Woman: What should be done for the lower bags and darkness -- relocation, removal and fat transfer? I've really tried to do my homework on the procedures and all it has done is confuse me and scare me. I've seen three surgeons that have good reviews and they all said I should do different things. According to what I have read off of this website, I should do what is best for my face and anatomy. Looking at my photos, should I do fat transfer with removal of fat-pads or should I do fat relocating and why? Which one will have the best results? Please help.

Dr. Prasad: Thank you for your question. As you stated in your question, you've really done your homework, and you met with three surgeons, and you're trying to look for the perfect solution for the bags under your eyes. Naturally to your surprise, there's inconsistency in the opinions of doctors as to what to do. To summarize, you were asking about removal, relocation, as well as fat transfer.

Your confusion is certainly understandable, and when we look at patients, we always look at the anatomy of course and we look at the context of their facial aging. I wrote a book a few years ago called "The Fine Art of Looking Younger", and I've been in practice for about 20 years, and a specialist in cosmetic oculofacial plastic surgery. I do a lot of eye lifts. I do a lot of face-lifts. Facial aging is something that I really spend a lot of time focusing on and helping people understand the elements of the facial aging process, and how any given particular plan impacts on that.

Let's just define a couple of things that are issues here. One is of course lower eyelid fat prolapse, and with your photo, you clearly demonstrate that. I also point out to most of my patients who come in for an eyelid consultation is to also look at the adjacent area, the area called the eyelid-cheek junction, as well as the area of the cheek or the submalar area. When you have bags under your eyes, it is often the dominant feature, and it's what really detracts from the overall appearance of your face. When people have this type of procedure done, and whatever surgery they have done, and the fat pockets have been properly addressed, then they look at the rest of their face and sometimes think that they look hollow or they look sad. Why? Because the adjacent areas of the face also have aged. Because they weren't dominant, their focus was not there.

Now in terms of distinguish procedures, as a specialist, I can tell you that in my experience, fat transfer to the lower eyelids is not advisable. I see patients from all over the world who have had fat transfer and they end up with irregularities, lumps, and it just doesn't work. The theory and concept is try to build up and restore the fat that's been lost, and try to then camouflage the fat pockets. Well, there's several defects in that idea. What is a problem is the fat that's under your eyes is actually prolapsed forward, so it's like a hernia. Therefore as herniated fat, it needs to be addressed in some way to restore it in its proper position.

MRI studies have shown that people with fat prolapse actually have more fat. In other words, they actually have an enlargement or increase in fat, thus it is justifiable to do procedures where you actually reduce or remove the fat. As far as transposition or relocation is concerned, this is an area that very often sounds much better than it actually is in practice. Moving fat from the orbit, from the space where it is and moving it to the adjacent areas may make sense, but a lot of people who get fat transposition will actually not have a good result and will actually have chronic swelling in the area where the fat is moved, into that eyelid-cheek junction. Although in my practice I do some fat transposition, the majority of the patients like you who have all this extra fat, I actually do fat reduction, because it is logical to reduce fat that is herniated past the rim and to get that type of contour.

Concerns about hollowing and things like that are always addressed, and that is where I think is your confusion is that why would three different doctors give you three different opinions. Because cosmetic surgery is an art, and it's not a commodity, and it isn't duplicated equally between doctors. Every doctor comes to the table with their aesthetic sense, with their experience, with their technical abilities, and of course with the procedures that best work for them. There is a lot of finesse in what we do, and that's why you can't just shop doctors like you shop for vacuum cleaners or televisions. Commodities that are absolute, you can certainly look for the lowest price and get what you want, but when it comes to medical care and surgical care, it is really more of a gestalt of how you feel in terms of your comfort level with the doctor, with the style, and that's usually demonstrated by looking at before and after results, and then getting a sense of the aesthetics and being in syner...

Buyer Beware: Fat Transfer Is Not Advised to Treat Bags Under the Eyes

Dr. Amiya Prasad discusses the problems with fat transfers when deposited in the under-eye area.