Blepharoplasty quandary. How does a surgeon determine the amount of filler to be used?

It is not reasonable to do the eyelid surgery and do filler at the same time. Filler services around the eye require finesse. It can not be properly judged with post operative swelling. Generally, one should wait about 2 months or more before doing the filler. In the case of grafted fat, the eyelid will stay swollen for 6 months or more. The filler service should be deferred until it is clear that it is needed. I am not a lower eyelid/midface fat grafting fan. These services are notoriously challenging to control. I see 3 to 4 new consults per week to manage patients with unsatisfactory lower eyelid fat grafts. Buyer beware.

In our practice, we simply remove the herniated fat bags in the lower lids through a trans- conjunctival approach on the inside of the lower eyelids. Some patients over 50 years of age requires pinch of skin when there's extra skin present which is located on the outside of the lower lid directly underneath the eyelash line. For long list of reasons, we do not recommend fat injections to the eyelids or fillers in that area

This area is complex and not always easy to assess or properly treat. In typical facial aging there are two opposing volume changes that tend to happen. Sometimes when is primary, sometimes the other, and sometimes it’s equal and both volume changes are contributing. In the youthful face, the contour of the lower eyelid should be tight and snug. the area immediately below, the lower eyelid should be full and plump into the upper part of the mid face.
With facial aging the opposite happening. The lower eyelid will show fullness because of weakness of the Peri ocular septum. The orbicularis oculi muscle can keep the fat pads tucked in but weakness in the muscle and weakness in the septum allow the fat pads to begin to herniate out. Just below this people often begin to lose volume in the tear trough and in the upper part of the mid face. It’s very important to distinguish if the primary problem is a loss of volume in the upper mid phase, or if the problem is bulging of the lower eyelid fat pads. If bulging fat pad is really the major problem and the patient has good mid phase volume and lower eyelid. Blepharoplasty is a far better procedure. This can be done with a trans conjunctival incision leaving no visible scar. If the problem is more related to lots of volume in the tear trough and mid phase and volume restoration with fillers, like you propose is a better treatment option.
Adding fillers by itself, does not make your fat pads stop herniating. Fillers restore lost volume. In that sense because your treatment plan isn’t addressing the primary problem it isn’t that important. What fat pads are doing on the day of the procedure.
Rather than worrying about what your eyelids look like on the day of the procedure, I suggest you focus all your effort and making sure your provider has an accurate assessment, and that the treatment plan is the best one. Secondly, I would focus on provider selection. And the hands of the right provider your assessment should be done accurately and the right procedure should be prescribed. There should be a clear understanding if bulging of the fat pad is primary or lots of volume in the mid face is Primary.
Without including facial pictures, we can’t begin to make an assessment. There is no correct answer to your question. It is what it is and your provider will do what they do. The best you can do is to make sure you’re in the hands of the right provider.
The following is a list of general recommendations to help find the best providers.
To find the best provider, I suggest patient schedule multiple in person consultations with experienced plastic surgeons in their community. During each consultation, ask each provider to open up their portfolio and show you their entire collection of before and after pictures of previous patients who have similar body or facial characteristics to your own. An experienced plastic surgeon should have no difficulty showing you the before and after pictures of at least 50 previous patients. An experienced provider should in fact have hundreds or preferably thousands of before and after pictures to choose from for commonly performed procedures.
Being shown a handful of preselected images, representing the best results of a provider’s career is insufficient to get a clear understanding of what average results will look like in the hands of each provider.
There is no correct number of consultations needed to find the best provider. The more consultations you scheduled the more likely you are to find the best provider for your needs.
Take careful notes during each consultation, especially regarding the quantity and quality of before and after pictures. It’s not a bad idea to bring pictures of your own body/face to use as reference when reviewing before and after pictures.
The biggest mistake patients make is scheduling only one consultation without properly vetting or comparing providers before scheduling surgery.
Best,
Mats Hagstrom, MD