Tear trough deformity - what to consider? (Photo)

Filler in this ar a is temporary and carries a small but definite risk of long term undesirable swelling that does not always resolve with dissolving the filler. Often fat grafting alone will give a longer term solution although in less experienced hands it carries some risk of lumpiness. For the most complete solution transconjuctival lower blepharoplasty to reposition fat combined with fat grafting is the most complete solution

The reason that there is absolutely no such thing as a permanent or very-long lasting treatment is simply because as we age, we lose fat, muscle, and even bone. So, no matter what permanent device, be it filler or surgical implant, is used, the only thing permanent will be the implant or filler. The improvement in appearance will therefore NOT be permanent.
So, given that any benefits from implants or permanent fillers will not be permanent, let's go over some downsides.
The use of permanent fillers, such as silicone, Bellafil and fat, can translate into permanent or persistent adverse reactions that cannot be dissolved nor easily treated should they occur.
When it comes to implants, in a few years the implant will likely need to be surgically removed (as changes in the underlying bone, muscle and fat take place) and a new implant put in. So, more surgery and more expense. And surgery always has the risk for the development of scarring and even tram track stitch marks.
Blepharolplasty, too, is not only expensive, but has the above-noted surgical risks for the development of scarring, and, it, too, is not really permanent, since age-related changes will occur that would then necessitate further treatments down the road.
Fraxel lasers and RF devices have a whole lot of marketing and social media buzz that surround their use, but unfortunately very little hard science to substantiate the hype. So, "buyer beware" when considering these.
Frankly, the use of an appropriate HA filler in the hands of an experienced, board certified cosmetic dermatologist filler injector would seem like a very rational option, especially in a young person. It is also something that can easily fine-tuned as time goes by and those age-related changes set in. It is exactly what I did for my daughters-in-law starting from their early twenties on.
You would be wise to consider the above and to consult with an experienced, board certified cosmetic dermatologist filler expert in whose hands one filler treatment taking only about fifteen minutes to perform is likely to give you the results you are looking for , immediately after the treatment, and with little to no significant downtime. Hope this helps and best of luck.

The undereye circle is a natural, if undesired, facial feature. All the treatment options you mentioned are unnatural means of attempting to address undereye circles. Some options are more disfiguring than others. Laser resurfacing and chemical peeling will not address the circle. Grafted fat is like injecting scar tissue into the glide planes of the cheek. This is often irregular and also changes the way cheek heaps when one smiles is a very unsatisfying way. The tear trough silicone implants can also cause this change. The silicone implant erodes into the facial bones over time causing long term damage to the appearance of this area. If you have sufficient under eye fat ( an examination is needed to determine this) you might benefit from a transconjuctival, arcus marginalis release. Well done Restylane filler is also an excellent option but it requires maintenance.

You do not have a tear trough deformity. That is the area transitioning between thick cheek skin and thin eyelid skin. You have moderate herniated fat bags in the lower lids creating the puffy look. A trans conjunctival conservative fat removal of the herniated fat bags in the lower lids can be accomplished to improve your look. This procedure performed under brief general anesthesia and outpatient procedure

Most things related to facial aesthetics are strongly correlated with underlying bone structure.
This is especially true for issues seen on young people.
For those who have insufficient projection of the maxilla, we often see what appears to be a loss of volume in the mid face with bulging of the lower eyelid fat pad.
All of the treatment options you mentioned are viable.
Even choosing from one procedure over the other is probably not as important as finding the right provider.
There are advantages and disadvantages to all procedures, including the use of fillers.
Fillers have an amazing advantage in that the results are temporary and if you’re not happy with the outcome, you simply just have to wait.
If you’re unhappy with the outcome of permanent surgery, then you’re in a bit of a pickle and this could have far greater implications.
Transfer is probably the most unpredictable, even though it may seem very appealing by its very nature.
Many people view fat transfer as a permanent version of fillers which it is not.
Fat transfer is by its very nature, unpredictable, imprecise, and unforgiving if patients don’t like the outcome.
Implants have lost favor overtime because of advancements in available fillers and procedures.
If you can find plastic surgeons who have a lot of experience with implants that it could be an option for you.
The key is always to find someone who’s really good at what they do.
Mid facelift Has some real strong point advantages, but also downfall.
The drawback to the procedure is that the recovery is really tough and patients are often swollen for months afterwards.
When done correctly, the procedure can give amazing results.
Before giving up on the idea of fillers, I suggest you take a look at the website of Dr. David Mabrie MD in San Francisco.
Real self will not allow me to include an outside website link so you’ll have to Google his name.
David is a facial plastic surgeon whose practice is devoted exclusively to facial augmentation using fillers.
He has an incredible collection of before, and after pictures on his website.
His work is the best I’ve ever seen.
it can be helpful to simply have an understanding of what can be accomplished using only fillers in the hands of the right provider.
I’m not suggesting everybody fly to San Francisco twice a year to get fillers by David.
I do think it is important to recognize what’s possible and what the gold standard is so you can compare this to what other providers in your community are able to accomplish.
Once you know what quality works look like you know what to look for before and after pictures when consulting with providers in your community.
This is true for any procedure.
To find the right provider exclusively on in person consultations, avoiding virtual consultations.
Bring pictures of yourself taken properly the same way plastic surgeons take before and after pictures.
Pictures should not be cropped the way yours are and should show with the full face.
Use those pictures as reference whenever reviewing before and after pictures.
During each in person consultation, ask each provider to open up their portfolio and show you their entire collection of before, and after pictures of previous patients who had similar facial characteristics to your own for whatever procedure they recommend.
Highly experienced providers should have access to hundreds or preferably thousands of before and after pictures.
This is the best way to get an understanding of how much skill and experience the provider you’re communicating with has and what your results are likely to look like.
If the provider does not have an impressive collection of before and after pictures, then that should be a big red flag and tell you to have Another consultation with another provider.
The provider may require consulting with quite a few plastic surgeons.
I think having four or five consultations seems reasonable, considering procedures that are permanent and irreversible.
This becomes especially true when the situation at hand is complex and not easily treated which I think is the case for midface volume augmentation.
All of the treatment options are viable and in the end, choosing which procedure is best for you needs to be done with a provider.
Focus on finding the best provider and everything else will fall into place.
This may take some time and require a significant amount of time and effort.
The biggest mistake I see patients make is trying to vet providers, using their phone or computer and scheduling only one consultation before having surgery.
By scheduling only one consultation patients are more or less eliminating the ability to choose a better provider.
I don’t think you can properly leave at providers without meeting them in person.
Surgeons are ultimately responsible for the surgical outcome, but patients are responsible for provider selection.
Provider selection is in my opinion, the most important variable and were all the effort should be focused.
Best,
Mats Hagstrom MD