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

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.

I absolutely agree with Dr. Steinsapir that there is no one correct answer.  What works in the the hands of one surgeon may not be successful in the hands of another.  I can tell you that my approach for you would most likely include a transconjunctival blepharoplasty to diminish the bulge under the eye, with the understanding that the optimal result might require the addition of fillers such as Restylane afterwards.  I also agree that while fat can achieve great results as a filler,  it can also produce complications that are very difficult to treat,  and I typically use Restylane around the eye. 

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.#ExperiencedBlepharoplastySurgeon

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.

I always tell my patients to have the surgery that makes the most sense to them, but to go with what the recommendations are with the Dr. that you choose.  This is because each Plastic Surgeon will have their preferred technique that works the best for them in their hands in a given situation.  If you were my patient, I would definately prefer fat transfer, because you do not have any laxity of the skin to warrant a blepharoplasty, and your bags are minimal.  Adding a small amount of fat would not only add volume, but would smooth the area.  Good luck!

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.

A lower blepharoplasty (through a transconjunctival approach) with fat transposition will fill in the bags and circles under the eyes quite nicely.  If there are any pigmentary changes of the skin under the eyes, this can be potentially be treated with a chemical or laser peel.

Fillers would also do the job quite nicely; however, in my opinion, they are inferior to fat transposition due to the fact that they are not permanent and need to be re-injected.

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.

You do have a variety of options to improve the "dark circles" under your eyes. You have to decide if you want a surgical approach (blepharoplasty) or nonsurgical approach (injectables such as Restylane vs fat).  What will give you the best longterm result is a variation of lower blepharoplasty called lower fat transposition where the buldgy lower eyelid fat is transposed to the hollow area underneath it.

Dr Taban

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.