Lower Blepharoplasty or Hyaluronic Acid/Restylane For Puffiness and Prominent Tear Troughs? (photo)

Hi, I'm 24 years old but I've had quite prominent puffiness and tear troughs around the eyes for about 2 years (they are much worse in the morning but don't go away.) I have consulted a plastic surgeon who immediately suggested a lower transconjunctival blepharoplasty but he doesn't know if a blepharoplasty will fix the dark line (tear trough). I've heard a could actually make them prominent. Please let me know what you think!

Doctor Answers 14

Tear Troughs in the Lower Eyelids

The wrong thing for you to do would be to let someone take the fat out of your lower eyelids.  The bags will improve, but you will have an aged, hollow, long lower eyelid. 

The best result would be possible only with surgery.  While many surgeons advocate fat grafting this process is fraught with problems.  Particularly the fact that fat survival is un-predictable, prone to future fluctuation and the procedure is not reversible.  Furthermore the added soft tissue volume tends to be too full when smiling.  It is my preference to use a tear-trough implant and based on your photograph you would be a very good candidate.  This can be thought of as reshaping the skeleton of the lower orbital rim/upper cheek area to bring the soft tissues of the cheek, the orbital fat, and the bony rim into proper alignment.  The goal is a soft round cheek blending seamlessly into the lower eyelid.  The implant feels like bone once in place, does not bunch up/move with smiling, and does not change over time.

Injectable fillers such as Restylane can provide descent correction of the problem temporarily.  I would suggest this if your budget doesn't allow for surgery, if you are just not mentally ready for surgery, or if you don't have any time for surgery.  Restylane into the lower eyelids should only be done by an experienced physician injector, preferable a surgeon.  A very thorough knowledge of the anatomy is necessary here.  Generally the procedure results in only mild swelling and slight or no bruising.  The correction will not be as complete as surgery but it can be very satisfying.  I would suggest using 1/2 cc on each side.  The product needs to be kept very deep (against the bone) to avoid bruising, lumps, and a bluish tinge to the skin.  An additional 1/2 cc per side may be beneficial but I would suggest waiting a few weeks after the first treatment before adding more (if at all).  When done with a proper nerve block, it is essentially painless.  I would say that Juvederm is acceptable but not as asspropriate as Restylane.  I would also tell you to absolutely avoid Radiesse or Sculptra in this area.

Austin Facial Plastic Surgeon
4.9 out of 5 stars 30 reviews

Best Treatment for Dark Circles and Hollow Lower Eye Lids in 24 Year Old Itallian Woman

Hi Valentina,

I would treat you with Ulthera (ultrasound tightening of your lower eyelid), followed by the injection of Restylane to fill any remaining lower eyelid hollow.  I would wait at least 3 months after the Ulthera before filling, as you will likely require much less.  The dark circles under your eyes should improve as the trough is filled.  Transconjunctival blepharoplasty (surgery) should be a last resort in a 24 year old Italian women.  Ciao bella.  Good luck and be well.


Dr. P

Michael A. Persky, MD
Encino Facial Plastic Surgeon
4.8 out of 5 stars 36 reviews

Lower eyelid procedures

The dark circles may be related to shadowing or discoloration. If shadowing, fillers such as restylane may help.  Conservative fat removal may be beneficial  as well but an exam is essential.  In addition during sugary, release of the arcs marginalis may help soften that depression

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 29 reviews

Lower Eyelid Bags with deep circles

Judging from your photo, I would not recommend surgery for several reasons. The appearance of bags in your case is not due to oversized fat bags but rather by a hollowed tear trough (the groove under the "bags". Performing surgery to remove the normal amount of fat you have would simply lead to hollowing rather than an improvement. In addition, because your young age, your face will change, particularly the skin and subcutaneous fat in this area.

The option with best results and lowest risks is filler injections, usually Restylane. As mentioned, the injections need to be performed by an experienced physician as this is a delicate area with a high risk of lumpiness in inexperienced hands.

