Blepharoplasty or filler for hollow under eye? (photos)

Thank you for your question. You are asking what is the better option, surgery or fillers to deal with hollows under the eyes. You submitted two photos that show this area very well, and describe your skin is very thin over these areas. I think your question is very relevant. You’re asking if the blepharoplasty would be more permanent, or will it sag over time.
I can certainly help you understand my perspective when I help patients who come to my practice with very similar scenarios and questions. A little background: I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I have been in practice in Manhattan and Long Island for over 20 years. Eye rejuvenation is the foundation of my practice as we do so much, and customize many different solutions to help patients who come to us from around the world.
It’s very important for you to have a basic understanding of the principles that guide what the solutions are. In your photo, what I see is the under eye puffiness. I also see the relative hollows that are below the eye, and relative volume loss in the cheek area. The skin quality is consistent with your type of skin - it’s relatively thin underneath the eyes.
Permanence is something people always want - they want a long-term, long-lasting solution. Understanding that facial aging with genetics and environmental factors makes long-term solutions variable in longevity.
Starting with the under eye fat pockets, these have prolapsed forward. We refer to it as lower eyelid fat herniation. For that area, I would consider, in the absence of a physical examination, a procedure like lower eyelid blepharoplasty. This is a procedure where I would go in from the inside of the eyelid called the transconjunctival approach, to address the fat pockets, reduce, and reposition as appropriate. This way, the under eye area will not have the bulge of the fat pockets, which I feel contributes to the perception of the hollow - the bulge is like a mountain, the hollow is like a valley.
Another question often comes up about tightening the skin. Often, it’s a misinterpretation that thinning skin quality is best treated by pulling and tightening the skin. Often, my colleagues who did a transcutaneous approach the outside of the eyelid, and take away skin with the intention of trying to make the skin tighter ends up with the lower eyelid retracting or everting called ectropion - a skin shortage of the eyelid.
I take the approach that lower eyelid skin, especially in a lighter skinned person, is very thin and should have minimal, unnecessary manipulation. What I typically do in a situation like yours is a PRP injection or platelet-rich plasma, the concentration of the wound healing and growth factors that stimulates collagen, blood supply, and improves skin quality. On the surface point-of-view, with the fine lines and wrinkling, I would use something like a fractional CO2 laser, or fractional Erbium laser to help improve the quality on the outside.
The relative hollows are best addressed with volume and by using fillers. I would evaluate the under eye tear trough area after surgery and see if there’s any indication of there being some volume loss to treat with a filler such as Restylane, or something lighter in the hyaluronic acid family.
One thing often overlooked when people focus on the under eye hollows are the areas of the cheeks. I don’t just look at the eyes, I look at the eyes in combination with the relative cheek projection. When I talk to my patients about this, I often suggest we do something called structural volumizing. Structural volumizing means placement of fillers that are longer lasting such as Juvederm Ultra Plus or Juvederm Voluma placed at the bone level. At that level, the material actually creates a better structure, more definitive angularity and structure to the cheekbones, so it balances out the area of the eye. Often, people focus on the area that bothers them the most, but they missed the forest for the trees. I think there is value especially with the long lasting fillers to help with the eye aesthetics. Long lasting means about 1-2 years to have this full correction, and the longevity that goes with it.
Permanence when it comes to soft tissue is something really difficult to achieve. I look at the skin quality and the challenges of dealing with genetics and environmental factors, whether it’s sun exposure, and breathing environment such as smoking or secondhand smoke. We’re dealing with factors which ultimately cause breakdown and cause aging. In a way, there’s always a benefit to a maintenance process whether it’s getting PRP injections every 3-6 months, some kind of ablative or non-ablative lasers such as Q-switch laser, or radiofrequency to stimulate collagen. Basically, looking at skin quality, there is a downward direction if you don’t do anything, and there’s mitigating those changes and getting enhancements if you do something. Surgery is not always the definitive procedure.
I think you have to consider this as embracing a plan rather than a single solution. A surgical procedure such as lower eyelid blepharoplasty, then PRP, fractional CO2 laser will be an improvement. To look good as possible, something like structural volumizing, the strategic placement of fillers, and the use of PRP in a schedule makes sense to you both in terms of logistics and financially, would probably give you the best long-term outcome. I always say it’s kind of like going to the gym - you can’t go to the gym once and expect to be in a good shape forever. These treatments require things like PRP or non-ablative laser are pushing your body to generate collagen, and without some kind of stimulation, it will only go in one direction.
Meet with qualified, experienced cosmetic surgeons to learn about your options. Try to look at the eye, not in isolation, but as it relates to the cheek, and I think it will give you a sense of what I’m describing. I hope that was helpful, I wish you the best of luck, and thank you for your question.This personalized video answer to your question is posted on RealSelf and on YouTube. To provide you with a personal and expert response, we use the image(s) you submitted on RealSelf in the video, but with respect to your privacy, we only show the body feature in question so you are not personally identifiable. If you prefer not to have your video question visible on YouTube, please contact us.

Transconjunctival lower blepharoplasty with fat/bags repositioning is a good option for you. The existing eye bags/fat is repositioned to fill the hollow area under eyes with predictable, lasting results. See following link. Filler is another option but less effective and short-term. 

Hello and thank you for your question.  The
best advice you can receive is from an in-person consultation.  With that
being said, based on your photographs, the best shape and contour could be
achieved with either lower eyelid blepharoplasty or filler placement or fat grafting.   Make sure you specifically look
at before and after pictures of real patients who have had this surgery
performed by your surgeon and evaluate their results.   The most
important aspect is to find a surgeon you are comfortable with. I recommend
that you seek consultation with a qualified board-certified plastic surgeon who
can evaluate you in person.
Best wishes and good luck.
Richard G. Reish, M.D.
Harvard-trained plastic surgeon