Which Between Fillers and Blepharoplasty Should I Have First?

About 8 months ago, I had lower blepharoplasty and CO2 laser. My eyes are hollowed out more so than ever, and extra skin is evident to the point that I'm afraid to smile. I've seen a few doctors and they all suggest different things - another lower blepharoplasty, or fillers. Some suggest a filler first, then a snip incision, and ssome prefer Restylane and some prefer Perlane. Does the order matter? My skin in fairly thin. Which between fillers and lower blepharoplasty should I have first?

Doctor Answers 9

Bleph first

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It continues to amaze me that surgeons still don't know how to do a bleph. History and excellent surgeons have taught us that "fat is youth." Most good surgeons understand that removal of fat will lead to sunken eyes. Unfortunately, you're there so let's fix it. If you still have excess skin then your surgeon used a transconj. incision to remove fat. So you need to have the skin removed, just a little bit of skin, and have the muscle tightened. After you heal, if you still have a hollow look, depending on how bad it is, I would recommend anything from a dermal fat graft to Radiesse+/- a hyaluronic filler.

See several surgeons before you decide who to go with.

Good luck

You need to find a doctor who makes sense and you trust.

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Dear Intears

Obviously you have a very significant problem because you have submitted multiple emails regarding your situation to Realself.

This can only mean that you have not found answers that make sense to you. You need to listen to your intuition and not ignor these feelings. You need to find a doctor you can trust. This is no easy prospect as you have learned. I think I have suggested to you that you may need to travel to find your doctor. There are only a handful of us in the World who specialize in fixing eyelids after unsuccessful eyelid surgery.

In many cases this is like trying to unstir the cream from the coffee. The problem in post operated eyelids are numerous. Not the least of which is many of the glide planes that need to function to make a completely normal eyelid are damaged by scar tissue that formed when the eyelids healed from the surgery.

I think it is also possible that your situation may lead you to a post traumatic stress syndrome or even chronic depression. This is not uncommon. Think of it this way, initially you did not have a care in the world and underwent eyelid surgery to improve your appearance with no thought that you could have this outcome (or you probably never agreed to surgery). Far from achieving the desired results, you are much worse off than than were you started from. It is a real loss. It is a loss that possibly can be helped by revisional surgery or perhaps this will be dissappointing to you also.

Now you question your ability to find a doctor you can trust. I find that it some times takes time for the brain to heal from these situations. If you don't first deal with your feelings of loss, I think there is a real risk that you make rush into a choice with a new doctor that also does not help you. Consider talking with a therapist about your loss. Consider doing some emotional healing before you rush into a new surgery. Being in a better emotional place will help you make better decisions about reconstructing your appearance.

Kenneth D. Steinsapir, MD
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

Fat injections best for hollowed lower lids.

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1) I am afraid you have a very difficult problem.  You can try Restylane under your eyes, but it may complicate the situation.

2) From your description, you really need a complex revision blepharoplasty with fat injections.  But this is difficult surgery.  Try to see an oculoplastic surgeon.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon

Fillers are not FDA-approved for usage around the eyelids

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Fillers are not FDA-approved for usage around the eyelids and should be avoided. In our practice, we have seen multiple complications from other offices where the Restylane was injected around the eyelids and created extended semipermanent puffiness underneath the eyelids for years after the injections. Patients were very unhappy with that result. If there are still issues regarding the puffiness and/or excess skin underneath the lower lids, they should be addressed with a blepharoplasty.

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 157 reviews

Contouring lower lids requires multiple adjustments

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Since we altered our lower lid technique about two years ago, we no longer have frequent touch ups regarding the results. We now perform as our standard a blepharoplasty, microFat or filler, skin excision or laser to address all the aesthetic concerns that transpire with lower eyelid aging. We have excellent results with fat or fill as well as pinch skin excision and fractional CO2 technology. Our technique is termed "Contour Lower Lid Blepharoplasty" because it accurated determines what the aesthetic problem is and how best to improve it.

Richard D. Gentile, MD
Youngstown Facial Plastic Surgeon
4.5 out of 5 stars 45 reviews

A mid face lifting procedure may be beneficial in this situation

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If in your first surgery the area was hollowed out it is important to have a thorough evaluation looking a items such as lower lid position, the level of descent of the junction point between your lower eyelid skin and your cheek skin, any remaining fat below the eye, globe position and cheek position as well as tightness of the lower eyelid itself. If you are hollowed out and have lose skin and you have some descent of the midface then a lifting procedure may be beneficial to blend your cheek in to your lower eyelid skin. In other word to ease the transition between your cheek and lower lid. This type of mid face lifting can be done with a procedure such as the MACS lift or others like it. This may help to fill the hollow void.

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

Dissatisfaction 8 Months After Lower Blepharoplasty

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Hi In Tears,

I empathize with your despair following your eyelid surgery. Know that your situation is correctable; it will require that you find a very good opthalmo-plastic surgeon. It appears that you have seen many surgeons in consultation which is a good thing.

Dr. Steinsapir has given you very good advice. You may want to speak with him, or Robert Goldberg, MD at UCLA. Both are excellent surgeons experienced in revision blepharoplasty here in Los Angeles.

If your excess lower lid skin bothers you most, I would perform a skin pinch first. Once that heals, if needed, Restylane may be used to fill any further hollowness of your lower eye area. I would avoid a thick filler like Perlane, as well as the very mobile filler Juvederm in this most delicate area.

Please save your tears, you should eventually be fine. You need to choose your revision surgeon most carefully.

Be well.

Dr. P

Michael A. Persky, MD
Encino Facial Plastic Surgeon
4.8 out of 5 stars 39 reviews

See an Eyelid Expert first

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When there is a problem that affects the eyelids, you should be evaluated by an Ocular Plastic Specialist. These doctors, like Kenneth D. Steinsapir, MD and myself, are Eye MDs who have specific further training in cosmetic and plastic surgery around the eye. There are some excellent American Society of Ophthalmic and Plastic Reconstructive Surgery physicians in Toronto (where I completed my fellowship).

To answer your question , the order of filler and / or skin removal or tightening is not as important as the choice of the correct physician. Restylane and Perlane are "cousins" and in the right hands, either one could make improvements. Cost should be a consideration but it should not force you to choose the wrong physician.

Mark Berkowitz, MD
Sterling Heights Oculoplastic Surgeon
4.8 out of 5 stars 65 reviews

Do not have fillers injected around the eyes!

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Filler injections around the eyes to correct dark circles, hollows and other problems frequently result in permanent visible lumps and discoloration. Filler injections around the eyes have caused blindness in a patient in England. The companies that make fillers do not recommend this use. You need to see a board certified plastic surgeon who specializes in eyelid surgery and has experience in correcting post blepharoplasty problems.

I use an open transconjunctival laser blepharoplasty (through a tiny incision on the inside of the eyelid) to correct these problems. I place a composite graft (a whole piece of fat harvested from the tummy) to restore fullness and take up slack skin in these situations.

Do not have fat injected with a needle; same risks as with a filler and more frequent lumps and bumps and misplacement of fat. You need to find an expert in your area, and make sure the doctor is board certified in plastic surgery and ask to see photos of his/her results. See before and after pictures of transconjunctival laser fat grafting of lower eyelid: Set 1 and Set 2

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.