Are my tear troughs too hollow to be filled? I can not afford fat grafting but was told fillers are too dangerous. (Photos)

Thank you for your question. You submitted several photos, and state you’ve been booked for Restylane injection by a dermatologist, then you went for a second opinion from another dermatologist who told you the risk for blindness from Restylane injection in the tear trough. You further describe that because of the thin skin and fat cheeks as you describe, you would end up looking like you had swelling or edema. So, there was no benefit from this doctor’s opinion, the second opinion. You say you can’t afford fat grafting, so you want to know what you can do.
I can share with you my perspective on this type of issue. A little background: I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I have been in practice in Manhattan and Long Island for over 20 years. Helping people with the under eye area, whether it’s surgical for under eye bags, or the use of injectable fillers for the tear trough or under eye hollows, are very significant parts of my practice, so I have a lot of experience with this, as well as dealing with the complications of injectable fillers and surgery in this area. Having an eye surgery background and understanding eye anatomy are relevant in this discussion, first to address the risk of blindness.
There is a risk of blindness described by the placement of injectable fillers in this area, as well as other facial areas in medical literature, and unfortunately is something doctors do report periodically with some consistency. However, the risk is not only very low, it’s also mostly associated with the technique. As much as doctors get sensitive about who has a better technique, there are methods that lower the risk significantly.
In my practice when placing filler in the tear trough area, I routinely use blunt cannulas. One of the anatomic issues with the placement of filler that results in blindness is filler injected directly into a vessel, that goes into the space where the vessels go into the eye. When you use a blunt cannula instead of a needle, you’re avoiding the potential penetration of the vessel, which is not impossible, but much less probable, so I would not dissuade you from doing this because of the risk of blindness.
As far as this doctor’s opinion about the potential for an edematous or swollen look, there’s a degree of potential of that occurring. We have seen many patients who had similar situations where in the attempt to help under eye hollows to hide under eye bags, the person can look more swollen, with their bags bigger. At the same time, there are certain ways to minimize that as long as there’s clarity about the kind of outcome.
If you have on physical exam very prominent under eye bags, you’re more likely a better candidate for lower eyelid blepharoplasty. If you have a minimal to moderate amount of fat prolapse with a relative hollow, then fillers can be placed at the tear trough area to soften and blend that area, without making you look swollen or edematous. It’s the art of the procedure, placement, and choice and the type of filler. That’s where different doctors bring different ideas to the table.
As far as your concern about not being able to afford fat grafting,  in my perspective, this can be a blessing in disguise. I think fat grafting in the tear trough area is not as predictable, and often results in irregularities and lumps, so I dissuade you from doing fat grafting.
Meet with doctors. If you really want to be cautious about the relative risk of blindness, it stands to reason to go to somebody with an eye surgery background and understands eye anatomy. This is where an oculofacial specialist, someone who is Board-certified or trained in ophthalmology and trained in oculoplastic surgery may be the type of doctor you will feel a little more comfortable with, given the fear of blindness. It’s also about the doctor’s experience, style, and methods they use. As I said, I use blunt cannulas and I am really a cosmetic surgeon, so I routinely do this procedure, and with that comes experience.
You have an opportunity now to meet with another doctor who is more specialized in the eye area to help you manage some of your concerns. I would say respectfully, I disagree with the second opinion that you received, and again, try someone who you will be more comfortable with this idea. As is the case for many things in this arena, you have to have a good meeting of the minds between the doctor and the patient. For me, as a physician doing this for my patients, there is a getting to know the patient process where I see the patient, I follow-up in 2 weeks, I evaluate the results, I compare the before and afters, and my patients and I get to have a longstanding relationship so I am able to do things with some consistency for them. I hope that was helpful, I wish you the best of luck, and thank you for your question.This personalized video answer to your question is posted on RealSelf and on YouTube. To provide you with a personal and expert response, we use the image(s) you submitted on RealSelf in the video, but with respect to your privacy, we only show the body feature in question so you are not personally identifiable. If you prefer not to have your video question visible on YouTube, please contact us.

Your photos depict the common effect of thinning SubOrbicularis Ocular Fat (SOOF) at the region of the orbital margin that defines the semicircular ring under the lower lids.  Injectable fillers are placed to raise the SOOF so that it can eclipse the lower lid fat pad and this will help to efface the tear trough.  However, injectable volume in the eyelid fat pad will make the "bags" worse and accentuate the tear trough.  Blindness is a rare complication that may be associated with injection into the Arcuate vessels at the lateral nose region, or into the infraorbital vessels.  Your lower lid configuration could be improved with injectable fillers, but I would recommend lower lid blepharoplasty with midfacial suspension to release the tear trough attachments and provide smoother structural reconstruction.  As many of my colleagues have suggested, it is important to find a qualified surgeon/injector who is well aware of the anatomy and location for the injectable fillers to provide the best results possible with the least amount of risk.  

Hello,As with any filler treatment on the face, safety and effectiveness is based upon the one performing the treatment.  Filler under the eyes, (aka:  tear trough treatment) is very safe and is our most common filler treatment for men and women in our practice.  Although injectors generally have their own techniques and products that they prefer, we believe that there is one tried and true technique in this delicate area (under the muscle) and we prefer Restylane as being safe and most predictable.  We do not find that using a cannula offers any benefit and sometimes will inhibit the artristy of a filler treatment.  The majority of injection treatments (filler and/or Botox, Dysport) are "off-label" procedures.  However, that does not mean they are not done routinely with a good track record.  Although you recognize that there is a cost difference between fat grafts and dermal fillers, you may also want to consider the amount of filler needed for full correction and compare that cost (and duration) with a fat transfer.  For example, you may need up to 3cc of Restylane for a duration of 9 to 12 months.  Although a tear trough treatment will not affect changes on the fat pads, they will be nicely camouflaged and more light/less shadows will be an added benefit.  Please see the below link for before/after photos of patients with similar conditions as yours.