Lower blepharoplasty - with or without fat transfer? (Photo)

Your questions are perceptive. Your anatomy is typical: some bulging
of the orbital fat combined with a tear trough line that is caused in part by
the insertion of the orbicularis muscle along the orbital rim and the tight
arcus marginalis. The best results can be achieved by a lower lid
blepharoplasty. I would use a transconjuctival approach and release the arcus
marginalis and the orbicularis insertion. I would make a decision
intraoperatively whether to simply reposition the fat, allowing it to flow over
the orbital rim or (likely) also remove a small amount. Then I would harvest
some fat from your abdomen with a fine cannula, and place some fat into the
tear trough area under direct vision. Fat grafting alone will help some but not
completely correct the problem. Your question about anesthesia is a
good one. This is an easy area to anesthetize with local anesthesia, but it
does require some experience to obtain effective complete local anesthesia.
I often perform this surgery in the office with light oral sedation. Many
surgeons will do this procedure only in the operating room using deep sedation
or general anesthesia, but in my hands, the results are equivalent either
way. Many patients are comfortable with light oral sedation, but some prefer
deeper levels of sedation, which requires an anesthesiologist.

Yes, hyaluronic acid fillers, specifically, Restylane can filler your under eye hollow and provide a result that is actually better than what can be achieved with surgery.  While the result is not permanent, it is generally quite good for 12 months before a top off is beneficial.  So I strongly recommend considering this option.  Provided you are getting a result you like, there is no reason you can continue to get fillers as need.  If you reach a point that the filler is no longer getting the job done, surgery remains an option.  Generally fat grafting is not a very good option.  It tends to make lumps and bumps and is impossible to adjust without more surgery.

It appears that fat repositioning with an arcus marginalis release would be very beneficial to improve the appearance of the lower eyelid.  Allowing the fat to prolapse down below the elevated muscle  is usually helpful in treating the prominent tear trough.  I will sometimes suspend the orbicularis muscle laterally which I find helps smooth out the muscle as well. The procedure can be done under local with sedation or general, so it should be up to you and your surgeon

Thank you for the question. First, I almost always perform blepharoplasties under local. Each surgeon has his own preference and no one is right or wrong. Secondly, you should have the fat anchored to your orbital rim to improve the tear trough region. If your surgeon is experienced with this technique if does not add much difficulty or time to the operation. Good luck.

You have a fair amount of prolapsed orbital fat in the lower lid with a deep tear trough.  You would do well with fat repositioning where your fat is moved down into the tear trough.  So then you wouldn't need a fat transfer. You could take out the fat, but risk making the area darker due to hollowing.  You can do it with local infiltration.  However with local, patients do not like the feeling when the fat is being moved or excised.  So it is easier for surgeon and patient to do some IV sedation.