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
