Ilya Reyter, MD

The key to understanding why a face appears "older" or tired is to look at what happens to facial volume over time.  By studying MRI images of the aging face, we have learned that fat and bone are reabsorbed by the body slowly over the years.  In time, this leads to sunken, hollow looking cheeks, especially the upper cheeks.  This can often lead to a deep valley, right underneath the lower eyelid, causing the lower eyelid to look like it is bulging out.

Previously, almost all lower eyelid bulging was treated by surgically removing the lower eyelid fat.  This eliminated the bulging, but somehow caused the face to appear even older as the person aged.  Young faces look full.  Older faces look skeletonized an hollow.  So, by further hollowing out the face, the patient looked even older.  Quite the opposite of what many patients were trying to accomplish.

Having understood the connection between fat loss and the aging face, many doctors are using new techniques for treatment of this condition.

One such technique is fat transfer.  Having taught fat transfer for years at the University of Southern California Keck School of Medicine, I know this to be an incredibly powerful procedure.  It can be performed using just local anesthesia in a doctor's office.  The fat is harvested almost painlessly from the thigh or abdomen, and injected into the face using a tiny needle or cannula.  The fat fills the valley in the upper cheek, and feels soft and natural.  Sure, some fat may be absorbed by the body, and a touch up fat transfer may be necessary, but a touch up is easy to do, and takes very little time.  

Another good option is using a hyaluronic acid filler such as Restylane.  This works just like fat transfer, by filling the valley where the lower eyelid meets the upper cheek.  The advantage, however, is that Restylane is very quick and easy to do, and eliminates the need for fat harvesting.  I do this quite often, and have developed a technique that leads to very little pain or bruising.  It is quite remarkable how often patients can avoid surgery just by doing this procedure.  

In regard to your question about where Restylane can be placed, it depends on technique.  With proper experience, it is possible to place Restylane almost anywhere along the lower eyelid.  There is always the risk of injecting Restylane directly into a blood vessel, and this can lead to retinal artery occlusion and blindness.  However, this is such a rare occurrence, that only very few instances were ever reported, despite the popularity of these types of injections.  I feel quite comfortable performing these types of injections, and would also feel comfortable having this performed on me or my family members (and in fact, I have performed this on many of my family members!)

Should the lower eyelid bulging be severe enough to warrant surgical correction, again, the key is volume preservation.  There is a trend developing toward preservation and repositioning of lower eyelid fat as opposed to removal of the fat.  By repositioning the fat, the surgeon can avoid the hollow, skeletonized appearance that can result as a person ages after having lower eyelid surgery done.  I almost always use this technique for lower eyelid surgery.