Lower Eyelid Blepharoplasty and/or A Fat Transfer The Best For Me?

I have been advised that treatment for my dark circles can be approached through lower eyelid blepharoplasty, filler (or fat) for the lower eyelid/cheek interface, or a combination of both these approaches. Which approach would you recommend? If I do not have filler and proceed only with blepharoplasty could I be headed for an overall magnified hollow look? If I only have filler or fat injections will my eyelids look too puffy? thanks for you help!

Doctor Answers 15

Recognize that there is no right answer.

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Much depends on your actual surgeon.  You could have benefit by a properly done lower eyelid surgery using an transconjunctival approach with arcus marginalis release.  I personally think fat is not a great option.  It tends to be disappointing over long periods of time.  I think for ease of having the treatment and the ability to adjust a service, Restylane and Perlane fillers are much better options.  However, there is more than one way to go about this.  A great deal will very much depend on who you see, and your on personal feelings about things.  I would recommend avoiding surgery that involves a cut in the lower eyelid skin or lateral canthal procedures.

Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

Lower Blepharoplasty

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Cosmetic lower eyelid surgery has undergone a paradigm shift over the twenty years since I began my plastic surgery training, as has facial rejuvenation surgery as a whole. The trend has been to move away from highly invasive procedures that focus on skin and fat excision and pulling skin structures as tight as possible (which tends to make a patient look less youthful and more like a stereotypical ‘plastic surgery patient’), and towards procedures that accomplish not only soft tissue preservation but also soft tissue enhancement – in the form of structural fat grafting. A typical 1970-1980’s era lower blepharoplasty usually consisted of the surgical removal of large volumes of lower lid fat, pulling the lower lid skin very tight and anchoring the lid laterally in a manner that often distorts the natural anatomy of the lateral canthus (lateral corner of the eye). I suppose you could say that this matches a windswept, pulled tight facelift - but it is not in any way truly rejuvenating.
Current, state-of-the-art lower blepharoplasty focuses on soft tissue preservation, including some or most of what appears to be ‘herniated fat’. A number of techniques have been described that restore ‘herniated lower lid fat’ to a more ideal anatomic position, although ideally such a procedure leaves the orbital septum intact as shortening of the septum by suture tightening or cauterization carries with it some risk of lower lid retraction.

The trend has been towards limiting fat reduction to primarily older patients with very prominent lower fat pads. In many cases, the appearance of lower lid fat pad fullness can be effectively corrected by a combination of structural fat grafting of adjacent hollow areas like the tear troughs, elevation of the midface and smoothing of the lid – cheek junction by means of a High-SMAS facelift (if indicated), and tightening the orbicularis oculi muscles to the lateral orbital rim – which effectively restrains the fat pads and improves lower lid contour. Lateral orbicularis oculi muscle suspension is a very powerful means for reversing lower lid aging changes, and for doing so in a manner that does not distort natural lower lid external appearance.
Preserving lower lid fat as much as possible, and restoring fullness in adjacent hollow areas by means of fat grafting, is a truly rejuvenating approach to lower lid surgery. Preserving and adding fat serves to enhance the soft tissue support of the lower lid and helps to maintain an ideal and youthful lower lid position over time. The more support you provide for the lower lid, the less you have to rely on internal support measures such as canthopexy and canthoplasty, which are useful for very lax and for overly long lower lids, but which also may distort the natural anatomy of the lower lid and upper lid.

Michael Law, MD
Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 123 reviews

Treatment of dark circles and hollowed out appearance in a male

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You have a typical V shaped deformity or polar bear deformity.  Your lower eyelids are hollowed out, you have a laxity of the lower eyelid ligament and a sharp division between the lower eyelid skin and the cheek. An ideal correction would be a lower eyelid blepharoplasty with fat redistribution, tightening of the orbicularis muscle, raising of the malar fat pad laterally, tightening of the lower lateral canthal tendon and a very small degree of skin removal.  

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

Fat transposition lower eyelid blepharoplasty for correction of dark circles

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Lower eyelid blepharoplasty should always be approached with extreme caution since this can be frought with irreversible complications. as we age we loose fat around the eye. if toomuch cat is remove the eye hollows out prematurely . Dark circles (valley) causing the tired appearance can be the result of bulging fat (mountain) In some case, as in your, it is advisable to move the fat (mountain) into the dark circles (valley) . This way volume is preserve and th eyelid smoothed out. I will recommend a fat transposition lower eyelid blepharoplasty with hidden incision inside the eyelid (transconjunctival blepharoplsty). While a filler can be used to fill the "valley", in your case too much volume will be require and it is likey to give you a puffy appearance.

