Third & final opinion. Lower bleph with or without fat transfer? (Photo)

Thank you for your question. You submitted a single photo of your eyes in close up, and state you had two consultations for lower eyelid blepharoplasty. One surgeon recommended lower eyelid blepharoplasty with fat grafting to address potential hollowing, and the other surgeon recommended lower eyelid blepharoplasty with fillers afterwards to address the hollowing if necessary. You’re torn between the risk of having fat grafting as you’re concerned about lumps and other potential issues, and you’re not excited about needing fillers.
I can share with you how I counsel my patients with exactly the same scenario. A little background: I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I have been in practice in Manhattan and Long Island for over 20 years. Helping people with under eye aesthetics including blepharoplasty, fillers, and other modalities like lasers etc. is a big part of what we do every day in our practice.
For the concerns about under eye hollowing after eyelid surgery, it’s important to first anticipate and recognize the risk of looking hollow after surgery. When people research eyelid surgery, they’re often afraid of looking too hollow. I explain the style and approach of how I do this surgery where I reduce the fat pockets so it looks as if you never had the bags to begin with. If you can imagine that, then you would probably not have the surgical procedure to fill the hollows given the modern choices there are now.
It’s also important to distinguish the relative hollowing in terms of the spaces relevant to creating the perception of hollowing. As we get older, we lose bone, and fat which create a diminishing of the structure of the facial architecture. When I look at a person’s eyes, I also look at their cheeks and how it relates to the whole face. Areas often overlooked are the cheekbones and the submalar space where there’s opportunity to add volume.
As far as the pros and cons of fat grafting versus filler, it’s fairly straightforward from my perspective. As a surgeon, I have done fat grafting and I still will do fat grafting. BI can tell you as a referral specialist that I have dealt with a lot of complications of fat grafting. Fat grafting can cause lumps, create bumps and irregularities. The surgery to address these issues is far more complicated and involved than using fillers. In contrast, hyaluronic acid fillers are reversible.
The other thing very important to understand is recovery. You also have to differentiate the type of blepharoplasty. Often the combination of lower eyelid surgery with fat grafting is popular among general plastic surgeons where they’ll make an incision on the outside where they approach the fat pockets, remove some skin, suture, then do fat grafting into that same space. These patients tend to look very swollen and bruised after one week ,and tend to have lingering swelling and bruising for weeks beyond that.
In the modern world, it is usually the desire of most people, regardless of the type of work they do, to get back to work pretty quickly. I generally do lower eyelid blepharoplasty from a transconjunctival approach done from the inside of the eyelid. Often patients come back to us after one week and they have no bruising. When it comes to expediency, I would say blepharoplasty alone from a transconjunctival approach is probably the quickest recovery, especially the way we do it in our practice which I feel is optimal with local anesthesia with LITE™ sedation. There’s no general anesthesia and no recovery from general anesthesia, and we do it in our facilities certified by the Joint Commission.
For the ongoing maintenance issue, most patients who pursue aesthetic procedures are obviously inclined to be concerned about their appearance. Not everything is a surgical procedure that can last for the rest of their lives. I look at maintenance as an exercise where you apply time and effort toward the most optimal look for yourself. The way I express it to my patients is you are trying to match the way you feel in the inside, with the way you look on the outside, so maintenance is important. That could mean getting injectable fillers in the cheeks, chin, and other areas, doing some non-ablative laser, facials, as well as injectables like Restylane or other hyaluronic acid fillers in the tear trough on a semi-regular basis.
From my perspective practicing in New York and having patients who come from all around the world, I would say predictability is critically important, and there’s very little tolerance for protracted and unpredictable healing time. I would lean towards being conservative because frankly, fat grafting, although techniques and technology have improved, but predictability has remained unchanged. 30-70% of fat can be absorbed, and some of that fat can result in lumps,irregularities, and scarring, which are outcomes not easy to manage.
In a situation like yours, I would generally say to considering doing just a transconjunctival blepharoplasty. If you are going to do fillers during surgery, you might think about fillers in the cheek area, but again that would be more of a consultation-dependent evaluation with multiple angles on the face. Then after 3-6 months, determine whether there’s opportunity to enhance the tear trough.
One last thought is fillers in the tear trough tend to last. Even though we’ll say they will last maybe up to 6 months based on manufacturer’s guidelines for expected longevity, there are patients who have had tear trough filler for years. The concept is probably due to some encapsulation of these fillers where they can last considerably longer.
Again, it’s about meeting with a doctor who gets this, and will be there for you in ongoing follow-up. In our practice, I’m not just a surgeon who does all these procedures, but I have also become their primary care doctor for beauty, so I end up doing a lot of others things to help maintain and optimize their appearance for many years to come. I hope that was helpful, I wish you the best of luck, and thank you for your question.This personalized video answer to your question is posted on RealSelf and on YouTube. To provide you with a personal and expert response, we use the image(s) you submitted on RealSelf in the video, but with respect to your privacy, we only show the body feature in question so you are not personally identifiable. If you prefer not to have your video question visible on YouTube, please contact us.

You are right to be concerned as this is a delicate  area.  More photo views would be helpful.  You do not appear to require  skin removal, so any surgical procedures would be best performed from inside the eyelid to remove of reposition fat  but avoid a scar. Fat transposition seems  like a good option but the possibility of insufficient fat, and maintaining proper placement during  healing can affect the final outcome. You could still need touch up fillers. The more conservative option would be sequential fat transfer with PRP in small amounts or fillers which at least can be dissolved.  Remember,  aging is ongoing and will require periodic touch ups and maintenance.   Other factors that contribute to transient eyelid swelling (like allergies etc. ) should be considered.    

Thanks for the excellent question and posting a photo! 
You bring up a "hot topic" within plastic surgery regarding lower blepharoplasty technique. Depending on which surgeon you ask, you'll likely get a variety of answers. Though it seems more papers are coming out these days describing techniques of lower blepharoplasty utilizing fat transfer, there still seems to be no consensus. 
Based on your picture, there are tear trough deformities on each side which can be corrected by either technique. Some surgeons will transpose/reposition the fat from inside the eye onto the cheek after doing the surgical dissection- this can help blend the eyelid-cheek junction into a smooth, softer look. Others- during a formal blepharoplasty- would inject fat around the bone just underneath the eye to help eliminate the sharp transition at the tear trough, or if you have a flatter appearing cheek (can't tell from the picture) then adding fat to this area can improve aesthetics. Another purported benefit of fat is that it may help improve the dark pigmentation of the tear troughs- though I'm not sure if there's definitive data on this. And finally, other surgeons would recommend against surgery altogether for isolated tear troughs and offer fillers only instead. 
I'm not sure there is a right answer- excellent results have been reported with both standard lower blepharoplasty as well as fat transfer, in addition to filler alone. You may opt to pick the surgeon whom you are most comfortable with and whose results you most admire. Each technique will likely deliver good results if performed by a qualified, safe surgeon!