Peri orbital rejuvenation - what is the best approach? (Photo)

Question

I'm a 49 yr old male. I am 11.2 stone. I have fair skin with mild rosacea on the nose and cheek. It creats a demarkation line between cheek and under eye. I've lost volume under the eyes , tear trough and temple. Basically I want periorbital rejuvination. Whether it's midface lifting with lower lid tightening or fat transfer and lasering. That smooth lower eyelid cheek junction. What is the best approach?

David C. Pearson, MD · Answer

Correcting these under-eye areas like the tear troughs and orbital rims can usually be done with an injectable filler. Likewise, the temporal hollows can often be improved this way. I tend to start conservatively with a temporary hyaluronic acid gel filler like RHA, Juvederm, etc. These usually last quite a long time in these areas--often a year or longer--which allows a patient to see it from various angles and under various lighting and photographic situations. If they enjoy the results from these temporary fillers, I will sometimes recommend a more permanent filler like Bellafill. Rosacea can sometimes flare up with the use of fillers, however, so be prepared to treat the rosacea more aggressively if necessary with your dermatologist.

I'm not a huge fan of fat transfer in these areas since they can sometimes produce some weirdly lumpy contours.

All the best,

--David C. Pearson, M.D.

I'm not a huge fan of fat transfer in these areas since they can sometimes produce some weirdly lumpy contours.

All the best,

--David C. Pearson, M.D.

Nelson Lee Novick, MD · Answer

At least from the one photo provided, volume deficit appears to be the major issue. So, if this is indeed the case, then volume restoration would appear to be the quickest and simplest approach to addressing all of the aesthetic problems of concern. There are HA volumizing fillers that can contour the cheeks, which thereby can secondarily improve both the smile lines and the under-eyes and also create a smoother, more gradual transition between the upper cheek and the lower lid regions.  If still necessary, there are HA fillers specifically made for treating tear troughs and under-eye hollows. And there are robust HA fillers that can help to remediate the temple hollows. In the hands of an experienced, board certified cosmetic dermatologist injector all three areas can be treated in about 45 minutes and with immediate, on-the-spot, results that typically engender a "Wow!" reaction. 
The hard science to support the use of expensive, "bells and whistles" fraxel lasers and RF devices unfortunately lags woefully behind the heavy marketing hype and social media buzz that surrounds promoting them. So, "buyer beware" when considering these. Fat injections, which I gave up performing many years ago, while offering the theoretical chance for a more durable result so often do not make good the promise, since most of the transplanted fat separated from its original blood supply does not survive. What's more, fat retains the characteristics of the area from which it is taken. So, for example, if the fat is taken from the abdomen, when, with time, the abdominal fat develops a midlife, midriff bulge, this may occur at the site where any of the transplanted fat has survived. And fat, once transplanted, is not easily removed should there be any adverse reactions. As for surgery (which is aggressive, invasive, requires downtime, and carries risks for infection, scarring, etc.), when volume is required, stretching skin and cutting off the excess will likely only create a more skeletal-looking face, since it does not supply and restore what is actually needed: volume. You would be wise to consult a board certified cosmetic dermatologist filler expert. And one more word of caution: you would also be wise not to go in to a consultation asking for a particular treatment because, to your likely later frustration and dissatisfaction, you are likely to get what you ask for. Hope this helps and best of luck.

Ajaya Kashyap, MD · Answer

Thank you for your query. The approach to peri-orbital rejuvenation may vary based on your wishes and your surgeon’s approach. Based on your single photograph, I would recommend nano fat grafting with a mid-face lift and  lower eyelid tightening. Please find an experienced board certified Plastic surgeon who can examine you and help you with all your concerns. All the best!

