Best Approach for Tear Troughs?

Our preferred option for your situation might be to do a transconjunctival blepahroplasty with fat repositioning and slight fat reduction, followed by fillers (usually Restylane or Prevelle). Pure fat transposition procedures can be prone to relapse of lower eyelid fat bulges as the attached fat contracts with healing, visibility of the transposed fat, or lumpiness in this very thin skinned area.

Extensive deep use of fillers are also possible around the eyes and may be the least invasive, most predictable method.

There is a single large vessel at the bony orbital rim which of course must be avoided or bruising can be significant, so knowledge of the anatomy is important.

It is also possible to place fat injection, with its usual pluses and minuses, or LiveFill, nontraumatized fat-fascial grafts, precisely in the tear trough. Any graft must go through an incorporation stage, so will be somewhat firm and may need to be nursed along.

All these advanced lower eyelid procedures are technically complex and warrant a thorough knowledge of procedures of the lower eyelid and midface.

There are many causes of eye bags/tear trough deformities. Some are shadow issues, some are discoloration issues.  Restylane can go medial but you want some demarcation medially or it will look odd. Below I copied the title of a few good articles you can pull up on google scholar if you are interested. These articles were given to me by a colleague and I use them in treatment protocols. You seem to know a lot about this so I think it will be helpful for you.   Even further below are some notes about causes and treatment options. 

"The Tear Trough Ligament: Anatomical Basis for the Tear Trough Deformity" Chin-Ho Wong, M.R.C.S.(Ed.), F.A.M.S.(Plast. Surg.) Michael K. H. Hsieh, B.Sc. Bryan Mendelson,F.R.C.S.(Ed.), F.R.A.C.S.,F.A.C.S.



"What Causes Eyelid Bags? Analysis of 114 Consecutive Patients" Robert Alan Goldberg, M.D., John D. McCann, M.D., Ph.D., Danica Fiaschetti, C.O.A., and Guy J. Ben Simon, M.D.



"Dark Circles Etiology and Management Options" Daniel P. Friedmann, MDa,*, Mitchel P. Goldman, MDb,c



1. Prolapsed orbital fat through the orbital septum: treated with lower lid blepharoplasty and fat re-positioning. Can also be helped with fillers or auto fat transfer to the face but the ideal treatment in my hands is surgery for this issue.





2. Ezcema: much more common in young people with fair skin. The treatment for this is to hold off on makeup and any manipulation of the lower lid for a few weeks and try some topical anti inflammatory creams. If you have allergies those should be treated also.  A dermatologist is the best person to see for this. We have a multidisciplinary clinic with myself, a plastic surgeon, and my partner, a dermatologist which I think is ideal!





3. Fluid accumulation and/or redundant skin. Could be possible in young patients but would need a good facial analysis and exam to determine. A low salt diet (< 1000mg/day) and a warm compress can help.  I would consider treating with filler/fat transfer, lower lid fractional ablative laser and/or lower lid blepharoplasty.





4. Descent of midface cheek pad. This then causes the nasojugular ligament to become more prominent creating a demarcation and separation of the eye from the cheek subunit. Treated with mid face lift and fat transfer.





It is all about the balance of this transition from the orbit to the cheek. There are many ways to treat this and they vary by the underlying cause. I recommend seeing a surgeon who also does a lot of these treatments. This can make a big difference as most people have a combination of the above that lead to the issue.





Hope this helps.





Best of luck,





DrC

Hi and thanks for your great question.  I think that surgery can be done but you may have a suboptimal result as you have more hollow than fat (substrate) to reposition and fill the hollow. After surgery don't be surprised if you still need filler as a top off.  Filler only avoids the need for surgery and may do the trick for now. Get a good evaluation and don't be pushed into surgery - best...

It's not unusual for patients with tear trough deformities to request plastic surgical consultation. When this situation arises, a variety of treatment options exist to treat this condition. These include surgical procedures that release the arcus marginalis and the use of injectable hyaluronic acid fillers that minimize tear trough deformities. It's extremely important to individualize the treatment of tear troughs. For this reason, the specific procedure chosen will depend upon the patient's anatomic findings and aesthetic goals.It's important to realize that lower eyelid filler injections can be very effective for treating tear trough deformities, but aren't for everyone with this condition. In some patients, the lower eyelid skin is extremely thin and for this reason, injectable fillers aren't always indicated. In this situation, injections may be accompanied by nodules and bluish discoloration.When patients have excess lower eyelid fat, arcus marginalis release and fat repositioning is appropriate. This procedure is associated with excellent clinical results.It's important for patients with tear trough deformities to consult a board certified plastic surgeon with experience in this area. This surgeon should be able to formulate a treatment plan that addresses your anatomic findings and achieves your aesthetic goals.

Thank you for your question. My patients love Juvederm filler (Restylane, also being a good filler), a lot of them will have filler for hollow eye, this is a great temporary solution.  Like yourself, a lot of patients have bulging fat pads, therefore I would advise a transconjunctival blepharoplasty with fat repositioning would be beneficial.  Please seek out a board certified plastic surgeon in your area with an expertise in blepharoplasty.  All the Best!

many options.  Lower lid bleph transconjuctival with smoothen the lower lids.  Fillers such as Restylane done appropriate would also helps.  Both of these procedures require expertise for best results.  

A single photo is not a substitute for an examination. Your photo appears to show hollowing and deep grooves beneath your lower eye lid fat pads. A well-performed injectable filler may be an option to explore. In our practice, we may prefer using Silikon-1000, an off-label filler for permanent results.Hope this helps you.Dr Joseph

Some patients are reluctant to have surgery and deal with a potentially prolonged recovery associated with lower   eyelid blephroplasty.  Injectables offer a great alternative for correction.  I use Teosyal's Redensity II product.  This has been specifically designed for the lower eyelid as it contains amino acids, antioxidants, minerals and vitamins to improve upon the dark colour of the skin also.  

I don't subscribe to this notion of tear trough deformity.  I also don't like injectable for the lower lids.  Having the excess fat removed is the best solution and it doesn't have to ve redone like injectables.

In my opinion, filler or fat grafting will not give you the result I believe you are seeking.  Your lower lid is quite loose and a canthopexy is required to restore your lower lid tone.My approach would be a transconjunctival release of the orbicularis retaining ligament and subperiosteal transposition of your fat pads.  By placing the fat pads in this layer, damage to the tear ducts can be avoided.  I would complete the surgery with a two layer canthopexy: muscle and lateral retinacular.  Finally a skin pinch excision would be done to tighten the skin layer. 

The depressions that cast shadows of your lower lids can be improved with fillers or fat preserving blepharoplasty either transconjunctival or incision beneath lash line approachesRegarding fillers:. In this area it is very important to have an experienced injector so as not to place the filler too close to the skin. I would recommend trying Jeuvederm or Restylane first as they are not permanent and can be reversed if you do not like the result. If you do like the result, then fat transfer is a good option for a more permanent correction