Blepharoplasty or Filler in the Tear Trough?

I think surgery is the better choice for you and here's why:
You have an abundance of fat that can be used to reposition over the hollow areas under your eyes and in your tear troughs. This method avoids the over-hollowing some patients experience. The fillers are fine but do not last very long and have a high risk of bruising (so does surgery but at least it's a one time thing). Just make sure you see a surgeon who is not overly aggressive about fat removal and more conservative in the approach, preferably to reposition the fat.

It's not unusual for patients with tear trough deformities to request plastic surgical consultation. When this situation arises, a variety of treatment options exist to treat this condition. These include surgical procedures that release the arcus marginalis and the use of injectable hyaluronic acid fillers that minimize tear trough deformities.It's extremely important to individualize the treatment of tear troughs. For this reason, the specific procedure chosen will depend upon the patient's anatomic findings and aesthetic goals.It's important to realize that lower eyelid filler injections are very effective for treating tear trough deformities, but aren't for everyone with this condition. In some cases, the lower eyelid skin is extremely thin and for this reason, injectable fillers aren't always indicated. In this situation, injections may be accompanied by nodules and bluish discoloration. Furthermore, this approach only provides a temporary solution to the problem.It's important for patients with tear trough deformities to consult a board certified plastic surgeon with experience in this area. This surgeon should be able to formulate a treatment plan that addresses your anatomic findings and achieves your aesthetic goals.

Judging from the picture I would recommend transconjunctival lower blepharoplasty with orbital fat translocation to pad the tear trough.  This approach minimizes the hollow sunken eye appearance.  The key is removing yet preserving enough fat to still be able to "pad" the tear trough and make it smooth and natural looking.  When done in expert hands, recurrence of that fat is minimized, however, not zero. 

You have dermatochalasis with too much fat to hide with a filler. The definitive treatment is lower eyelid blepharoplasty. Possibly fat transposition would be appropriate in your case, but it is too difficult to see in the photo. Good luck.

Although you don't have much excess skin, you are a good candidate for lower blepharoplasty with repositioning of the fat pads over your year trough. Fillers can camouflage the tear trough but you would still be left with bags. Surgery would correct both of your problems.

I suggest you see an experienced board certified plastic surgeon who has performed blepharoplasty many, many times. They can help you determine the best treatment, which would probably be surgery.

You are asking a very important question that deserve a careful answer.   Fillers are a good way to improve the lower lid appearance by filling the dark circles that start by the nose, the so called tear trough area. This can be done safely and effectively by a technique that I describe in a blog on my web site today in response to your question and other questions that I have received recently. In your situation you present with an eyelid bag which is the orbital fat protruding through eyelid soft tissues. The best and most permanent solution is to conservatively remove the excess fat or use the fat to fill in the tear trough during a surgical procedure. Fillers, if done properly could give you an improvement but could not completely resulve the problem. If you didn't have the bulging fat you would have been a perfect candidate for fillers. 

I think everyone is in agreement that a combination approach is best.  That is, a transconjunctival approach to the lower lid and transposition of fat. Then either fat grafting or Restylane or Juvederm would help with the overall picture.

1. From your photo it is tought to tell exactly what you need but a filler such as juvederm may improve your cosmetic problem in that area quickly and with minimal downtime.
2. A transconjuctival bleparoplasty with fat transposition would likely give a longer lasting solution

I would agree with Dr. Aldea. The decision comes down to a topographic decision. Is the prominent orbital fat the problem or the sagging cheek fat creating a depression? In my opinion, it appears that the prominent orbital fat is the main culprit. Conservative removal of the fat should be a realitvely simple and long term solution. This can be done through a concealed incision behind the eyelid. The Restylane could be injected at a later date if the cheek fat is also responsible.

Based on your photo, a lower blepharoplasty would be the best procedure for you; not a filler. The type of blepharoplasty would preserve your fat and reposition the fat; not remove fat. This can be done through an incision on the inside portion of your lower eyelid with no external scars or incisions. You do not need any skin removal either. The lower portion of the eyelid which is causing this appearance (septum) needs to be tightened with sutures, this will create a natural appearance and transition from your lower eyelid to cheek.
Please consult with a board certified plastic surgeon who is experienced in this particular type of lower eyelid surgery.
Best wishes,
Dr. Bruno