I prefer 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 microinjected in a series of discrete layers to gradually 'build' new soft tissue structure. As there is space between each microinjection, new blood vessels are able to grow into the grafted fat, allowing it to persist. If this process of blood vessel ingrowth (neovascularization) does not occur, then the injected tissue cannot truly be considered a 'graft' and is instead just another 'soft tissue filler' of limited duration.
Fat Grafting requires specialized training and specialized surgical instruments, as well as patience and attention to detail on the part of the surgeon. When performed properly, permanent improvements in facial plastic surgery are possible.
Structural fat grafting can be performed on eyelid hollows, to fill sunken cheeks, for filling sunken hollows under eyes and is often used for blepharoplasty correction when too much skin and or fat has been removed in an eyelid surgical procedure. Some people who have experienced fat loss as a result of procedures such as IPL or Thermage can also benefit greatly from permanent fat injections.
When selecting a plastic surgeon to perform fat grafting be sure that they have performed this technique with success for a significant period of time and that this is a procedure they perform very frequently. You don't want a fat grafting surgeon who performs the procedure just once or twice a month. Looking at many before and after photos, including images months and years after the procedure can be helpful, and speaking to patients is very important.
Pearl fat grafting uses multiple small pieces of fat, composite fat grafting uses one larger piece
Pearl fat grafting uses multiple (usually 3) small pieces of fat to plump the hollow eye caused by previous blepharoplasty. Composite fat grafting uses a custom formed whole piece of fat to fit into the hollow deformity. Both work well, and some favor the pearl method because they believe the "take" or survival of the graft will be better.
I use the whole "composite" graft technique because I like the uniformity of the result, and I "overgraft" to compensate for the dissolution of the graft during the time required for the graft to gain new blood supply. Final size and shape of the graft occurs between 4-6 months.
Do not confuse pearl grafting and composite fat grafting with fat injection techniques. Most doctors today are injecting fat through a syringe and calling it fat grafting. It should be called fat injection.
The take of fat that is injected is, in my experience less reliable than with fat grafting and pearl grafting. I believe the injection process damages the fat.
The fullness you note means that the grafts have taken, but I can assure you that they will decrease in size for 3-4 months, possibly longer.
I have my patients massage the swelling of the grafts which I believe helps the grafts settle in-but check with your doctor to make sure he approves of massage.
The hyperpigmentation can be easily removed with IPL treatments-I use the LuxGreen IPL made by Palomar.
Fat grafting vs Pearl fat grafting
Fat grafting is the procedure.
Pearl fat grafting in a technique.
Fat grafting can be accomplished using injections (closed technique), or surgical transfer (open technique) of pieces of fat with or without skin (dermis). These pieces can vary small to large. The pearl grafting technique uses an open technique with transfer of pearl sized pieces of fat. IT is generally practiced by oculoplastic surgeons.
It maybe that more of the fat survived than you would like. I would address this with your surgeon.
There are several problems with Pearl Fat Grafting
Three months is early on in the healing process and the "puffiness" will probably get better. I am not a fan of Pearl Fat Grafting. Pearl Fat Grafting has been advocated by certain specialists. The technique involves inserting small "pearls" of fat as grafts into pockets created under the eyes. I think there are several problems with this approach:
1. The fat pearls are usually too big to have consistent graft survival, meaning there will be variability in the final graft size and thus total graft volume.
2. The fat pearls can be visible under the thin skin around the eye.
3. It is difficult to graft the entire area adequately with pearl grafts.
I prefer "micro fat grafting" to correct the tear trough and infra-orbital areas. The grafts are placed with a small needle-sized cannula with multiple passes from multiple directions and at different levels under the skin. I believe that this technique for volume restoration is superior to pearl fat grafting.
Wait longer, revision or open procedure might be needed
They are both the same. Injection of microfat around the eye, is a very technical procedure. The key is always to place the fat deep enough to acheive the volume augmentation with no surface irregularities.
You will have to wait a little longer, maybe close to 6 months. If you still have the same problem, a revision or an open procedure might be needed.
As other physicians have noted, I would agree that microfat transfer is a bit more reliable than Pearl fat grafting, though every physician has their preference and there is no scientific data to promote one over another. I would also agree that 3 months is early on in the healing process and would likely wait about 6 months before undertaking any other corrective procedures.
Fat Grafting on the tear trough
The photos look better, but I see your concerns. I think that if he filled you a little more in the tear trough you would not be as tired looking. The hyperpigmentation should resoolve with time- sometimes it takes 6 months to see resolution.
Look for doctors who perform the Viafill procedure.
Pearl Fat Grafts vs Lipoinjection (micro fat grafts)
Pearl fat grafts are just what it sounds like - placing pieces of pearl size fat using an open approach. This is to be contrasted with lipoinjection, or structural fat grafting, where small amounts of fat are placed in a layered fashion to encourage better survival. In my experience there is more control and predictability with lipoinjection.
Probably more important than the technique and the most important factor of all is the skill and experience of the surgeon. Always check out his/her before and after photos and ask to see long term results and most of all that he is trained and a board certified plastic surgeon by the American Board of Plastic Surgery or board certified Oculoplastic Surgeon.