LOWER BLEPHAROPLASTY OR HYALURONIC ACID/RESTYLANE FOR PUFFINESS AND PROMINENT TEAR TROUGHS?

Question:
I’m 24 years old but I’ve had quite prominent puffiness and tear troughs around the eyes for about 2 years (they are much worse in the morning but don’t go away.) I have consulted a plastic surgeon who immediately suggested a lower transconjunctival blepharoplasty but he doesn’t know if a blepharoplasty will fix the dark line (tear trough). I’ve heard a could actually make them prominent. Please let me know what you think!

Dr. A’s Answer:
The wrong thing for you to do would be to let someone take the fat out of your lower eyelids. The bags will improve, but you will have an aged, hollow, long lower eyelid.

The best result would be possible only with surgery. While many surgeons advocate fat grafting this process is fraught with problems. Particularly the fact that fat survival is unpredictable, prone to future fluctuation and the procedure is not reversible. Furthermore the added soft tissue volume tends to be too full when smiling. It is my preference to use a tear-trough implant and based on your photograph you would be a very good candidate. This can be thought of as reshaping the skeleton of the lower orbital rim/upper cheek area to bring the soft tissues of the cheek, the orbital fat, and the bony rim into proper alignment. The goal is a soft round cheek blending seamlessly into the lower eyelid. The implant feels like bone once in place, does not bunch up/move with smiling, and does not change over time.

Injectable fillers such as Restylane can provide descent correction of the problem temporarily. I would suggest this if your budget doesn’t allow for surgery, if you are just not mentally ready for surgery, or if you don’t have any time for surgery. Restylane into the lower eyelids should only be done by an experienced physician injector, preferable a surgeon. A very thorough knowledge of the anatomy is necessary here. Generally the procedure results in only mild swelling and slight or no bruising. The correction will not be as complete as surgery but it can be very satisfying. I would suggest using 1/2 cc on each side. The product needs to be kept very deep (against the bone) to avoid bruising, lumps, and a bluish tinge to the skin. An additional 1/2 cc per side may be beneficial but I would suggest waiting a few weeks after the first treatment before adding more (if at all). When done with a proper nerve block, it is essentially painless. I would say that Juvederm is acceptable but not as asspropriate as Restylane. I would also tell you to absolutely avoid Radiesse or Sculptra in this area.

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