Under eyes/mid face fat loss issue - what are my surgical options?

I would recommend facial fat grafting---one OR procedure--the result lasting a decade or more, and their stem cell help circulation which would minimize the lower lids pigmentation as well as the malar edema.
This is based on a 20 plus years history of fat grafting for lower lid contour, pigmentation and circulation(malar bags).
Hope this helps; let me know if you have any additional questions

The lower eyelid mid cheek interface is a very complicated anatomic region were opposing forces shows signs of premature aging and looking tired.

It is a difficult area to work in and there are different ways of achieving improvements.

For some people the primary problem is the bulging of the lower eyelid fat pads and in others it is the lack of volume immediate below this in the tear trough.

Some people have both.

When coming up with a surgical plan it’s a good idea to differentiate if the lower eyelid fat protrusion is the primary or secondary problem or if the lack of volume is the primary issue.

A lot of this stems from skeletal structure which pre-disposes people to this look with age.

It’s unlikely enzyme reversal changed your subcutaneous fat distribution. what is likely is that the area has continued to progress on a yearly basis or even less than that.

In a nutshell there is no one better or worse procedure in regards to the treatment options you’ve listed.

All of them have delivered excellent and less than excellent results.

Making a good assessment by understanding what the primary and secondary problems are is a pretty good start to deciding what procedure to choose.

Obviously removing volume or adding volume are opposite procedures. In this area many people need both and the transition zone is very small and can be a bit unforgiving.

As it’s true with so many other procedures the most important decision and variable is finding the most talented and experienced provider.

In many ways what procedure you choose there’s not nearly as important as finding someone who is really good at what they do.

If you approach this in that way you are more likely to have a successful outcome.

Focus all your efforts and finding the most experienced and talented provider who has a proven track record of treating this area with success.

Do so by scheduling multiple in person consultations.

You’ll know you have the right provider when they hand you a collection of before and after pictures that reads like a telephone book.

I also recommend reading all the reviews on various physician review websites and avoiding providers with any significant number of justified negative reviews.

Best,

Mats Hagstrom MD