Age 40 & at a loss for deep tear troughs - what can I do? (Photos)

You have a prominent tear trough and mild festoons. In my hands, I think you would benefit from a lower lid blepharoplasty with CO2 laser. This procedure would move lower lid fat into the tear trough to smooth the transition from the lid to the cheek. The laser would then help tighten the skin and reduce wrinkles. Best to see an eyelid specialist.

Looking at your photographs one option may be to use a transconjunctival blepharoplasty. In this surgery the existing fat pockets of the lower eyelid are redraped downwards over the teartrough and they fill the groove. Its is a scarless procedure since the surgery is performed from the back of the lower eyelid. You may also need some fat transfer in combination along with possible laser tightening of the skin. These assessments can be made at an in person consultation

Thank you for your question and providing your photos.
Based on your explanation and assessment of your photos, here’s what I believe should be addressed:
1: deep tear throughs 2: excess skin and laxity in lower eyelids plus some degree of per orbital fat herniation.3: lack of volume in mid face
To address all the above, I would recommend a lower blepharoplasty surgery with fat transfer (including stem cell) to tear throughs and cheek area. And to further improve skin elasticity, Morpheus8 (Radiofrequency microneedling) would be a good complementary treatment to have few months after surgery.
Wish you all the best. Allen Rezai M.D.

The photos are not enough to determine what’s going on, but you may have lower eyelid fat bags and edema, malar edema, skin laxity, flat cheeks, and possibly a negative vector eye morphology. You also have a strong demarcation of the tear-trough and this likely represents the ligamentous attachments and may be exacerbated in appearance because of the flat cheeks and eyelid edema.

I would start with thoroughly dissolving all the filler and evaluating you for various medical conditions that could cause eyelid edema, such as thyroid eye disease.

I would then evaluate you for surgical lower blepharoplasty with fat repositioning, addressing the ligamentous attachments and improving the deep tear-trough. There are other procedures you may also need.

I would also consider you for skin tightening, but unlikely a skin pinch as that could make things worse. Rather possibly a CO2 laser resurfacing procedure.

My Undereye Weekend Lift is a way to improve the cosmetic appearance in patients who don’t want surgery. You can access my videos on this platform.

See an Oculoplastic surgeon for a proper evaluation and recommendations.

I agree with the replies regarding tightening the skin. The best treatment is a laser. I prefer Erbium YAG Sciton because it has less tendency for hypopigmentation than the older CO2 lasers. I am sure providers can dial back the CO2 settings to minimize risk of hypopigmentation, but I am not sure if it will maintain the same effectiveness. The full ablative laser will give the best tightening. The fractionated laser will give good tightening and be easier to recover from than the full ablative laser (middle of the road option). Radiofrequency microneedling is another way to tighten the skin, although it will likely take a series of 3 treatments to do so. The recovery is easier than laser, but results are not quite as good.
Secondly, I recommend either nanofat or exosomes. In the US, exosomes are not FDA approved for injection treatment (approved for topical treatment), though we have had good off label success doing so. A comparable regenerative treatment is nanofat which uses your own stem cells and requires fat harvesting typically from the abdomen. These treatments help the tissue with color and volume by supporting the body in healing itself. I think one of these is a better option than fat grafting, although that can give nice results. Uncommonly, fat grafts can be associated with lumpiness. Even if fat grafting is done well, unfortunately, fat grafts can grow with body weight so it depends on guaranteeing that you will never gain weight in the future.
If unsatisfied with the previous 2 steps alone, then it is reasonable to treat the cheeks. Cheek treatment can be approached from the addition of volume and/or with lifting. Adding volume can give nice results. It can be done with fat grafting, filler, or submalar implants. A midface lift from a temporal incision can reposition cheek soft tissue back where it originated and give a nice, refreshed look. This often also helps the under-eye area.