I have fat pockets under my eyes. What is the best treatment? Some doctor say surgical removal others say filler.

    This would be difficult to make a determination without an examination or pictures. Kenneth Hughes, MDLos Angeles, CA

Most expert experienced artistic plastic surgeons have a variety of procedures at their disposal to produce excellent cosmetic results in the appropriately selected patient with bulging herniated fat pads and accompanying areas of hollows of their lower eyelids: temporary fillers with hyaluronic acid fillers like Restylane which usually last 6 months to 1 year, micro-fat grafts of your own tissue - 30-50% lasts permanently, and blepharoplasties . There is no one best procedure that would be applicable for everyone. Each has benefits and potential drawbacks. The vast majority of board certified plastic surgeons with extensive experience in eyelid surgery and soft tissue fillers would warn against using a permanent synthetic filler because of the long term complications which can occur even years after injection and are difficult if not almost impossible to correct.The best option in any particular patient needs to be individualized based on desired outcome and personal anatomy. If the fat pad fullness is significant just adding a filler or fat grafts generally does not produce a satisfactory cosmetic improvement.Following the advice of anyone who would presume to tell you exactly what to do without seeing photos and without taking a full medical history, examining you, feeling and assessing your tissue tone, discussing your desired outcome and fully informing you about the pros and cons of each option would not be in your best interest. Find a plastic surgeon that you are comfortable with and one that you trust and listen to his or her advice. The surgeon should be certified by the American Board of Plastic Surgery and ideally a member of the American Society for Aesthetic Plastic Surgery (ASAPS). You should discuss your concerns with that surgeon in person.Robert Singer, MD FACSLa Jolla, California