Tear Trough Treatment? (photo)

Please have a look at my awful eyebags. I am 31 years old and quite unhappy about my look. What would you say is the best treatment? I had Restylane about 6 months ago and it helped a bit but its certainly depleted now. Do you recommend implants, fillers or lower lid blepharoplasty? I am keen to get something long lasting done asap.

Doctor Answers 11

Tear Trough Treatment?

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Most expert experienced artistic plastic surgeons have a variety of procedures at their disposal to produce excellent cosmetic results in the appropriately selected patient with bulging herniated fat pads and accompanying areas of hollows of their lower eyelids: temporary fillers with hyaluronic acid fillers like Restylane which usually last 6 months to 1 year, micro-fat grafts of your own tissue - 30-50% lasts permanently, and blepharoplasties . There is no one best procedure that would be applicable for everyone. Each has benefits and potential drawbacks. The vast majority of board certified plastic surgeons with extensive experience in eyelid surgery and soft tissue fillers would warn against using a permanent synthetic filler because of the long term complications which can occur even years after injection and are difficult if not almost impossible to correct.

The best option in any particular patient needs to be individualized based on desired outcome and personal anatomy. If the fat pad fullness is significant as it appears to be on your photos, just adding a filler or fat grafts generally does not produce a satisfactory cosmetic improvement.

Following the advice of anyone who would presume to tell you exactly what to do without seeing photos and without taking a full medical history, examining you, feeling and assessing your tissue tone, discussing your desired outcome and fully informing you about the pros and cons of each option would not be in your best interest. Find a plastic surgeon that you are comfortable with and one that you trust and listen to his or her advice. The surgeon should be certified by the American Board of Plastic Surgery and ideally a member of the American Society for Aesthetic Plastic Surgery (ASAPS). You should discuss your concerns with that surgeon in person.

Robert Singer, MD FACS

La Jolla, California

La Jolla Plastic Surgeon
4.6 out of 5 stars 22 reviews

Tear trough

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Your tear troughs appear to be worse due to the herniated fat bags.  A transconjunctival lower blepharoplasty would be the best approach. This will remove the bags and create a smooth contour in that area of the eyelid.  In addition a canthopexy may be needed for the significant amount of scleral show that is present.

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 157 reviews

Fat Repositioning in Lower Blepharoplasty: A Long-Lasting Option

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This is a great question and a truly frustrating problem.  From your photos, it appears that you have some prominent lower eyelid fat pads. The reason that this is so noticeable, however, is the hollow area underneath (often called the "tear trough" region). There are many available options: trying to camouflage the deep area with fillers, removing the fat pads, placing an implant... and, in my opinion, the best option -- repositioning the lower eyelid fat pads to fill in the tear trough region. As you know, fillers are temporary, and I wouldn't recommend putting an implant in this sensitive area.  Removing the fat pads will make the are more flat while you're young, but can create an overly hollowed out look as you get older. For my patients, I use the fat that's already right there to fill in the tear troughs and then remove a minimal amount of excess skin.

Lower eyelid bags, blepharoplasty

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When one is not satified with the longevity or degree of correction of lower eyelid bag correction fat grafting, Artefill or Sculptra may be of benefit.

Lower eyelid blepharoplasty with fat transposition will address more sever cases and last longer.

Please consult with an experienced Board Certified Plastic Surgeon in person prior to making treatment decisions.


Luis A. Cenedese, MD, FACS
New York Plastic Surgeon

Tear Trough and Eye Bag Treatment

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It appears as though you have lower eyelid bags as well as a loss of volume directly below the bags, known as a "tear trough" deformity.

I would recommend that you visit a plastic surgeon for a consultation regarding removal of a small amount of the fat that pooches out through the lower eyelid. This fat can then potentially be repositioned to treat the tear trough below. OR fat can be transferred from your abdomen to fill this area. This is known as "fat grafting". Lastly, fillers ie. Restylane can be used to fill the tear trough if for some reason you were not able to have your own fat placed in this area.

I hope this helps. Best of luck to you!

Lower Eye Bags

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A very common aging change in the lower eyelids is the development of 'bags', which are in most cases due to an outward bulging of the fat pads behind the lower lids. These 'bags' of fat can be improved by conservative removal through an invisible incision on the inside of the lower lid (trans-conjunctival approach) in patients that do not require skin excision, or through the under-eyelash (sub-ciliary approach) in patients that are having some excess lower lid skin removed.

As with skin removal, I believe that the reduction (NOT total removal) of lower lid fat pads should be conservative. Excessive removal of lower lid fat pads results in a hollowed-out appearance that makes blepharoplasty patients look tired or even ill. I see quite a number of eyelid surgery patients who require structural fat grafting of the lower lids to improve that very problem following an over-aggressive lower blepharoplasty in the past.

In some case lower lid 'bags' can be improved by repairing or reinforcing the soft tissues that normally hold them back. Additionally, excessive lower lid fat can sometimes be mobilized and transposed inferiorly to fill in periorbital hollows or depressions such as the 'tear trough' at the medial junction of the lower lid and cheek.

