Should I Have a Blepharoplasty Instead of Restylane?

I am 48 with lax under eye skin, hollowness and herniated fat. I was told by one PA that I needed lower blepharoplasty and another said that I needed Restylane injection because lower blepharoplasty would cause more hollowness.

I am scheduled for Restylane this week but now not sure. I had upper eyelid surgery 2 years ago but my under eye area makes me look much older. I’m afraid that Restylane will just cause puffiness and I’ve read a lot of people were unhappy with it.

Doctor Answers 15

At Age 48, Restylane in the Tear Troughs is a "B" Procedure

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

Although Restylane is an option in the tear trough region, the results provided by the procedure combined with the frequency of complications, makes it a second tier procedure.  The problem with filling the tear trough lies in the anatomy: a confluence of thin skin, muscle, and the bone of the orbital rim that is difficult to fill significantly.  One of the most common problems is a bluish discoloration and swelling known as the Tyndall effect.  I have seen this problem (in patients who have been injected elsewhere) for up to 18 months after Restylane or injection of other HA fillers.  The actual percentage of the Tyndall effect is probably much higher than reported, because mild cases can be covered with makeup; this is especially true in patients who would be better served with a lower lid Blepharoplasty.  Although this problem is reversible with Hyaluronidase, it can be distressing to the patient.

Although no definitive opinion can be given without an examination, much less a photograph, I would expect some of the typical periocular signs of aging at age 48.  For pseudoherniation of fat, and/or lowering of the lid-cheek junction (two of the factors that can enhance the appearance of a tear trough), a lower lid Blepharoplasty is, by far, the better choice.

Fort Myers Facial Plastic Surgeon
4.9 out of 5 stars 104 reviews

Restylane is not FDA-approved for use around the eyelids

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

Restylane is not FDA-approved for use around the eyelids and should be avoided. In our practice we have seen multiple patients who come in with puffiness around the eyes that has lasted over a year, made by inadvertant placements of Restylane around the eyelids. It is not a good idea. The goal of a lower blepharoplasty is primarily to remove the fat pads which cause puffiness in the lower lids, and sometimes take a small pinch of skin if there is excess skin noted on the lower lids.

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 158 reviews

Make sure your surgeon performs both

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

When in doubt about the choice between two techniques, make sure the advice you consider comes from someone who is expert at both. We love fillers and fat around the eyes and have performed hundreds, if not thousands of blepharoplasty procedures. The choice advantages and disadvantages should be presented to you in such a fashion that the best choice becomes obvious.

Richard D. Gentile, MD
Youngstown Facial Plastic Surgeon
4.5 out of 5 stars 45 reviews

Sometimes multiple procedures are needed

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

The lower eyelids go through many changes as we age. The fat around the eye starts to bulge out causing the bags, and the fat over the bone under the eye starts to droop downward with the cheek. With the goal being to restore the youthful smooth contour of the lower eyelid/cheek complex, you probably need some of the fat removed to reduce the bags, with some injection of either Restylane or fat over the bone to fill in the depression. Be sure to discuss these options thoroughly with your surgeon

Andrew Miller, MD
Edison Facial Plastic Surgeon
4.8 out of 5 stars 222 reviews

Sounds Like You Need Surgery

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

A blepharoplasty does not have to make you more hollow-only if excess fat is removed will this happen.

So I would suggest, without the benefit of pictures, a lower lid canthopexy, muscle tightening and skin removal-no fat.

If you are still hollow after this I like to use Radiesse. This can be injected down near the bone to pump up the tissues without the lumpy/bumpy look you can get from a more superficial hypaluronic filler.

I don't think you'll get much bang-for-the-buck with Restylane now.

Should consider surgical option

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

You would be best served by having a lower eyelid blepharoplasty. There are a number of techniques that could give you an excellent and long lasting result. Injectable fillers in this area can be done. The injection needs to be deep at the level of the orbital rim and used sparingly. It sounds like your condition is past the point where a soft tissue filler would be beneficial

Jeffrey Zwiren, MD
Atlanta Plastic Surgeon
4.5 out of 5 stars 20 reviews

You need to have the right kind of lower blepharoplasty.

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

Hi! It sounds to me like Restylane would be a bandaid approach for you. The typical lower blepharoplasty will indeed make you look more hollow because fat is taken out.

You probably would do best with an operation that repositions the fat or with fat injections to create a smooth contour.

These are tricky procedures. Go to a board certified plastic surgeon who does a lot of eyelids. Listen to what he says. Ask to see a lot of before and after pictures.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon

Consider This.

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

Resytlane is temporary, so even if you hate it, it will go away. It may be worth a try as the cost and down time are less than surgery.

On the other hand, lower bleph doesn't have to make the hollow eye worse. Some techinques to move the fat, or even give some lift to the cheek can be employed.

As the other doctors have said, you need to have a good evaluation to help determine the best treatment for you.


Best to consult a board-certified plastic surgeon

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

A "two pronged approach" using fillers and surgery is the modern approach to facial aging. There are things that can only be done with fillers, and there are things that require surgery. A consultation with a Board Certified Plastic Surgeon would be best to advise you. You can check what a doctor is board certified "in" at the the web site for the American Board of Medical Specialties.

I use both techniques and suspect that you may already be a surgical candidate. Discuss this in person with your plastic surgeon for the best advice.

Darrick E. Antell, MD
Manhattan Plastic Surgeon
4.7 out of 5 stars 37 reviews

Avoid filler injections around the eyes

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

I strongly advise against filler injections like Restylane around the eye. The eyelid skin is very thin and the filler is often very visible and shows irregular lumps around the eyelid. The companies do not recommend it so this is an "off label" use.

If that is not enough to dissuade you, there has been a case of blindness in England caused by filler injection around the eye.

The modern approach to blepharoplasty for lower eyelid rejuvenation is to use a transconjunctival incision through the pink portion of the eyelid. This avoids an external incision which can disturb eyelid support and create a sad eyed look.

In addition, today we do not remove the fat that causes the eye bag, rather we re-position the fat or graft the excess fat into the dark circle beneath the bag. I call this an arcus marginalis release and fat grafting or fat repositioning.

This technique avoids the hollow eye and more importantly plumps the upper cheek area which rejuvenates the midface by adding fullness to the depression caused by downward migration of the cheek fat pad which occurs with aging.

Plastic Surgery--especially around the eye--is a very sophistoicated field which requires 7-8 years of training after medical school. A PA should not be giving advice on such an important issue. Consult 2 board certified plastic surgeons who are experienced in eyelid surgery; experience is so important.

See before and after pictures of the transconjunctival blepharoplasty with arcus release and fat grafting: Set 1 and Set 2

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.