Should I get dermal fillers or surgery for my left eye?

Question

I’ve recently had 3 consultations with 3 separate Ophthalmologists, with varying opinions on my issue. My issue being my left eye. Throughout the day, the eye area becomes more hollow, giving a slight droop effect. My eyebrow also seems to raise or arch in-line with this. I’ve always had this problem. One doctor advised dermal fillers and Botox. Another advised interior ptosis surgery. Another suggested fat grafting. I also tried the drops which elevate the lid slightly. No improvement…..

George Yang, MD · Answer

Hi BethValan,
If the ptosis eye drops are not showing the type of improvement you are looking for, I suspect the ptosis surgery may not meet your expectations. 
Note in your morning photo, when your eyelids are more puffy, the eyelid opening on both sides is more symmetric. Yet later in the day when the morning swelling drains away, your left eye the hollowing appears as well as the ptosis. 
Which came first? The chicken or the egg. 
If the ptosis is causing the hollowing, then the ptosis eye drops can mimic an internal ptosis surgery (no external incision, tightening of the Müller muscle).
If the fat loss of hollowing is causing the ptosis, then morning swelling may help with the appearance of the ptosis. In some cases, the hollowing creates a pseudo ptosis appearance where the deflated brow exposes too much eyelid “platform” (the eyelid showing under the crease) which gives a. “Sleepy eye” appearance. 
Additionally, when there is hollowing of the upper eyelid/brow area, a proper eyelid crease may not fully form and a double or triple fold may occur.
You can check to see if your left brow fat area is “bonier” than your right brow fat area by raising your eyebrows. You may notice than the fat just under the left eyebrow has less “padding”. If so, that would be the area I would fill. 
In an alternate possibility, the brow fat pads are symmetric, but the hollowing is between the brow bone and the eyeball, then that would be the area that I would fill. 
Upper eyelid/brow filling does not come in one size, and if done incorrectly, can result in lumpiness or strange bulges when raising your eyebrows. When taking pre- and post photos, I am checking flyover make sure it looks natural in various eye gazing positions. (Looking up/ down, raising eyebrows, etc). Many before and after photos only show the patient looking straight ahead, which may look fine, but in other eye positions, weird things show up. 
Prior to 2008, I was surgically inserting fat grafts, in the same areas. This was my initial technique which helped, but left a lot to be desired. The fat survival is variable and was lumpier than the later technique using the filler. Also, when the patient gained weight the fat would grow and when they lost weight it would shrink. 
The filler is more stable, and smoother. If the patient gains weight, and the filler looks too puffy, the filler can be dissolved. If they lose weight, they may want more filler in the same area, in which case the old filler and new filler can blend together as one smooth result. 
With fat grafting the fat heals into a specific shape (or clump) and if you add more fat , it may be adding an additional clump on the original clump. 
With the filler technique I use, it would be like adding air to a automobile tire. When the air deflates over time, you can just add more air to the tire to get the recommended tire pressure. 
Lastly, patients ask about how long filler lasts in this area. It ranges from 18-24 months on the short end where the patient may want a touch up, to 5-6 years before they may want a touch up. I go over this during my consultations by showing examples of patients over the years and how the filler lasts. 
Hope you found this helpful. 
Have a great day!
Best,
Dr. Yang

Leonard Grossman, MD · Answer

I definitely agree with the Doctor Who recommended fat grafting. Fat grafting in the hands of an experienced plastic surgeon when it comes to fat grafting techniques, should produce natural and permanent results. I hope this helps and good luck from New York City plastic surgery

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