Dissolve Restylane Under Eyes Before Fat Transfer?

I am planning on having a SMAS lift and fat transfer to upper/under eyes. I currently have Restylane injected to both of these areas a few months ago. In order to have the best possible outcome, would it be wise to dissolve these areas? Thank you for your suggestions. By the way, I love this forum!

Doctor Answers 7

Best to wait until Perlane dissolves before eyelid surgery with fat grafting

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I frequently do fat grafting to the eyes as part of a blepharoplasty.  I find it impossible to accurately place a fat graft with Perlane present beneath the eyelids.  My preference in my practice is that you wait until the Perlane has dissolved before considering eyelid surgery.

Eyelid Restylane--should it be "dissolved" prior to facelift and fat grafting?

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I have read all of my colleagues' answers, and feel that some may have not read the question carefully, and also might be missing an essential bit of information.

First of all, you are contemplating fat grafting for the periorbital areas, not the rest of the face.  If indeed these areas have deficiency and you have appreciated the results that your HA filler injections have provided, this is not an unreasonable plan. However, a couple of caveats should be considered.

Eyelid skin is very thin and shows an incredible amount of underlying detail, so the grafts must be precise and conservative. Since not all transplanted fat survives, it is better, IMHO, to graft more than once than to "overgraft" and hope that the exact "right" amount of fat survives in exactly the "right" locations. Be aware that transplanted fat retains the biophysical characteristics of the donor area, much like hair transplants. Let me explain.

The naturally-occurring periorbital fat that you and most everyone has is biochemically different (in terms of receptors, metabolism, and growth) than fat from, say, the abdomen. Think about morbidly obese individuals--their abdominal fat can be massively enlarged, whereas the periorbital fat is essentially stable--or else their eyeballs would bug out of their bony eye sockets. This is just one example of how belly fat is distinctly different from eyelid fat.

The reason this is important is that even if the fat transplanted from your abdomen to your eyelids is done perfectly, if you gain weight, your eyelid fat will gain also, causing unsightly bulges. I can hear some of my colleagues saying "No way!" but I have removed bulging fat grafts from the eyelid of patients who had fat grafts from their abdomen to their eyelids, gained weight, and developed eyelid bulges ("bags") that were as much of a new cosmetic problem as the initial lack of fat you presently are bothered by.

So, I'm not saying don't do it, I'm saying this needs to be considered carefully, and would recommend that if you have adequate eyelid fat that can simply be repositioned to reduce tear troughs or nasojugal grooves, along with arcus marginalis release, this may be a superior option. But you may simply not have enough of your own eyelid fat for upper and lower deficiencies. So if grafting is to be done, ask your surgeon to be extremely conservative and consider that two procedures here is better than one overdone graft session followed by several "fix-it" re-operations!

Now, on to the question about "dissolving" Restylane. Certainly the presence of HA filler in the areas to which your surgeon is suggesting grafting makes accurate estimation and grafting more difficult, if not outright impossible. SO, I wouldn't recommend proceeding with facelift surgery and fat grafting till all this is gone--that is, assuming you want the best results. It is pretty common to read about the dissolution or enzymatic breakdown of HA (hyaluronic acid) fillers by the use of hyaluronidase (Wydase). 

The commonly-misunderstood fact is that Wydase does not really "break down" the injected HA filler (Restylane or Juvederm, etc.), as these products are crosslinked molecules that are inherently resistant to breakdown so they last as long as possible in the body. If they were biochemically identical to the hyaluronic acid in our own tissues, these fillers wouldn't last very long and would be a less profitable product. That's why they are designed to last as long as possible in the body.

Wydase works by breaking down hyaluronic acid, and it does so the best in those HAs that are LESS crosslinked than those that are intentionally made to be more crosslinked. Thus, your natural HA is broken down somewhat more preferentially, while the "designer" HA (Resylane or Juvederm) is less affected--because it's made that way. The net effect is still volume reduction--which is why it is used in cases where "too much" HA is injected (Why is that, BTW? The stuff is expensive, so shouldn't it be injected more carefully and judiciously?). But the injected, more crosslinked, more "resistant-to-dissolution" HA remains and the actual deficient contours are not necessarily recreated. So, precise grafting is more of a "crapshoot."

Thus, my advice is not to waste time, money, or misdirection on Wydase injection. Rather, wait for at least 6 months (longer is better) and then proceed with your surgery, contingent upon the discussion about grafted fat retaining the characteristics of the donor site, especially when used in the eyelids. For the rest of the face, this is less of a concern, though facial fat grafting should still be done very carefully and precisely in tiny droplet-by-droplet tunnels to achieve maximum "take" and smoothness. Good luck and best wishes! Dr. Tholen

Richard H. Tholen, MD, FACS
Minneapolis Plastic Surgeon
4.9 out of 5 stars 263 reviews

Dissolve away

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lovelyjo: The presence or absence of the restylane is unlikely to significantly impact your facelift, but it will affect your fat grafting results.  With restylane in there, your surgeon will not know what your true anatomy is like.  Seeing as fat grafting is intended to be a long-lasting and hopefully permanent filler, it would be best if you dissolve the restylane beforehand.  This can take more than 1 injection of hyaluronidase (Vitrase) so plan ahead.  Best of luck. 

Garrett Griffin, MD
Minneapolis Facial Plastic Surgeon
5.0 out of 5 stars 14 reviews

Dissolving Restylane Before Fat Transfer?

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Yes, it would be best if you have the Restylane dissolved prior to undergoing the facelift and fat transfer.

Babak Azizzadeh, MD
Beverly Hills Facial Plastic Surgeon
4.1 out of 5 stars 9 reviews

Dissolve fat beneath lower eyelids before fat transfer

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Yes, definitely. If you are definitely going to have fat grafting in that location, your surgeon won't be able to determine exactly how much fat to put in.

Get Rid of Filler before Placing Fat?

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Since you don't want to repeat fat transfer too often (expensive and 2 surgery sites - more risk), you want to be able to transfer as much fat as possible at one setting (without overdoing it). If you already have volume due to filler, you can't place as much fat for obvious reasons.

So it makes a lot of sense to either wait until the filler has fully dissolved (I would suggest waiting at least a year) or, if you're in a hurry, dissolve it with hyaluronidase, before you place the fat. It certainly isn't necessary to do so, but you'll get the most bang for your buck with the fat transfer if you get rid of the filler first.

Richard Parfitt, MD
Madison Facial Plastic Surgeon
4.4 out of 5 stars 36 reviews

Facelift and Fat Grafting - Los Angeles

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I combine fat grafting with facelift surgery and have found that it is not necessary to dissolve previous injections prior to fat transfer. Raffy Karamanoukian Los Angeles

Raffy Karamanoukian, MD, FACS
Los Angeles Plastic Surgeon
4.8 out of 5 stars 95 reviews

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