For Best Results - Enhance Facial Volume

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.

Our preferred option for your situation might be to do a transconjunctival blepahroplasty with fat repositioning and slight fat reduction, followed by fillers (usually  Restylane or Prevelle).  Pure fat transposition procedures can be prone to relapse of lower eyelid fat bulges as the attached fat contracts with healing, visibility of the transposed fat, or lumpiness in this very thin skinned area.

Extensive deep use of fillers are also possible around the eyes and may be the least invasive, most predictable method.

There is a single large vessel at the bony orbital rim which of course must be avoided or bruising can be significant, so knowledge of the anatomy is important.

It is also possible to place fat injection, with its usual pluses and minuses, or LiveFill, nontraumatized fat-fascial grafts, precisely in the tear trough.  Any graft must go through an incorporation stage, so will be somewhat firm and may need to be nursed along.

All these advanced lower eyelid procedures are technically complex and warrant a thorough knowledge of procedures of the lower eyelid and midface.

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David,

This is a very intreresting and challenging case you have brought into this arena.

I think you have many great answers here...

From your pictures, it looks like you have a real lack of fat.  There is fat missing, not only in your tear troughs, but in your cheeks. 

Restylane injections can be placed on the orbital rim, and all the way up to the medial canthus (inner corner) if the injections are placed in the correct plane.  Restylane injections may do wonders for your tear troughs, but will certainly be insufficient for the cheek volume that you will also need replaced. 

Fat transposition surgery is also great for tear troughs, but again, be aware that there will still be a depth, and a lack of volume in your cheeks that will not correct with fat transposition lower eyelid surgery.

What you would probably benefit from the most (based on your age) is fat grafting to your face.  The process involves removal of fat using liposuction techniquest and grafting or implanting of the fat in your face.  This process is very customized as fat can be replaced to the degree needed in the places you need it.

If you were older, I would suggest fat transposition lower lid blepharoplasty at the same time.  Had you only had tear troughs without such a loss of fat in the cheeks, I would suggest restylane, but the picture above looks like more volume would be needed.

I hope this helps, and don't hesitate to contact my office or email me for more information.

Dr. T

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