Lower blepharoplasty - with or without fat transfer? (photos)

Question

I've been considering a bletharoplasty for a very long time. However, I opted at first for smaller options-such as tear trough filler and cheek filler (restylane and RFA). I've had mixed reviews regarding blepharoplasty as an option for me. Some plastic surgeons have told me mixed answers. I've attached my face before and after filler. Should I remove filler before surgery? Should I get fat transfer with blepharoplasty? I've attached first 2 without filler and second 2 with. Would I need a fat transfer to my cheeks along with a lower bletharoplasty? What would be the estimate cost? I have had RFA in my cheeks and Restylane under my eyes. Would I need them removed prior? I've attached photos with and without filler for reference. Thanks so much

Andrew Miller, MD · Answer

Based on your photos, you are a great candidate for lower lid bleph with fat transfer. This will give a great long term result that will look very natural, without the need for regular fillers. Ideally, it would be best to dissolve the fillers first as we have done many times in the past. Cost for everything can vary, but usually is around $8000. Be sure to see a facial specialist for consultation.

Eric M. Joseph, MD · Answer

In general, we are not big fans of fat grafting since results can be somewhat unpredictable, and the under eye area is very thin and very sensitive to irregularities. If the bags under your eyes are bothering you, it's a relatively straightforward procedure to remove these fat pads without an external incision. I hope this helps, and I wish you well moving forward. Sincerely, Dr Joseph

John Michael Thomassen, MD · Answer

I would recommend you do the lower lid transconjunctival bleph with a fat transfer to the tear trough and malar eminence for a nice midface volumization procedure.  You do not need to dissolve prior fillers before doing this.

Kenneth D. Steinsapir, MD · Answer

The filler you received was not optimally placed in my opinion. You did not get treatment of the under eye circle. What you had was volume in the cheek which actually makes the under eye hollow worse. It is possible to precisely place product in the gap between the herniated lower eyelid fullness and the top of the cheek. By filling this in precisely, it is possible to address the under eye circle. Treatment is not permanent, the service last about a year or so before needing to be topped off. Eventually, the all of the filler should be removed with enzyme. This is done approximately every 4 years. The rationale is that as the old filler ages, it hold more water and does not look right. If I were treating you, I would remove all of the filler and retreat just the groove as described. It is a fussy service. Most injectors seem to be incapable of providing it. I see people from all over the world for this service.

Regarding lower eyelid surgery, be careful. When you say fat transfer that is a term that means different things to different surgeons. Generally the term "fat transfer" means harvesting fat from a donor site (usually the abdomen) and injecting it into another location. Do not do this procedure with eyelid surgery. The grafted fat is like injecting scar tissue embedded with fat. It will harm how the cheek heaps up when you smile. The procedure caused irreversible scaring in the tissue planes where it is placed. Instead you are much better off with a tranconjunctival lower eyelid arcus marginalis release. The living fat that makes the bulge in the lower eyelid is moved to the top of the cheek. This is a great procedure and eventually what you should have when you are ready for lower eyelid surgery. When that time comes, do not settle for a local surgeon. Find a highly experienced aesthetic eyelid surgeon.

Zoran Potparic, MD · Answer

It appears that you have smaller cheek bones, condition known as malar hypoplasia, which is the cause of early aging in the area of lower eyelids and cheeks. Correction of malar deficiency with small cheek implants or periorbital fat grafts is way to correct this deformity. Lower, transconjuctival blepharoplasty would correct current lower eyelid problem. In person or teleconference consultation with a board certified plastic surgeon with expertise in these procedures is recommended. Good luck.

William Portuese, MD · Answer

The primary goal for lower eyelid surgery for patients less than 50 years old is to remove the fat bags creating the puffy look through an incision on the inside of the eyelid known as a trans conjunctive approach. No external incision is required. The procedures performed under general anesthesia as an outpatient procedure. The limited photographs demonstrate some degree of fat pads in your lower lids. We would recommend having the fillers reversed prior to surgery and do not recommend fat injections in this area.

Mats Hagstrom, MD (license on probation) · Answer

We need quality standard pictures to make a quality assessment, especially if we’re going to compare the outcome of a procedure. Look at how plastic surgeons take before and after pictures. 
This area is complex, and there are a number of variables to take into consideration.
The fullness in the Lower eyelid transitions into the loss of volume in the upper midface.
On top of this, it’s not simply soft tissue issues, but these intern are primarily driven by facial skeletal structure.
There’s a reason some people get bulging lower eyelids early in life and others do not.
There’s also a reason some people get sunken midface prematurely as well.
When the facial structure doesn’t give a strong foundation the soft tissues aren’t supported well. 
My best suggestion is focus on finding the best provider and there’s two is complex and really difficult.
I wish I could say something was great and easy, but this kind of work is not really like that. 
Good outcomes are possible but outcomes the gave some improvement and some new problems are also common. 
To get a good understanding of what can be accomplished using only fillers take a look at the website of Dr. David Mabrie MD in San Francisco.
I’m not suggesting people fly to San Francisco, but I believe seeing his results can be a powerful tool helping people understand what can be achieved in the hands of the right provider.
Once you understand what good results can look like you can use that knowledge to help find the right provider in your community.
 Above all my best suggestion is to have as many in person consultations as possible, when contemplating permanent irreversible surgery, especially of the face.
Providers open up their portfolio and show you their entire collection of previous patient who had similar facial characteristics.
Bring proper facial pictures of yourself to use as a reference during the consultations.
In the hands of the right provider things get much easier and the chance of consistent quality results go up.
Good luck,
Mats Hagstrom MD

Mustafa Aydinol, MD - Account Suspended · Answer

Based on your description and photos, it sounds like you may benefit from a transconjunctival lower blepharoplasty, especially if the primary concern is under-eye bags or puffiness without significant skin laxity. This approach allows for fat repositioning rather than removal, which helps avoid a hollow or sunken appearance post-surgery.
Fat grafting can be a good complement to this procedure, particularly if there is noticeable volume loss in the tear trough or midface area. It creates a smoother transition between the lower eyelid and the cheek, enhancing the overall result. Since you’ve had fillers, dissolving them before surgery can provide a clearer view of the underlying structures and ensure a more accurate surgical plan. It can also be dissolved immediately before the surgery.
In addition to surgery, microneedling can improve skin texture and fine lines around the eyes post-recovery. It promotes collagen production and enhances skin quality over time, offering a more comprehensive rejuvenation.

Lower blepharoplasty - with or without fat transfer? (photos)

Answers (8)

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