I have under eye hollowness post blepharoplasty with laser tightening. I'm 6 months out from my lower lid blepharoplasty and have the dreaded hollow under eyes. Can Fat grafting or fillers work? Which is better way to go? How do I find an MD with good technique that I can trust? What is the downtime? (I am a fair skinned northern European male who does not want to wear makeup Thank you!
Fat Transfer or Fillers for Under Eye Hollowness?
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Fat Grafting Post Blepharoplasty for Under Eye Hollows
With each passing year I find myself performing less 'invasive' lower lid surgery (i.e a formal lower blepharoplasty) and more lower lid rejuvenation by means of structural fat grafting. The reality of aggressive lower lid surgery - which involves some combination of skin excision, fat pad reduction and/or fat pad transposition, orbicularis (muscle) redraping and excision, and canthal support (to hold up the lateral aspect of the lower lid while everything heals) - can easily create an 'operated' appearance. Every experienced blepharoplasty surgeon understands quite well that the lower lid can be very unforgiving, and that an 'operated' appearance can be produced despite the best efforts of even the most skilled hands.
Patients with full cheekbones and excellent lower lid support usually do very well with a traditional lower blepharoplasty, although if I feel that I can produce an equivalent result by means of fat grafting and a modest amount of skin excision I will certainly choose the less invasive (and quicker recovery) fat grafting option. Patients with poorly projecting, flat cheekbones in which lower lid support is lacking, on the other hand, are at significant risk for post-blepharoplasty complications and that obvious 'operated' lower eyelid appearance. These patients are often best served by structural fat grafting to camouflage the hollowness and create some lower lid support.
Adding fat definitely improves lower lid support, and it often reduces the amount of lower lid skin excision that is required to produce an improved lower lid appearance and a blended lower lid / cheek junction. I frequently see patients who have previously undergone a blepharoplasty procedure in which an excessive amount of upper and/or lower lid fat has been removed, and they invariably report that since that surgery they feel that they look tired, older, and even ill. For patients with post-blepharoplasty hollowness, the only way to restore a healthy and more youthful appearance is to restore the missing soft tissue volume, and this can reliably be accomplished by means of structural fat grafting.
Structural fat grafting is a procedure in which small amounts (less than 0.1 cc at a time) of fat are carefully introduced in a series of discrete layers to gradually 'build' new soft tissue structure. As there is space between each micrograft, new blood vessels are able to grow into the grafted fat, allowing it to persist indefinitely. If this process of blood vessel ingrowth (neovascularization) does not occur, then the transferred fat cannot truly be considered a 'graft' and is instead just another temporary 'soft tissue filler' that is broken down and reabsorbed over several weeks. Fat grafting requires specialized training and specialized surgical instruments, as well as patience and meticulous attention to detail on the part of the surgeon. When performed properly, permanent and natural-appearing aesthetic enhancements can be achieved.
Because the lower lid tissues tend to be quite thin, a conservative approach is an absolute necessity for fat grafting of this area. If one overfills the lower lid /cheek junction, and most of the fat persists, then the patient ends up with unnatural fullness that needs to be corrected. I tell patients that our plan will be to add fat until an ideal contour is achieved and then we have to let it heal and see how much persists. Because the amount of fat that survives is variable, some patients require a second and rarely even a third fat grafting procedure to reach the desired endpoint of improvement. As fat grafting can be performed as an office procedure under mild oral sedation, and fat grafting recoveries are brief compared to traditional lower blepharoplasty surgery, supplemental fat grafting procedures are easily accomplished.
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Fillers work for under eye hollowness.
Various fillers do good for under eye hollowness but expect it to be done in 2-3 sessions a week or 2 apart. Juvederm or Restylane ($550 per syringe) usually needs 2-3 syringes. Diluted Radiesse ($650 per syringe) usually needs 1-2 syringes. Fat injections are very variable and can look great initially but get lumpy as they disappear in 6 months ($1500-2500 per session) and are done every 3-4 months.
