Very deep tear troughs, do not want filler. Surgical or non surgical route? (Photos)

Hi, thanks for your question! In general, options for tear trough management include 1) Dermal fillers such at Restylane 2) Fat grafting (usually taken from the abdomen, thigh, or gluteal region) and 3) Lower blepharoplasty with fat repositioning. Surgical treatments tend to be more durable, but some patients find it helpful to trial filler (which is shorter lasting) before comitting to a procedure. As always, I recommend consulting in person with your physician before making any treatment decisions. Hope this is helpful!

I don't see any eye bags in the photos, but I do see the deep tear troughs. Without using fillers ( HA or biostimulatory), I would recommend autologous fat injection or fat transfer from the lower eyelid. In your case, there is no need to remove any bulging fat. Both procedures would provide an improved contour to this area. The fat is usually taken from the abdomen or inner thigh to be transplanted to the eyelid and cheek junction.

In cases like yours, deep tear through deformity can be treated with transconjuctival lower blepharoplasty. This will improve TT without need for skin removal. In person consultation with a board certified plastic surgeon familiar with this procedure is recommended. Good luck.

Since you haven't done anything yet to this region, I would recommend that you start slowly.
PRP/PRF/PRF gel are all great options for the undereyes. The risks of doing these are very low, the results are nice but not overdone, in the right hands, and can also help in collagen regeneration.

Fillers, which you noted you want to avoid, can be done, but a very smooth and thin one must be used for this delicate area. Despite the expectation that fillers (HA) will dissolve, they don't always, so that must be considered when using these anywhere but especially the unforgiving undereye region.

Fat can be a nice option but since you haven't done anything yet, I wouldn't recommend jumping into this potentially permanent option.

Sculptra is not intended to be used in this area though some providers use a more dilute solution for this off-label indication. I wouldn't jump into this option yet either.

Anatomically, the eyes appear to be significantly recessed backward. The eyebrows are protruding, while the eyes themselves are sunken inward.As a result, there is a lack of volume under the eyes, and the tear trough is deeply pronounced.There is a severe tear trough hollowing accompanied by protruding fat, creating a noticeable step-off that casts shadows, making the area appear more severe and tired.A surgical option to consider is lower eyelid fat repositioning. This procedure approaches through the conjunctiva to release adhesions around the tear trough and repositions the fat to fill the hollowed areas.Based on the photos, there seems to be limited fat under the eyes, so additional fat grafting may be necessary.

The anatomic area where the lower eyelid transitions to the mid face is indeed a difficult area to work in.
Fundamentally the issue is based on bone structure and not soft tissues.
Insufficient midface skeletal support is causing this problem.
There are several ways of addressing this.
Volume restoration of the midface can be done using implants, fillers, fat transfer, and a mid face lift.
Removal of the fat in the lower eyelid is done through lower eyelid surgery, which can be done from the inside or the outside of the lower eye lid.
Some providers may recommend volume and have spent of the midface while others may think it’s easier to get the results by removing fat from the lower eyelids.
Considering that the primary problem is lack of skeletal structure support volume enhancement is probably your best option.
Fillers are the most predictable and forgiving so that would be the place to start.
The difficulty with fillers is finding someone with sufficient skill and experience to do a good job.
Average providers do average work and because this area is technically difficult average work sometimes isn’t very good.
I generally do not prefer fat transfer.
I found it to be too inconsistent.
A mid face lift could give a very good improvement, but is a fairly involved procedure.
Implants are typically not used anymore, but were an option decades ago.
The main reason providers typically don’t use implants is because we have such great fillers to work with.
To see what fillers can accomplish consider looking at the website of Dr. David Mabrie MD in San Francisco.
Real self will not allow me to include a website link so you’ll have to Google his name.
His website has an impressive collection of very good before and after pictures.
David is a facial plastic surgeon whose entire career is devoted only to injecting fillers.
His work is the best I’ve ever seen.
His outcomes are what I consider the gold standard for what can be done using only fillers.
I’m not suggesting everybody fly to San Francisco to get fillers.
I do think seeing his results can be a powerful tool, helping people understand what can be accomplished using only fillers in the hands of the right provider.
Personally, I recommend starting with fillers because if you don’t like the results, they are reversible.
This cannot be said for surgical intervention.
Best,
Mats Hagstrom MD