Kofi Boahene, MD
Baltimore Facial Plastic Surgeon
4.5 out of 5 stars 26 reviews

Preferred Treatment for Under-Eye Hollows

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Your condition is a relatively common one and deserves accurate analysis and discussion. Your esthetics after a procedure will vary greatly by the route you choose with your surgeon. The treatment approach should always be guided by your anatomy. It looks to me that you actually have normal lower lids but significant deficiency of your central cheek bone. This leads to the appearance of baggy under eyes. Without examining your side view photos, it is a little difficult to determine.

Imagine that you want a smoother transition from cheek to lower lids. You can achieve this by removing the mount (fat), filling the valley (cheek and tear trough) or both a little. Fat removal from your under eye region may make your lower lids look even more hollow because they are brought back to the level of the valley (cheek) which is already too sunken.

Too make a long story short, I would probably recommend fat grafting alone to build up the cheeks and tear troughs to a more appropriate level. Restylane is another option but usually not quite as effective. Personally, I do not like implants for the tear trough region.

Frank P. Fechner, MD
Worcester Facial Plastic Surgeon
4.6 out of 5 stars 48 reviews

Blepharoplasty for bags under eyes with dark circles.

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Blepharoplasty for bags under eyes with dark circles and the transfer of fat should resolve all of your issues unless you need something for pigment in the skin.  The fat is removed from the mountain and put in the valley of your lid.

Toby Mayer, MD
Beverly Hills Facial Plastic Surgeon
4.8 out of 5 stars 38 reviews

Finding Experienced Blepharoplasty Surgeon

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These are all great questions. The key is to find the most experienced plastic surgeon to examine you and answer them rather then relying on random opinions in this forum. Expert Eyelid surgeons include Board Certified Plastic Surgeons, Facial Plastic Surgeons (ENT), and ophthalmology. There is no such thing as a "eyelid fellowship". The most critical decision to be made in achieving the best plastic surgical result is picking the most experienced and talented, that is the best, plastic surgeon possible. Too often, patients choose a physician based on a catchy ad, the brand name of a technique, the basis of one or two before and after photos, or their web site’s search engine ranking. These criteria will not find the most experienced and talented plastic surgeon. See the below link on how I would research the identity of the best plastic surgeon for your eyelid surgery.

Eyelid Surgery

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Dark circles can be caused form many factors.  Too little fat, lax skin, skin vascularity, hyperpigmentation, and anatomical bone structure, and others.  You need to have the problem defined, and start with least invasive to more invasive.  I am only moderately fond of filler under the eyes.  On some occasion, there can be a puffy appearance.  This is not one of the ironclad injection sites.  The body response is not always predictable.  Proceed with caution.

Vivek Bansal, MD
Danville Plastic Surgeon
4.9 out of 5 stars 26 reviews

Treatment of Dark Circles Under Eyes

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Both injection of filler (including fat) and Lower Blepharoplasty alone when done properly can markedly improve dark circles under the eyes. Which is best depends on the specific problem and the anatomy causing the problem. The only way to know for sure is with a consult and examination of your eyes by a surgeon who specializes in eye rejuvenation. If a Blepharoplasty is done, you need fat moved into the lateral area to disguise the bony orbit there. I would, therefore, not remove any fat, simply move it to where it will do the most good.

Robert T. Buchanan, MD
Highlands Plastic Surgeon

Dark Circles Blepharoplasty and Filler injections.

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In short: combination of both lower trans-conj Blepharoplasty and filler injections. Per the pictures I can see fat herniation of the medial and central fat pads but also a trough (or hollowness) at the junction between your cheek and the lower eyelid. I usually address the hollowness first with Fillers (I prefer Radiesse for that region) and if I cannot camouflage entirely the fat pads then I would do a conservative (to avoid the hollowness) trans conjunctival Blepharoplasty. I would avoid HA fillers because of the Tyndall effect. 

Henri P. Gaboriau, MD, FACS
Massena Facial Plastic Surgeon
5.0 out of 5 stars 7 reviews

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.