Mats Hagstrom, MD (license on probation) · Answer

There’s response was dictated. I apologize in advance for grammatical errors.
Facial aging is often quite universal and many senior plastic surgeons who focused their careers un facial rejuvenation typically approach the face in a more global way, addressing multiple aspects at the same time, rather than focusing on one area alone.
Often age shows in many parts of the face.
I will focus on the lower eyelid and midface region since that appears to be your main concern.
 to start with the area is complex and not always clearly understood by both providers and patients.
There are generally two variables that happen in conjunction and act as opposing forces, the differentiate the youthful face from that of older individuals.
The first is the lower eyelid, which in youthful individuals tends to be tight and snug.
 Immediately below the lower edge of the lower eyelid. The upper part of the midface should be full and plump.
With facial aging both of these areas reverse course.
The lower eyelid instead of being tight and snug behind to bulge as the peri orbital septum begins to weaken, allowing the weight of the eyeball to press supporting lower eyelid, fat pads forward. 
Immediately below the lower eyelid, the area loses volume and develops a sunken appearance.
When, making an assessment, we typically start by determining if bulking of the lower eyelids is the primary issue, if loss of volume in the upper midface is primary or if they contribute equally.
 Determining which is the primary secondary variable helps direct treatment options.
Textbook, treatment for bulging lower eyelid fat pads is reducing the fat through a lower eyelid blepharoplasty.
Reestablishing midface volume can be done using implants, fillers, fat transfer or a mid facelift. 
Individuals who present with both variables contributing significantly, will probably have a better outcome, addressing both variables.
This, for example, could be a treatment plan like a trans conjunctival lower eyelid, blepharoplasty with fat transfer of the midface.
The easiest, least invasive, and most forgiving option, would probably be using fillers only to restore, midface volume.
Depending on the significance of the condition of the lower eyelid, fat pads, volume restoration alone can be surprisingly effective.
To get an understanding of what volume restoration alone, using fillers can accomplish I suggest you check out the before, and after pictures on the website of David Mabrie, MD yourfaceinourhands dot com. He is a facial plastic surgeon located in San Francisco. His practice is devoted exclusively to working with facial fillers. His work is some of the best I’ve ever seen.
I’m not suggesting people fly to San Francisco to get filler treatments, but reviewing his results can give a better understanding of the gold standard, and what is possible with the use of fillers alone.
It’s always good to have a reference of what a procedure is truly capable of in the hands of the right provider.
For most plastic surgery procedures, quality outcome is based on two variables.
The first is patient candidacy, and the second is the skill and experience of the provider.
There isn’t all that much patience can do regarding their own candidacy.
What patients do have control over is provider selection.
 This means the provider selection is basically the single most important variable and probably in the end more important than what procedure you choose.
Finding the right provider is far more difficult than most people realize.
Most people use poor discretion in deciphering information regarding provider selection.
The best plastic surgeons often do not focus efforts on self promotion, advertising, social media, or Internet presence.
Instead, they focus their efforts on patient care which is what they do for a living. Period.
 Famous plastic surgeons are if anything inversely correlated to talented plastic surgeons. 
To find the best provider, I suggest patients consider the following.
Start the process by having a good set of standard facial pictures, the same way plastic surgeons take before and after pictures.
Make a list of local plastic surgeons in your community who seem to excel at facial aesthetics.
 Reviews can be particularly helpful at finding providers to avoid, but do not necessarily help in finding the best providers.
After having a list of local providers who may be quality contenders schedule, multiple in person, consultations with each of those providers.
During each consultation, ask each provider to open up their portfolio and show you their entire collection of before, and after pictures of previous patients who had similar facial characteristics for whatever procedure the provider is recommending.
 Take careful notes during each consultation, especially regarding the provider ability to make a quality assessment and clearly understand what the underlying problem or diagnosis is.
Take careful notes, especially regarding the quality and quantity of before and after pictures.
An experienced plastic surgeon should have no difficulty showing you the before and after pictures of at least 50 previous patients for commonly performed procedures.
Highly experienced surgeons should in fact of access to hundreds or preferably thousands of before, and after pictures for common procedures.
 Being shown a handful of pre-selected images, representing only the best results of a providers career may be insufficient to get a clear understanding of what average results look like in the hands of each provider, what your results are likely to look like, or how many of these procedures they have actually done.
 There’s no correct number of consultations needed to find the right provider.
Sometimes it is simply a matter of luck.
The more consultations you scheduled the more likely you are to find the better provider for your needs.
The biggest mistake patients make is scheduling only one consultation and then scheduling surgery.
Scheduling only one consultation, more or less eliminates, the need to find the better provider.
 Whenever dealing with situations that are inherently complex, patients should anticipate that providers will have different recommendations and different solutions.
In the end quality procedures are always based on having a clear understanding of what the underlying problem or ideology is.
The best treatments are focused at directly treating the primary problem.
 unfortunately this is sometimes inherently challenging.
Attempted solutions that partially address the primary problem will give partial improvements.
The best bang for your buck or simplistic approach to signs of facial aging based on the photo included would be volume restoration in your midface.
Fillers are ideal for this.
Fillers are precise, predictable, and forgiving, if patients don’t like the outcome.
Fillers lack is permanence and for some individuals this makes fillers and undesirable option.
Fat transfer is by its very nature, unpredictable, imprecise, and potentially unforgiving if people don’t like the outcome.
Implants are considered by many to be a bit outdated as a treatment option, but was historically used much more frequently.
Mid facelift was very popular in the late 1990s and early 2000s.
The procedure lost some popularity as providers became more proficient with the use of facial fat, grafting and greater availability of quality fillers.
The procedure has great potential, but can have a slightly lengthy recovery in regards to facial, swelling and bruising.
Fillers are in many ways, simply ideal.
Finding providers who truly mastered the art of facial volume restoration using fillers is another story.
There seems to be no shortage of people offering, promising and providing the service.
Few even come close to delivering what doctor Mabrie has been able to achieve in my opinion.
There is plenty of hidden talent in almost every community.
In the end understanding your own candidacy and provider selection are the two most important variables.
I highly recommend people avoid virtual consultations whenever possible.
Generally speaking, I recommend people avoid traveling along distances for elective surgical procedures, but recognize that sometimes travel may be necessary.
The more extensive and involved the surgery is the less appropriate. It seems to travel for the procedure.
Best,
Mats Hagstrom, MD

Peri orbital rejuvenation - what is the best approach? (Photo)

Answers (4)

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