I am 35 and am bothered by lower eyelid puffiness. More often, I am having people tell me I look tired when I've had a full night's sleep. I have talked to an oculoplastics surgeon who recommended removal of the lower medial fat pads only. I am concerned this will result in a hollow underneath my eyes as I age. Should wait to have a transcutanous bleph and just have filler done in the mid cheek area to smooth out this puffiness or have it done now to prevent more sagging of the undereye area?
Lower Transconjunctival Bleph +/- Filler? Second Opinion? (photo)
Doctor Answers 7
Re-position of Lower lid fat pads prevents later hollowing
From the limited photos you provided you have two options that I would recommend.
1. Transconjunctival fat pad adjustment either with a conservative removal or releasing the restraining membrane (arcus marginalis) and allowing the fat pad to be redistributed to blend in with your cheek fat. If done conservatively I do not think you would be at increased risk for any abnormal hollowing.
2. Use of fillers beneath the fat pad to camouflage the bulging fat (this would only be temporary solution
As with skin removal, I believe that the reduction (NOT total removal) of lower lid fat pads should be conservative. Excessive removal of lower lid fat pads results in a hollowed-out appearance that makes blepharoplasty patients look tired or even ill. I see quite a number of eyelid surgery patients who require structural fat grafting of the lower lids to improve that very problem following an over-aggressive lower blepharoplasty in the past.
In some case lower lid 'bags' can be improved by repairing or reinforcing the soft tissues that normally hold them back. Additionally, excessive lower lid fat can sometimes be mobilized and transposed inferiorly to fill in periorbital hollows or depressions such as the 'tear trough' at the medial junction of the lower lid and cheek.
Some eyelid 'bags' involve redundant muscle tissue which must be removed and/or repositioned, usually in patients who are in their sixties or older. This is performed through an under-eyelid (sub-ciliary) incision which is extended laterally into the 'crow's feet' area.
Treatment of tear troughs
I think you could get what you want from just placing a filler in the groove or trough. You will need to discuss which filler with your surgeon. I think if you just take out the fat you will end up skeletonizing the area leaving you with a hollowed out appearance.
My response to your question/post does not represent formal medical advice or constitute a doctor patient relationship. You need to consult with i.e. personally see a board certified plastic surgeon in order to receive a formal evaluation and develop a doctor patient relationship.
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Thanks for the photo. I would first do the transconj including 2 of the 3 fat compartments. Allow 2 to 3 months healing than use a filler if needed.
A transconjunctival bleph is usually the best for young patients with lower eyelid fat. I do not like fillers in the lower lids, removing the fat is usually the best treatment.
Please post better photo.
From the photo you posted, it seems to me that using fillers or fat grafting would give you a more natural result right now. Photo does not replace the need for a good hands on exam, and it may be your surgeon is correct, and that I will come to the same conclusion if I examined you in person.
Get a second opinion. Not all surgeons are comfortable with fillers.
An ASOPRS trained Oculoplastics surgeon near you is available on ASOPRS dot org.