Blepharoplasty with or without fat transfer? (photo)

Question

I have been looking around for a surgeon to fix my under eyes for a long time. I've had tear trough filler and cheek filler (Restylane and RFA). However, I would like to finally resolve the issue. I am wondering if I would need a bletharoplasty under eye with or without fat transfer to my cheeks. As I've been told differently. I've attached pictures without filler (first 3) and with filler (RFA) (last 2). I want to get filler dissolved as well thank you

Andrew Miller, MD · Answer

Based on your photos, you are a great candidate for lower lid eyelid surgery plus fat transfer to give you a long term correction of your issues. The filler can be dissolved prior to surgery, but you should have a great result with a well performed procedure with a facial specialist.

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.

Allan E. Wulc, MD · Answer

You look very young. 
Obviously, this is not an aging problem but one that relates to the position of your eye relative to the cheek bone that supports it and to fullness and minimal skin changes (the dark circles). Other causes like sinus problems can give rise to dark circles.
Your filler might not have been successful because (1) small puffs of your lower eyelid fat would be difficult to conceal without overfilling, (2) the dark circles remain concave and lower toward your cheeks-not right up against the eye, and (3) filler can cause a bluish discoloration right where you want to be improving the darkness. 
Ultrasound can be useful in locating and dissolving the filler and you're right--you should absolutely do that before any surgery. Filler can muck up the surgery by clogging up the lymphatics that drain swelling and also can't tell you what the endpoint should be with regard to the sculpting.
In my practice, we've had success performing transconjunctival blepharoplasty and taking the fat into the hollow (adjacent fat transfer) which, because it has volume and is yellow, helps improve the darkness in that location and lifts and supports the cheek. I'd probably add additional fat (liposculpture) to areas that needed additional volume in small quantities, and use nanofat to help with the discoloration. (Because of your age--you have so much ahead of you--I would be conservative on the amount of fat added by liposculpture--who knows whether your weight will fluctuate in the future and the grafted fat can increase in amounts and cause lumps.)
I think this would provide you with an excellent improvement and be a very good solution to what is bothering you!
Good luck
Allan Wulc, MD, FACS

William Portuese, MD · Answer

Regarding the lower lids, it's probably best to have those fillers reversed before making a surgical decision. At your young age, the fat deposits which are herniated orbital fat can be removed through a trans conjunctival approach with the incision located completely on the inside of the lower lids. No external incision is required. We do not recommend fat injections into the eyelids. Choose your cosmetic eyelid surgeon wisely based on extensive experience producing natural results.

Douglas McGeorge, FRCS(Plast) · Answer

A lower lid blepharoplasty with lifting of the mid-face tissues will help address your issues.
I would suggest a consultation with a surgeon, comfortable with mid-face lifting.

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