Filler or Lower Blepharoplasty for Lower Lids? (photo)

I am 40 and have genetic under-eye hollowness. It has become markedly worse over the past few years. I really want to do something more on the permanent side, but am now thoroughly confused: An oculoplastic doctor has said that I am not a candidate for a lower bleph/that it wouldn't make me look good. I have, however, seen that it gives amazing results on plenty of people with similar appearances. So - do I add or remove? Advice welcome! Thank you.

Doctor Answers 15

Lower lid bags

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I would recommend that you try Restylane first for the lower lid bags before opting for a blepharoplasty.  Based on the appearance of your cheeks, you are not ready for mid-facelift and I think you can hold off on surgery for at least five years.  Restylane is an office based, inexpensive procedure which I think would produce a fine result in your case.

Blepharoplasty or fillers?

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You appear to be relatively young. A filler is temporary and is quick and should not have a complication. You are probably not ready for a mid facelift. When I do a blepharoplasty on lids like your I remove fat from the bulge and put it in the valley below. Without seeing you that is what I think you would want.

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

Lower lid surgery or filler for puffy lids?

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Thank you for the photos. The angle of the camera makes your fat look worse than it actually is. I would recommend filler first (no downtime if one uses hyaluronic acid gel) or fat with minimal downtime. I would not remove fat from you lower eyelids, you already are exhibiting signs of hollowing out. The fillers are reversible (if you don't like them), not burning any bridges, maybe a few bucks, but surgery is more permanent.

Tear trough deformity

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You appear to have a deep tear trough deformity that accentuates a mild lower lid pseudo-fat herniation. I would recommend to my patient to try diminishing the deformity with an HA filler first and if that sufficiently improved the appearance of the eyes, then it can be repeated with longer lasting fillers such as PLLA or Autologous Fat. Tear trough injections require extensive skill and experience. I would strongly recommend finding such a provider in your area if this is the option you choose. Otherwise, you may benefit from a lower lid Blepharoplasty with fat repositioning or even a tear trough implant.

Edwin Ishoo, MD
Cambridge Facial Plastic Surgeon

By photographing yourself looking up, you make your lower eyelid fullness look its worst.

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The advice of the oculoplastic surgeon you saw is probably sound.  Unfortunately so often a surgeon offers you something because that is what they do, right or wrong.  There is no question that for many people what they really need is not lower eyelid fat removal but lower eyelid hollow filling.  The hollow develops do to deflation and ptosis of the cheek fat right at the top of the cheek.  This helps restore a more youthful heart shape face.  For some individuals that actually benefit from a combination of surgery and mid face fillers.  Please recognized that under eye fillers is a bit of an art form.  So I am confident that numerous surgeons may respond to your post and suggest that, yes, you should have eyelid surgery.  I think you received sound, honest advice from someone who was not looking to hustle you into surgery but rather making a recommendation regarding what is aesthetically best for you.

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

Filler or eyelid surgery?

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It looks like you have excellent skin tone in your lower eyelids. I would try filler injections first and then consider removing fat if you are not satisfied with the results.

Realize that plastic surgeons make a lot more money operating on people than injecting fillers. I suspect you have found an honest doctor who genuinely wants to do what is best for you. There are many times when surgery is not the best option. 

I prefer Restylane in the the under eye area. For most patients, the treatment lasts a full year or more and the treatment can me modified as your face changes with time. If you hate the treatment for some reason, it can always be dissolved. If you have a permanent filler or fat injected under your eyes and you are not happy with the results, you are stuck with it forever.

Mitesh Kapadia, MD, PhD
Boston Oculoplastic Surgeon
4.9 out of 5 stars 182 reviews

In most cases, transconjuntival removal of the fat bags in your lower eyelids will solve the problem.

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It appears that you have prominent fat pads in the lower eyelids.  These can be removed or repositioned.  After surgery,  If the tear troughs still appear hollow one month after surgery, I would  recommend a filler such as Restylane.  In my experience, most patients do not need the filler if the bags are removed. 

Mark Taylor, MD
Salt Lake City Dermatologic Surgeon
4.2 out of 5 stars 18 reviews

Lower eyelid surgery

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A very common aging change in the lower eyelids is the development of 'bags', which are in most cases due to an outward bulging of the fat pads behind the lower lids. These 'bags' of fat can be improved by conservative removal through an invisible incision on the inside of the lower lid (trans-conjunctival approach) in patients that do not require skin excision, or through the under-eyelash (sub-ciliary approach) in patients that are having some excess lower lid skin removed.
As with skin removal, I believe that the reduction (NOT total removal) of lower lid fat pads should be conservative. Excessive removal of lower lid fat pads results in a hollowed-out appearance that makes blepharoplasty patients look tired or even ill. I see quite a number of eyelid surgery patients who require structural fat grafting of the lower lids to improve that very problem following an over-aggressive lower blepharoplasty in the past.
In some case lower lid 'bags' can be improved by repairing or reinforcing the soft tissues that normally hold them back. Additionally, excessive lower lid fat can sometimes be mobilized and transposed inferiorly to fill in periorbital hollows or depressions such as the 'tear trough' at the medial junction of the lower lid and cheek.
Some eyelid 'bags' involve redundant muscle tissue which must be removed and/or repositioned, usually in patients who are in their sixties or older. This is performed through an under-eyelid (sub-ciliary) incision which is extended laterally into the 'crow's feet' area.
As mentioned above, it is very important to preserve (or restore) soft tissue volume in the lower lid. When I review with eyelid surgery patients some photographs from their twenties, in most cases we find that years ago there was no visible demarcation between lid and cheek, but instead a smooth, gently convex curve extending downward from the lower lid margin.
In patients who have developed deep 'tear troughs' at the junction of the lower lid and cheek, adjacent to the side of the nose, the meticulous grafting of fat harvested from the patient's abdomen, hips or thighs can build this area back up and nicely restore a more youthful contour. In some blepharoplasty patients this depression or 'hollow' extends horizontally across the entire junction of the lower lid and cheek, and this must be corrected to obtain the ideal postoperative result.
In select patients, lower lid rejuvenation may consist of conservative reduction (not removal) of the lower lid fat pads or 'bags', in combination with structural fat grafting of the 'tear trough' hollow immediately below. As with all aesthetic surgical procedures, it is absolutely essential to customize the surgical plan to the specific needs of every patient.

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

Lower lid fat transposition blepharoplasty

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Although fillers have a definite role in helping dark circles. you are a candidate for lower blepharoplasty with fat transposition, meaning the fatty buldge is moved down to the hollow area.  See another oculoplastic surgeon.

Dr Taban

Mehryar (Ray) Taban, MD, FACS
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 91 reviews

Treatment of the tear trough

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It is clear from your photos that you do not need and should not have tissue removed. You are assuming that blepharoplasty surgery means tissue is removed. Althought that was the case 20 or 30 years ago that is no longer the case. The surgery can also be done to repositiion tissues within the eyelid without removing any of them.

The desired look is to soften the junction between the lower eyelid and cheek so it is less noticeable and smoother. This can be done by joing the eyelid fat to the cheek fat, grafting fat into the junction or injecting a filler into the junction. It is impossible to tell from the limited information in your post and photos taken at a single angle with you only looking upward which would be best for you.

I hope you realize that this format of posting questions and receiving answers lacks the face to face direct communication required for you to make an informed decision regarding your surgery.

My response to your question/post does not represent formal medical advice or constitute a doctor patient relationship. You need to consult with i.e. personally see a board certified plastic surgeon in order to receive a formal evaluation and develop a doctor patient relationship.

Aaron Stone, MD
Los Angeles Plastic Surgeon

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.