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.  

It is always hard to evaluate lower lids with just a photo.  However, it looks like you do have some skin excess and fat herniation.  Personally, I address that with a release of the muscle and redistribution of fat instead of grafting.  Can it be done under local? -- sure!  Is it hard to find someone who will do that? -- yes...  Lower lid surgery can certainly be uncomfortable when you start tugging on the orbital fat.  I do this with IV sedation -- you still need an operating room though.  If you wanted to avoid surgery you could start with a filler to help fill the tear trough, but surgery may be the best option.  

 We have performed  a lower blepharoplasty on many physicians in our practice and for patient safety and comfort, we place them under general anesthesia by a board certified physician anesthesiologist. A lower blepharoplasty is not a clinic procedure, it is a invasive surgical procedure only performed  in an operating room. In the state of Washington,  all surgery such as this must be performed a certified AND licensed outpatient surgery Center. The fat pads of the lower lids have very deep proprioceptive nerve fibers that do not numb up to the lidocaine, so teasing the fat is very painful under local . Electric cautery is also used to stop any bleeding of the fat inside the orbital septum. 

It seems like you have received some conflicting opinions regarding the best way to rejuvenate your lower eyelids.  Although fat removal still works well for some cases, many of the current trends towards more natural-appearing results have led more progressive surgeons towards fat-sparing or volume replacement techniques for lower eyelid blepharoplasty.  This is especially important in younger patients or in those without large, prominent bags due to the risk of looking hollowed around the eyes with fat removal, which can give a more aged appearance.  There are still many different techniques that can achieve an excellent rejuvenated appearance in this area of the face.  Be sure to effectively communicate your aesthetic goals to your surgeon.

Not all surgeons use fat grafting to the tear trough.  Some use the herniated fat and redrape it, but it often doesn't reach the area in the medial aspect.  Fat grafts placed can lead to lumps which are difficult to treat. Most use anesthesia because an infraorbital nerve block often is not enough to go through the transconjuctival approach.  Best of luck. I prefer to use dilute restylane for the medial tear trough if necessary after releasing the arcus marginalis attachments during the bleph.  There are many ways to skin a cat!

Fat removal will leave you with hollow eyes and loose skin.Arcus Marginalis release with fat grafting will address the dark circles and superior tear trough. Composite open fat grafting should not leave lumps as fat injection does.The infraorbital block does not adequately anesthetize the deep periocular structures and infraorbital periosteum which is elevated during Arcus Marginalis release. For more  information please read the link below: