Should I Have Blepharoplasty or Restylane on Tear Trough?

I am trying to decide if lower blepharoplasty (fat repositioning) or tear trough rejuvenation with Restylane is best for my problem? I have fat prolapse on my right side resulting in a more puffy appearance above the tear trough and on the left have more extensive hollowing. I am just lost as to which gives best results. I am getting married in August & concerned with complications / recovery of the surgery but wonder if ultimately it is the better option? I have also been told that my mid face area seems to be attributing to the overall problem?

Doctor Answers 25

I'd recommend the fillers

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As said before, you are showing your eyelids in their most unflattering pose. Even here, though, I don't think you have enough fat to reposition and effectively hide your tear troughs. In my opinion you would still need fiiler so why not just do it all with the fillers in the first place. It eliminates the risks of eyelid surgery which are higher in the lower lids and sometimes are hard to correct. Even though they need repeating, the results are actually better looking that what surgery could do for you. You could also enhance your cheek volume at the same time.

Transconjunctival Blepharolasty with arcus release and fat grafting

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I do not recommend filler injections into the tear trough. While many doctors do them I have seen many complications such as visible lumps and discolorations. Blindness following filler injection around the eye has been reported in England.

The transconjunctival blepharoplasty with arcus release and fat grafting or repositioning is the most effective treatment for dark circles and tear trough deformity.

The puffiness of the lower lids will be corrected as well.

See before and after pictures.

Restylane vs. surgery

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The photograph is not completely telling because you are looking up and a bit to the side, which accentuates the bags under the eyes. Your eye configuration is one of a prominent eyeball (globe); hand in hand with a large eye is often a very visible fat bulge below the eyes.

The most effective way to treat a bulge below the eye is with a transconjunctival blepharoplasty. That way the danger to the lower eyelid is very low.

If you try to build up the areas surrounding the bulges with temporary filler, even if you don't have a complication, you will likely be much poorer (the amounts needed will be significant) and in my opinion I would not recommend that course of action, especially from an aesthetic standpoint.

Aesthetically, you can do the math and see how bulging your lower eyelids would be if everything were brought to the level of the lower eye bulges... not very attractive. Sometimes a small amount of lighter HA filler is excellent at producing camouflage of the bumps without breaking the bank, a good compromise if the patient doesn't want to have surgery and doesn't mind frequent treatments. Typically these treatments would need to be repeated every six months in this area.

It is indeed possible to adjust the lateral canthus to reduce the appearance of a prominent globe with the aid of a limited incision cheeklift. It is also possible to elevate the midface slightly through a cheeklift. But again, lots of surgery. Many articles and chapters on our website under Articles.

Fat transposition surgery usually requires an incision below the eyelid and division of the arcus marginalis. For the small amount of fat you have, I wouldn't recommend that approach. Relatively invasive and complication prone in the wrong hands. I would rather see you have a transconjunctival blepharoplasty and later do small amounts of filler below the eyes.

Restylane and Juvederm are heavy fillers and can in some patients cause edema around the eyelids that is long-lasting (Juvederm more than Restylane), so if you have an important upcoming engagement, do you want to take that chance? There are lighter fillers such as Prevelle which are less risky.

And Radiesse, Artecoll, and any semipermanent filler are in my opinion a terrible idea because of the potential for untreatable lumpiness and chronic inflammatory complications in the future.

Brent Moelleken, MD
Beverly Hills Plastic Surgeon
4.9 out of 5 stars 188 reviews

Lower eyelid rejuvenation

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Many doctors promote under eye fillers. But fat grafting is the only material I think is reliable for under eyes. My eye rejuvenation gallery includes many fat grafting before and after images. I have yet to find a large number of  other before and after fillers under the eyes.

However, from this single photos, I cannot determine which approach could be best. fat repositionsing might be a good approach for you. 

Michael Law, MD
Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 123 reviews

Eyelid surgery v Restylane

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I agree that the photo isn't the most flattering but you should see how the Dept of Motor Vehicles captured me on my license picture! Either procedure would improve your appearance but I generally recommend that patients try a Restylane treatment initially. It's inexpensive, has basically no downtime and may give you an improvement. If you want to enhance the appearance of your eyes even more, then surgery is definitely an option. Congratulations on your forthcoming marriage!