Mark Samaha, MD
Montreal Facial Plastic Surgeon
4.8 out of 5 stars 77 reviews

Fillers would be a better option

With your age, and the appearance of good skin elasticity, I would not normally recommend surgery. Properly placed filler in that area can help reduce the "dark" circle look and is very safe. Taking fat out now would only to later "hollow" out your eye and actually make you look older. Filler in this area last a very long time, often 1-2 years and usually does not require a large amount of filler.

Samson Lee, MD
Seattle Facial Plastic Surgeon
5.0 out of 5 stars 7 reviews

Transconjunctival lower blepharoplasty would classically be offered.

However, removing the lower eyelid fullness will leave you a bit hollow under the eyes.  The state the art treatment for this would be under eye fillers with Restylane.  It is essential that you find a cosmetic surgeon who regularly performs this treatment and understands how to shape and adjust this product with enzyme when necessary.  This type of treatment typically last about a year or more and it is likely that you can continue to have these treatment for a very long time, making surgery unnecessary for the foreseeable future.

Kenneth D. Steinsapir, MD
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

Lower eyelid bags and tear trough options.

At 24 years old the lower eyelid area should just be beginning to show early signs of aging. In some cases, the lower lids area can appear more aged due to a genetic preponderance of volume loss over the inferior orbital rim. This leads to tear trough deformity and accentuates the early appearance of "eyelid bags" in this area. Volume addition using injectable fillers or fat grafting can help to refill thehollowing tear trough area. Often this your of treatment yields more natural looking results than traditional blepharoplasty techniques that rely on removal or repositioning of fat. My recommendation would be to consider fillers or fat graft at this time. There are examples in the photos section of my profile for your review. Good luck! Dr. Torkian

Behrooz Torkian, MD
Beverly Hills Facial Plastic Surgeon
4.3 out of 5 stars 17 reviews

HA fillers for tear troughs and peri-orbital hollowing #plasticsurgery

The fat that you see along your lower eyelids is normal. You would benefit from more volume along the tear trough and malar zones - this would raise the apparent junction between your cheek and lower eyelid and would help to conceal the peri-orbital fat pads that you see. Restylane and Voluma are good fillers for this application and need to be placed on the bone and massaged after injection. Fat grafting is a long-term option with less predictability.

Scott C. Sattler, MD, FACS
Seattle Plastic Surgeon
4.8 out of 5 stars 65 reviews

Lower Eyelid Surgery or Filler for Young Patient

Thank you for sharing your photographs.

Generally, there are a few options to improve the appearance of the lower eyelids, eye bags, or dark circles. First option includes basic skin care, tretinoin, and/or chemical peels. This nonsurgical method helps improve the skin quality, reduce pigmentary changes, and improves overall appearance of the lower eyelid & cheek areas.

Second more advanced option is an injectable filler or fat to plump up the area. Fillers are made of material that is slowly removed over time, such as Restylane. Facial fillers treatment is quick and performed in the office with minimal recovery.

The last option, and also the most aggressive, is eyelid plastic surgery (blepharoplasty). Cosmetic surgery of the lower eyelid may remove or reposition fat in the eye bag area, and possible remove some sagging skin. Plastic surgeons typically don't recommend cosmetic eyelid surgery in young patients. However, each patient is unique and circumstances may vary. Age alone is not a determining factor if a person is a cosmetic surgery candidate.

Only after a comprehensive evaluation can a specialist help determine appropriate options for you. Best of luck.

Dr. Chaboki

Houtan Chaboki, MD
Washington DC Facial Plastic Surgeon
4.9 out of 5 stars 85 reviews

Blepharoplasty in 24year old

You have prominent fat in your lower lids. this is unusual in someone you age. Assuming no medical issues for your problem I would address the 'puffyness" under your eyes. The treatment for the fat would be a re-positioning of the herniated fat and possibly a resection of a portion of the fat. The discoloration is a difficult problem that is rarely totally corrected. the discoloration can be improved with a combination of bleaching agents and laser in my experience. The tear trough regionis improved by re-positioning a portion of the fat.

Jay M. Pensler, MD
Chicago Plastic Surgeon
4.6 out of 5 stars 14 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.