most 22-year-olds do not have issues with needing lower eyelid blepharoplasty's and facial fat transfer. Those to do almost 100% of the time have a facial skeletal structure that lacks projection in the mid face. The bone involved is called the maxilla. This is sometimes referred to as someone lacking malar projection. It causes two adjacent undesirable contour changes. Let me see if I can explain this using simple language. In the ideal facial contour the area in the lower part of the lower eyelid is usually snug, tight and has a concave shape. The area just below this is full and volume and has a convex shape. I Deleigh the overall shape starting at the lashes of the lower eyelid should have a smooth continuous S-curve onto the cheek. In your case there is a change in volume in the opposite direction. The lower eyelid is bulging out words giving a convex appearance. This happens because the bony structure does not give good support to a membrane call the psi-orbital septum. When this membrane becomes a week or does not have good support the weight of the eyeball pushes three separate small fat pads under the eye forward against this membrane. The result is the bulging in the lower eyelid. Just below this the volume decreases from the ideal and while not necessarily concave lacks the desirable volume for a youthful non-tired look. Since there are two adjacent volume issues this can be approached by either adding a volume below the lower eyelid trying to match the bulging fat pads, removing the fat pads to create a concave curve in the lower eyelid or a combination of both. There are a few different approaches to removing or decreasing the fat pads in the lower eyelid. The most straightforward and simple way is to remove some of the fat creating a better contour. This can be done with an incision along the lash line or an incision on the inside of the eyelid call the trans conjunctiva blepharoplasty. When an incision is made it is generally called simply a lower eyelid blepharoplasty or an incisional blepharoplasty. Both approaches are fine. Personally I'm a believer that it's a bad idea to remove skin and muscle from the lower eyelid because people have a tendency to later in life developed a condition called and ectropion. This is a pull down of the lower eyelid showing to much of the white sclera of the eye. There's a greater propensity for this to develop if someone has had an open lower eyelid blepharoplasty with the removal of skin and muscle. Adding volume in the middle cheek can be done in a variety of ways. Historically facial implants were popular. In the 1990s a procedure called a mid face lift( very different than a facelift) was somewhat en vogue when facial fat transfer became more popular after textbooks and lectures by Dr. Sidney Coleman. As fillers became better and better with the addition of HA fillers less people opted for lower eyelid blepharoplasty is because a lot can be accomplished adding volume below the bulging lower eyelid fat pads camouflaging this. If you want to see what can be accomplished by adding volume correctly check out some of the results from Dr. David Marbie in San Francisco. Just go to his website and look at his before and after pictures. This is some of the best work with fillers I've ever seen. So there are generally two opposing contour irregularities that can be treated in conjunction, one or the other. I no longer perform these procedures but when I did I would classify my patience as having one primary and one secondary condition. In other words which was more prominent or important, removing a fat from the lower eyelids or adding volume just below. Based on that I would give recommendations. Of course some patients are apprehensive about surgery and want to go in on surgical route. Sometimes this is appropriate while other times it is simply not doing the best procedure. It is not unusual to get different opinions about treatment options for this area. There are many many different alternatives available. Each provider will have their own personal view on this. Of course if you go to someone with limited experience or techniques then they will simply steer you towards what they have access to. In other words if you see a board-certified plastic surgeon or facial plastic surgeon then the provider will most likely have the skills available to deal with both problems. If you see a nurse who does Botox and filler's then that person would most likely only recommend fillers and adding volume and not and lower eyelid blepharoplasty. You should only see providers who are trained and can offer all the alternatives. Fat transfer is by its very nature somewhat unpredictable and not particularly great in doing precision work. It's good for giving defuse overall volume. It's not good for giving very accurate small increments of volume especially around the eyes. It works reasonably well in the mid face but not as you get into the tear trough. This is my personal opinion and has been my experience. Other providers will have different opinions about this. To me without even seeing pictures I'm going to go out on a limb and say the best options will most likely be a lower eyelid blepharoplasty, most likely trans conjunctival with adding fillers to the mid face. As described above lots of plastic surgeons have done other procedures giving great results like adding facial implants. This does make sense if you look at the primary fundamental problem which is almost always skeletal. Treating skeletal issues with soft tissue manipulation's are going to give her somewhat limited results. Still, in this case soft tissue work is what's available and nobody would suggest skeletal surgery. The drawback to facial fat transfer is that the amount of fat that survives long-term is unpredictable. If to much fat survives patients in desperation ask how fat can be removed on real self. Taking the fat out is much more difficult than putting it in. If not enough that survives and patients complain that they spent thousands of dollars and didn't get results. When working with fat the best approach in my experience was to plan on a few sessions a fat transfer space six months apart slowly building up volume. One argument for the use of fillers is that the treatments can be adjusted overtime until you get the absolute best results. You can change providers, you can have the provider add volume in certain areas and hence fine-tune the results which by its very nature will be better than a single go around with fat. That was a pretty extensive explanation. It's just my opinion and to get accurate information the provider needs solid information to work from which in this case primarily involves a physical examination or at least seeing pictures. Lower eyelid blepharoplasty's are fairly straightforward and most experienced talented providers can do this procedure consistently. Fat transfer is different. The same can be said for fillers. At least fillers are temporary. It's important you choose providers that are supremely talented and experienced. Best of luck, Mats Hagstrom MD
