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.

There is a great art to performing skin closures after Mohs surgery. Regardless of who performs the closure, it does take some time for the skin to heal, and the swelling to go down. Immediately after surgical closure of the wound, it is not unusual for significant swelling to occur, distorting tissues, and sometimes causing a temporary pulling and tightness of the skin.

Fortunately, these changes dissipate over 1-2 weeks after surgery. Occasionally, however, it may take longer for the post-surgical changes to go away, sometimes as long as several months.

With that said, I always make it a point to see my patients a few days after surgery and I continue seeing them regularly as the healing progresses. At these visits, I discuss the surgical closure and ask the patient if they have any concerns about the cosmetic or functional outcome of the surgery.

Although a revision surgery may be performed to correct an unexpected surgical outcome, this is very rarely necessary, especially when the procedure is performed by someone accustomed to performing Mohs surgery closures.

I would encourage you to bring up your concerns to the surgeon at your post-operative visit. If none was scheduled, call the surgeon's office and ask to see the doctor to discuss this soon.

Accutane is a wonderful medication, but it can be pretty hard on the liver. In fact, one of the main side effects seen in many people who take the medication is alteration of liver function enzymes. We check these regularly when someone is taking Accutane.

The safest way to perform liposuction is to use the tumescent technique, or injection of large amounts of dilute local anesthetic solution. Lidocaine is the anesthetic used. Lidocaine can be toxic if high amounts are in the body. The liver has the job of clearing lidocaine from the bloodstream.

If the liver is irritated, damaged, or not working properly as a result of a medication such as Accutane, toxic amounts of lidocaine can build up in the body and lead to very serious complications.

I would advise any patient to wait until they were off Accutane, even if the liver appears to be working properly on the medication. It is simply not worth the risk.

The laser that your dermatologist is using is likely very different than the Med Spa laser. Typically, only a physician will perform intense facial resurfacing. At a med spa, typically nurses perform the treatment, which limits the power of the treatment that can be used.

My favorite laser for facial resurfacing, after having tested them all, is the Active Fx. It has the power to deliver real, visible results after one treatment. The downside is that it usually takes 4-7 days to recover from the treatment. I generally avoid "minimally invasive" lasers for resurfacing, since they typically produce minimal results. In my practice, I have many patients who have done multiple Fraxel treatments elsewhere that come in to see me regarding more intense facial resurfacing. Quite simply, no laser matches the improvement that a carbon dioxide laser can achieve on skin tone, texture, and wrinkles.

I have been using Active Fx since the machine came out on the market several years ago. I remain very impressed by the results that this laser delivers. After having tested most of the competing devices, I know that the Active Fx is able to produce real, visible improvements after just one treatment.

The main indications for performing an Active Fx treatment are: fine lines/wrinkles, acne scars, sun spots and skin laxity caused by years of sun exposure, and uneven skin tone/pebbly skin texture.

The Active Fx laser is much more powerful than many of its competitors, and has the capacity to deliver a true, non-fractional carbon dioxide laser treatment, should that be necessary. For a younger person, I usually use the Active Fx, fractional settings, which generally deliver impressive results after just one session. The healing time after a standard Active Fx treatment is generally 4-7 days, depending on the settings used.

Occasionally, it is necessary to repeat an Active Fx treatment to enhance the results, but it is the expectation, not the rule.

Some people try to avoid the healing time by choosing to do a less intense treatment with an alternate laser. Unfortunately, minimally invasive laser resurfacing generally produces minimal results.