What is the Best Approach for Tear Trough Deformity if Fillers Are Not Giving the Desired Result?

I have fat loss/ mid face descent tear trough deformity awful dark circles. Large eyes, create double whammy of shadow. I have filler but I still look bad. If filler doesn't do the job what is the best approach for my eyes? Do I need a mid face/cheek lift, fat transfer, archis marginal release or implants? I have also been told who ever does it needs to be super careful or it will make my lower eyelids droop. Should I only have this done by an ocular plastic surgeon ?

Doctor Answers 14

Tear trough and eye-cheek junction rejuvenation

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Often, the cheekpad has drooped, leaving the lower eyelid hollow with a bulge due to the prominent fat.

We get our best results with modification of the fat and a suborbicularis cheeklift (USIC cheeklift, ultrashort incision cheek lift).

Sometimes there's just no substitute for lifting the cheek pad.

As to who should do the procedure, some plastic surgeons have a published interest in the mid face and extensive experience with midfacial and cheek procedures, and some don't, so research carefully!

Beverly Hills Plastic Surgeon
4.9 out of 5 stars 194 reviews

Dark Circle and Lines Beneath Eyelids

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The first suggestion I would make would be to send some photos to get the best answer in this type of forum.  All the suggestions that you have made are reasonable but this is where the picture helps.  You certainly can have an ocular plastic, facial plastic or plastic surgeon address your concerns.  The key is that you select a surgeon that has experience with correcting concerns and is board certified in the one of those specialities mentioned

Dr. ES

Treatment of the Tear Trough Deformity

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While fillers can often soften the valley along the lower eye socket, they only address one aspect of the tear trough. The best approach depends on your individual anatomy and should be assessed in person. Excess skin and fat can be improved through a lower eyelid approach. Arcus marginalis release can allow some lifting of the cheek fat pad, but it is very important to avoid excess tension on the lower eyelid to avoid any drooping. Facial plastic, oculoplastic, and general plastic surgeons may all be able to perform such surgery, but it is important that they are experienced in the required procedure. Fat transfer is another technique that may help soften the hollow of the tear trough and improve the deflation of the cheek fat pad.

Gregory J. Vipond, MD, FRCSC
Inland Empire Facial Plastic Surgeon

lower blepharoplasty and cheek implants for midface descent and fat loss

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 In the   aging process the  the midface loses volume and does  not necessarily descend with gravity. The best treatment for volume loss in the mid face is not a vertical upward  lift, but a conservative augmentation of that area with Silastic cheek implants. Any additional herniated fat in the lower lids creating puffiness is removed with a transconjunctival  approach. The dark  discoloration of the skin will still need to be treated with make up for camouflage

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 157 reviews

Tear Trough

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Without a photo or an exam it is hard to answer. The tear trough area in the medial lower lid is amongst the first area where aging shows. As we get older, our facial structures get longer from gravity and weakening of our suspension support system. The tear trough is a space inbetween two muscles so in the early years fillers are great. As we get older orbital fat preservation and blepharoplasty are helpful here and with a lift of the cheek pad. All the best.

Correction of Tear Trough Deformity of Lower Eyelids

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If fillers have not corrected your tear trough deformity, then an aggressive lower blepharoplasty is probably indicated, though it would be impossible to tell without a full examination. The procedure I do is a form of cheek lift with full arcus marginalis release, rotation of the fat over the orbital rim and securing the muscle and septum to the lateral orbital rim. It also usually includes a canthopexy or canthoplasty. The latter two parts are designed to stabilize the lid upward and laterally and prevent droop. There are, of course, other methods, but, having tried them, this is what I find works best for me. Who does this should be very expert in the procedure with verifiable results whether they are occuloplastic, plastic or other.

Robert T. Buchanan, MD
Highlands Plastic Surgeon

Tear troughs and under eye circles

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If hyaluronic fillers (I prefer Teosyal Redensity II) are not doing an adequate job, you may need further correction with fat grafting to add greater volume to the region. There are implants available for the tear trough, but most surgeons have avoided them due complications in the area (the skin is very thin, with minimal coverage.)

Jamil Asaria, MD
Toronto Facial Plastic Surgeon
4.8 out of 5 stars 139 reviews

Your tear troughs

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You are correct in your conclusion that fillers in the tear troughs are a less than ideal solution.  Without seeing you in person or seeing images of your eyes, it is hard to determine exactly what you need.  However, my most common solution for this problem is a transconjunctival lower eyelid blepharoplasty with arcus marginalis release and fat transposition.  This moves some of the fat under your eyeball to the tear trough area filling it in.  The fat is placed under the periosteum, the coating over the bone.  I have attached a link for you to review. Who does it depends on the experience of the surgeon and how much you like the surgeon.  Facial plastic surgeons, general plastic surgeons and oculoplastic surgeons all do the procedure.

Stuart H. Bentkover, MD
Boston Facial Plastic Surgeon

Tear Trough Deformity and Dark Lower Eyelid Circles

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It sounds like your face is begging for the endoscopic brow midface lift with simultaneous microfat grafting to the periorbital fat pads.  I prefer to do this through a temporal incision and expect rejuvenation to cover a broad area including the forehead, lateral brow, eyelids, cheeks and high SMAS which extends just beyond the corner of the mouth.  No effect will be seen in the neck so a tuck is sometimes desired to blend this area.  I avoid incisions that cut the orbicularis muscle so as to avoid lid droop or rounding of the corner of the eyelids.

Steve Byrd, MD
Dallas Plastic Surgeon
5.0 out of 5 stars 22 reviews

Lower eyelid blepharoplasty for correction of deep tear trough problem

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Soft tissue fillers to the tear trough area will have a limited effect on some lower eyelid conditions.  If you have thin tissues of the lower eyelids and fullness due to herniated fat then a  lower eyelid blepharoplasty may be a better choice.  There are several important components that would need to be considered in this particular situation.  The fat can be used to fill in the tear trough groove from the mid pupillary line medially.  If you have any degree of lateral thinning and exposure of the lateral orbital rim then the upper malar cheek can be elevated and used to fill in this zone.  The orbicularis muscle can be tightened and a small amount of skin could be removed.  If the lower lid is lax then it may need to be tightened using a cantholysis and canthopexy.  A photograph would be helpful to determine the extent of your problem.  

Jeffrey Zwiren, MD
Atlanta Plastic Surgeon
4.5 out of 5 stars 20 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.