Treating under eye hollowness post blepharoplasty
Hollowness alone is best treated by injectable fillers, Juvederm or Restylane if the patient cannot or does not wish to have surgery. This is a fine solution, and if patients don't mind the temporary and changing nature of filler injections, it is an excellent solution. In fact after any type of surgery, no matter how comprehensive or successful, fillers help to iron out small irregularities and hollow regions.
Fat injections are indeed often lumpy and their survival is not always predictable, resulting in asymmetries.
If there has been drooping of the cheek, raising the cheekpad can hide the eye-cheek junction. This is called a cheeklift, and in order to effect changes in the lower eyelid area, this should be performed through the lower eyelid. Our preference is to avoid the orbital septum completely and perform a minimal incision (termed USIC cheeklift, an ultrashort incision cheeklift).
A cheeklift has the ability to raise the thicker cheek tissue to an area below the eye, diminishing the appearance of hollowness below the eye. Rather than placing a graft of fat injection, which is mostly dead, we place an autologous graft of fat-fascia specifically at the eye-cheek junction and conservatively into the tear trough to minimize the appearance of hollowness.
This is especially successful in the post-blepharoplasty eye where there has been a change in the eye shape such as rounding of the eye or pulling down in the corners of the eye.
So one more option for you to consider.
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Fat works great for under eyes
Fat injections work very well under the eyes as well as loss of fullness from the cheeks. This procedure is very technique-dependant but can produce natural and lasting results
Fat transfer to lower eyelids
You can use either a filler or fat. However, I personally like the results with fat better since it looks and feels more natural. Fillers are useful as a first round of evaluation. If you are happy with the result, you cna then move to a more permenant result with the fat.
Fat and fillers work well for under eye hollowness
Fat injections and fillers (Restylane, Juvederm) are both excellent ways to address the lower eyelid hollows. I prefer fat as it has a longer lasting result that is very natural. I use the fillers for patients who want to "try it out" before they commit to fat injections. Often, I combine fat injection with lower blepharoplasty for a more complete result. This eliminates the kind of result that you are complaining about. Good luck!
Fat vs fillers for under eye hollows
Fat is a wonderful natural filler, especially in relatively young people and may take as a permenant graft. However, a word of caution, successful fat grafts can change with your weight. - so if you loose a lot of weight the correction may be lost, and if you gain weight, it may become lumpy. Fillers are a good way to find out how the correction will look with out having permenancy, and my choice in that area is Juvederm. It usually lasts 9 months to 1 year. Most dermatologists or surgeons who do liposuction will do fat transfer.
Treatment of post blepheroplasty hollowness can be treated by either modality fat transfer, or Hyaluronic acid filler.
What is important is the experience of the surgeon doing the injection, simillar to the blepheroplasty, the results are dependant on the experience of the surgeon.
Fat Transfer or Fillers: In Your Case Fillers
I tend to use fat transfer as a permanent panfacial treatment, i.e., over the entire face for several reasons.
1. Although in my hands, fat transfer is permanent and smooth (non-lumpy), the take under the eyes can be variable in the sense that it can look better but may not be all the way filled. I think by forcing the fill, you take a risk in having problems, which I don't do.
2. Therefore, when I do full face work, if one area is not as perfect as possible, then the face still looks great. That for me is the principle I call the 5% rule. If 20 small facial areas look better but not perfect with fat, the face looks better. That is the trick.
Therefore, in your case, when people just want lower eyelid fills, I tend to steer them away from fat and move them toward fillers.
That is my opinion.
Dr. Sam Lam
P.S.: A video on the 5% rule.
Fat grafting or fillers for under eye hollows
If your lower lid is hollow after surgery, fillers may improve your look. I prefer to use Restylane or Juvederm for this area, and place it underneath the muscle. This is an off-label use of the filler but many physicians do see great results. Lumpiness may occur, especially if the filler is placed above the muscle or close to the eyelid margin, and possibly a greater chance of lumps with fat than the hyaluronic acids such as Juvederm and Restylane.
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