Best treatment for deep under eye hollows. Tear trough injections, fat grafting or Restylane?

Our office prefers to use Restylane in the under eye hollows. The reason for this is Restylane has finer particles than fat itself, and thus lends itself to settling and adhering to the under eye area more naturally and noticeably. For this reason the best results are seen with Restylane.  Fat transfer can be more tricky to use in that region, with problems, should they occur, a bit more difficult to reverse.

There are many ways to treat dark circles, as well as under eye wrinkles and bags. It is important to note however, that the majority of times the cause for discoloration is genetic and due to the viability of the blood vessels below the skin. A combination approach is always needed to get the best results in this area and this includes: topical skin care, laser and/or radiofrequency treatments, and fillers if placed appropriately. All my patients are on topical lightening agents, typically a vitamin C serum product in the AM and a brightening agent and/or a vitamin A based product in the PM. Sun protection is essential.Resurfacing and tightening are essential. My patients get offered a menu of options, for which a combination gives the best results. Light salicylic acid peels help give textural and pigment improvement; nonablative lasers (Fraxel or Clear + Brilliant) can be used to tighten and improve fine lines/wrinkles and crepe skin; fractional radiofrequency devices (Sublative, Viva) are cutting edge and improve texture, tone, and wrinkles with very little downtime; radiofrequency with pulsed electromagnetic fields (Venus) are amazing for puffiness and bags, in patients who do not want eyelid surgery; appropriately placed fillers can replace lost volume, cover up the vessels and fat pads below improving the appearance -- patients should pick a well experienced practitioner to prevent complications such as Tyndall (blue discoloration) and irregularities, one that uses a cannula for injection will help give results with little bruising or swelling; microsecond Nd:YAG laser treatments (Laser genesis) has produced dramatic improvement in discoloration in some of my patients and is safe in dark skin types, similar to the radiofrequency devices. For lifting, ablative laser resurfacing such as co2 laser combined with monopoloar radiofrequency deep heating (thermage) give amazing results. The key is for a patient to see a cosmetic dermatologist with experience in all the latest devices and techniques so the persons goals can be met by a combination approach of individualized treatments and skin care. In some cases, those who smile and have crepe skin or under eye wrinkles, a small amount of neurotoxin (botox, dysport, xeomin) strategically placed in the lower eyelid skin can improve wrinkles dramatically and give the eye a more "open" appearance.

Restylane
is likely the most common recommendation because it is safe, reversible, and a
great single treatment option with immediate results. Its chemical properties make it an ideal
filler for the area under the eye.

Fat grafting involves liposuction (often of the abdomen, thighs, or buttocks), isolation and preparation of the fat obtained from those areas, and then injection of that fat under the eyes. The main issue with this procedure is the relative unpredictability of the final result. Because it takes weeks or months until the cosmetic changes “stabilize”, and because injected fat can actually grow and expand, there’s an inherent element of uncertainty with this procedure. Additionally, grafted fat can be difficult to remove after the procedure, so over-filling can become an issue in some cases. That said, many people obtain fantastic results with this procedure in the hands of a talented surgeon. Choosing someone with significant experience treating the tear troughs via this method is crucial to getting a result that keeps you happy.Fillers such as Restylane give results that don’t last as long as fat grafting – usually the cosmetic improvement lasts about 6 months. However, the cosmetic changes are apparent immediately when injecting Restylane, and adjustments are much more easily made when compared to fat grafting.It is worthwhile to consider treatment with Restylane initially. This would allow you to see what aesthetic changes are possible before pursuing fat grafting, which is more expensive, longer-lasting, and somewhat less predictable than fillers. In my practice, we pay particular attention to rejuvenation based on our patient’s existing overall facial anatomy, and frequently achieve great natural-appearing results using Restylane around the eyes.Regardless of the method you pursue, the most important decision you will make is choosing a doctor with strong experience performing these procedures.

I find that Restylane gives me the most control and produces good results. I don't see any real cons except that it needs to be repeated. You may want to try it first to assess the outcome and whether it is enough for you. If not, then consideration can be given to more interventional procedures.

I prefer to use Restylane in the tear troughs, injected deeply under the muscle.  Usually I prefer to do most injections with a cannula to reduce the risk of bruising. Most patients are very happy with this treatment.  Restylane can be dissolved with hyaluronidase if needed, which adds to its safety.  Fat cannot be dissolved.  

To treat under eye hollows or deep tear troughs, I prefer to use restylane or restylane fine lines. I've used this for many years with terrific results. Bruising is always a risk, and some people swell a fair bit when treating this area. The results are very consistent and reliable, which is not the case with fat injections.

For deep hollows I prefer fat transfer because of greater longevity; often many years. It is a quick and easy procedure performed with only local anesthesia. However if donor site fat volume is inadequate, then HA fillers such as Restylane or Belotero are fine. Microcannulas are used in our office to prevent bruising, and longevity up to 1 year is possible. Seek an experienced surgeon for either approach.