A combination procedure works great for tear troughs

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Removal of the excess fat is important to a great long term result, but be careful not to over resect it. I like to combine the fat reduction with a fat transfer into the tear trough or line under the eye. The fat transfer can give a very long lasting result and is quite predictable. A fat repositioning procedure has a little higher chance of resulting in lumpiness or incomplete correction. If the correction is incomplete with the fat transfer, you can simply put more in. Juvederm and Restylane are temporary and you have to be careful not to overinject which could result in prolonged swelling. Good luck.

Save yourself and don't have lower eyelid surgery.

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Dear Eyebaghell

First it is not possible to position your face in a more unflattering manner. Looking up brings out the lower eyelid fat. So this will be your lower eyelid bulges at their absolute worst.

Second, there is no substitue for a personal consultation. Having said that, the biggest problem you have is a relative weakness in the projection of the orbital rim at the top of the cheek. This makes this area lack aesthetic strength and accentuates the tear though area. The arcus marginalis release will take volume from the lower eyelid and place it at the top of the cheek. This will be helpful but the overall effect will be quite modest at best. More radical surgical approaches involve the placement of a tear trough implant or an orbital rim implant like an ePTFE implant. However, these are very big surgeries. Generally I reserve this approach for people who have been disappointed (doctor speak for wrecked) by prior eyelid surgery.

In contrast, filling the lower eyelid with Retylane and the top of the cheek with Perlane will be brilliant. The key is getting enough of these products to make a real difference. It will cost like surgery but I think you need two milliters of Restylane in each lower eyelid (a total of 4 ml) and 0.5 milliliters of Perlane placed at the top of the cheek (a total of 1 ml). The result properly done will be better than any surgery you could have. The service will last about a year and a half.

Don't let anyone talk you into other fillers. Juvederm is a little too "soft" for this area and tends to drift out of the tear trough area and into the top of the cheek. Radiesse can be lumpy in this area as can virtually any other filler including evolence. The other thing about the Restyalne and Perlane is they can be adjusted with Hyaluronidase, an enzyme that erases the filler. This fexiblity is simply not available in nonhyaluronic acid fillers. Because this area has such thin tissue covering, this ability to adjust these treatments make the non surgical make over of this area possible.

Given that you are in the UK, I am going to recommend that you stay away from general plastic surgeons who are going to be primarily interested in cutting you. You really need a cosmetic dermatologist who is doing a lot of under eye Restylane treatment and knows what they are doing. This means doing your homework. I would recommend an eye plastic surgeon but in the UK, these are very rare birds who are too busy to bother with silly treatments.

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

The Management Of Tear Trough Deformities

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It's not unusual for patients with tear trough deformities to request plastic surgical consultation. When this situation arises, a variety of treatment options exist to treat this condition. These include surgical procedures that release the arcus marginalis and the use of injectable hyaluronic acid fillers that minimize tear trough deformities.

It's extremely important to individualize the treatment of tear troughs. For this reason, the specific procedure chosen will depend upon the patient's anatomic findings and aesthetic goals.

It's important to realize that lower eyelid filler injections can be very effective for treating tear trough deformities, but aren't for everyone with this condition. In some patients the lower eyelid skin is extremely thin and for this reason, injectable fillers aren't always indicated. In addition, this technique only provides a temporary solution to the problem and can sometimes result in lower eyelid discoloration and nodule formation.

When patients have excess lower eyelid fat, arcus marginalis release and fat re-positioning is appropriate. This procedure is associated with excellent clinical results.

It's important for patients with tear trough deformities to consult a board certified plastic surgeon with experience in this area. This surgeon should be able to formulate a treatment plan that addresses your anatomic findings and achieves your aesthetic goals.

Filler for undereye

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I have good experience with fillers for the under eye area (tear troughs) and have seen beautiful results achieved. I use Teosyal Redensity II, a filler that is specifically for the lower eyelids. It can also help with any dark circles in the area.

Combination of bleph and fillers

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From the photograph, you have a little fat in the lower eyelids bulging forward. You also have slight loss of your mid-face(cheeks). A lower blepharoplasty with fat transposition would shift your fat down towards the cheeks. In addition, a little extra volumizing with fillers in the mid-face would accentuate the overall look. See an oculoplastic surgeon who specializes in both procedures. 

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