When to decide between using a filler or blepharoplasty for lower eyelids?

The tear trough or lower eyelid deformity can be caused from skin and muscle being tethered down inside the inferior orbital rim to the periorbita by the orbital malar ligament. This causes a depression and demarcates the lower eyelid. Because of this, we can see tear trough problems in young individuals as well as older ones. As we continue to age, there is volume loss, fat prolapse, and thinning of the skin which can accentuate the appearance of the lower eyelid ‘bags.’

Volume replacement with fillers are not a substitution for conventional surgery. While surgery can be used to treat a number of eyelid issues, fillers also have a role in delaying or complimenting surgery. So which treatment is best for your lower eyelid?

Some patients have a deep tear trough deformity that can accentuate the appearance of pseudo-fat herniation. This gives the impression of ‘puffy bags with a darker circle.’ These dark circles demarcate the eyelid-cheek junction and this elongates with age. Often in such patients, using a hyaluronic acid based filler like Restylane or Juvederm, can help create a more uniform and smooth surface thereby creating a more youthful appearance. Injection of the lower eyelid is not a treatment to lighten darkened skin. It is important to emphasize that hyaluronic acid injections help improve the appearance of dark circles that are caused by shadowing, but will not work if the lower eyelid is stained.

Hyaluronic acid fillers help restore symmetry and replenish volume loss experienced in the ageing face. Hyaluronic acid found naturally in our bodies help maintain skin elasticity, stimulates collagen production and work as an antioxidant. This is a quick procedure that has little downtime.

Some other patients have the appearance of ‘bags’ under their eyes because of fat herniation. The lower eyelid has three separate fat compartments behind a thin layer of connective tissue called the orbital septum. When the orbital septum becomes attenuated, the fat then protrudes forward creating the appearance of bags. If lower eyelid ‘bags’ are caused by fat prolapse, lower eyelid blepharoplasty can be done to remove or reposition fat and/or remove lower eyelid skin to create a more youthful appearance. This can be done as a day case procedure under local anesthetic either through incisions underneath the lash line or from inside the eyelid.

Younger patients with a tear-trough indentation, minimal or no fat prolapse with thick skin are excellent injectable candidates. Older patients with a significant amount of fat prolapse and skin laxity are better candidates for surgical intervention.

Tear trough injections and lower eyelid blepharoplasty require skill and experience. It is important to understand that there is great variation in results obtained from either injectable fillers and surgery based on the clinician that is administering the treatment. It is important to discuss the risks and benefits of each procedure with your doctor to find the solution best suited for your eyes.

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