Some eyelid 'bags' involve redundant muscle tissue which must be removed and/or repositioned, usually in patients who are in their sixties or older. This is performed through an under-eyelid (sub-ciliary) incision which is extended laterally into the 'crow's feet' area.

Structural Fat Grafting of the Lower Lid

As mentioned above, it is very important to preserve (or restore) soft tissue volume in the lower lid. When I review with eyelid surgery patients some photographs from their twenties, in most cases we find that years ago there was no visible demarcation between lid and cheek, but instead a smooth, gently convex curve extending downward from the lower lid margin.

In patients who have developed deep 'tear troughs' at the junction of the lower lid and cheek, adjacent to the side of the nose, the meticulous grafting of fat harvested from the patient's abdomen, hips or thighs can build this area back up and nicely restore a more youthful contour. In some blepharoplasty patients this depression or 'hollow' extends horizontally across the entire junction of the lower lid and cheek, and this must be corrected to obtain the ideal postoperative result.

In select patients, lower lid rejuvenation may consist of conservative reduction (not removal) of the lower lid fat pads or 'bags', in combination with structural fat grafting of the 'tear trough' hollow immediately below. As with all aesthetic surgical procedures, it is absolutely essential to customize the surgical plan to the specific needs of every patient.

Michael Law, MD
Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 123 reviews

Treating deep and enlarged tear troughs

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Thank you for your question about tear trough treatment and providing pictures of your condition. Judging from your pictures alone, your tear troughs look deep, but it is not uncommon and can be resolved. Understanding the reason behind this will help you determine what treatment is best for you.

Your condition may be caused by the elevation of the fat pockets adjacent to the tear troughs. These fat pockets create bulges that make them look deep. It can be hereditary, but this condition has nothing to do with age, as I've had patients as young as 14 with the same condition. People in their 30s and 40s with this condition tell me that they've had it since their teens.  I may advise filling the tear troughs, but this procedure has its limits, and if overdone, can lead to a second eye bag, which then appears as a single large bag under the eye.

Based on your photos alone, I recommend that you have transconjunctival blepharoplasty. This procedure requires going inside the eyelid to access the fat pockets, concentrating on those that are pushed forward, and carefully sculpting them with a combination of transposing, tightening, reduction, and other techniques until we reach the desired smoothness around the eye. If necessary, I'd use fillers on the hollow or shallow areas to achieve the desired results. In my practice, we use platelet rich plasma and platelet rich fibrin matrix to restore volume and give you a more natural contour.  So my recommendation is transconjunctival blepharoplasty as your main option, with any other procedure or treatment beyond that just as an enhancement.  I understand that it’s difficult to consider a surgical procedure and its cost, but continuing with fillers will also cost time and money without achieving your desired results.

Before making your decision, consult with an experienced cosmetic surgeon that specializes in the eye area.  Again, thank you for your question and I hope that this information is helpful.

Amiya Prasad, MD
New York Oculoplastic Surgeon
4.4 out of 5 stars 80 reviews

Treating early lower eyelid bags

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Early lower eyelid bags can be common in younger patients with loose tissue of the lower lids and under-development of the cheekbones.

Fillers can help, but only to a point.  

A combination of repositioning of the lower eyelid fat to "fill in" the hollow areas and de-emphasize the prominent areas is a great option.  Combining this with a cheek implant can make the effect even more powerful and long-lasting.

A consultation with a board-certified plastic surgeon in your area can help you decide which is the right treatment option for you.


Jason J. Hall, MD, FACS
Knoxville Plastic Surgeon
5.0 out of 5 stars 12 reviews

Tear Trough Treatment in a younger patient.

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It appears that you have a hereditary predisposition towards early tear trough formation from pseudofat herniation of the lower eyelids.   A conservative transconjunctival/inner eyelid blehaproplasty would bring the plane of the lower eyelid closer to the orbital rim making the transition smoother.  Too much reduction would not be a good thing as it could lead to hollowing. One must always think  not only about the short term effect of surgery but also the long term impact 10-20 years later. 

 Sometimes I will combine the lower lid procedure with a small fat transfer for a more comrehensive rejuvenation.  That is taking some away where it is in relative excess and adding it were it is relatively deficient. Because of your darker skin color, you are not a candidate for aggressive resurfacing which can also cause some skin tightening and deminish the appearance of aging.  Hope that helps.

Arthur N. Falk, MD
Albany Facial Plastic Surgeon

Tear trough treatment

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It does appear that you have some bagginess of your lower eyelids due to fat. Your option would be to either have surgery to remove some of the excess fat or to use a filler, such as Restylane (as you previously had).  The surgical option will be longer lasting.  I do not think you need an implant in your lower eyelid area.  

Michael I. Echavez, MD
San Francisco Facial Plastic Surgeon
4.5 out of 5 stars 18 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.