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.    

Thank you for your question and for posting your photo. More photos showing oblique and side (profile) views would be helpful. 
With the caveat that a formal recommendation can only be made after in-person consultation, based upon your photo I would likely recommend transconjunctival (incision behind the eyelid) lower blepharoplasty with fat transposition. During fat transposition, instead of removing fat from the medial and central compartments, this fat is moved (transposed) into the tear trough (hollowing under the eyes) in order to add volume and fill this depression. 
This will give you natural results, with removal of lower lid fullness, smoothing of the lower lid-cheek transition, and filling of the tear troughs. Fat grafting is not the wrong answer and when expertly performed it will give you great results. Fat transposition will also give excellent results and without the need for the addition of fat transfer.
Best of luck!