid surgery--to recontour baggy fat and/or "lift" loose eyelid skin. Others, of course, merely have hollowing and would be better served with fillers such as Juvederm. Others still need a little bit of both. Or neither.

All the best,


P.S. Although opinions vary, I'm not a big fan of fat injections in this area. Too often I see patients who've had very poor results from fat: lumpy, misplaced, hardened, etc. There are few good options to correct those outcomes many times.

David C. Pearson, MD
Jacksonville Facial Plastic Surgeon
5.0 out of 5 stars 23 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.