Thank you for your question.
You submitted a single photo and you’re asking what is the best technique for lower
eyelid blepharoplasty and you mention in your question that you are confused about fat transfer
and muscle suspension and that you have heavy upper eyelids and that you don’t want to
look like you have hollowness under your eyes after surgery.
Well, I can certainly share with you my perspectives and my experience with these type of questions
which is one of the most common questions we have who come to us in our practice.
A little bit of background, I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial
plastic and reconstructive surgeon.
I’ve been in practice in Manhattan and Long Island for over 20 years and dealing with
eyelid rejuvenation and under eye bags is the most common issue that we deal with in
our practice.
And certainly the procedures you discussed, you submitted certainly are amongst the spectrum
of options that you can consider and I can understand that it can be very much overwhelming.
So whenever I try to help a patient understand their options, I think that there are very
specific issues that first have to be understood and so we will begin first with anatomy and
with the under eye bags, we will focus on that.
The under eye bags are due to something called lower eyelid fat prolapse.
Lower eyelid fat prolapse means that the fat from behind the eyelids pushes forward, creates
a bulge and makes the under eye area look puffy.
Now when it comes to eyelid surgery, a lot of times people are afraid of looking hollow
under their eyes after eyelid surgery and it’s been my experience that most of the
time, it’s because of essentially two issues.
Number one, the procedure is done in a way where the lower eyelid ends up sagging or
rounding and it is called eyelid retraction.
Now that can make the eye look very hollow.
The other side of that is that people are often not educated about the area directly
under the under eye bags where the cheekbone is projecting and so they feel like even though
the bags are gone, they still look relatively hollow and that’s because they have a volume
deficiency in their cheek area.
Now if you were to look at the medical literature about optimal ways to do lower eyelid surgery,
you will be overwhelmed by the numerous articles and techniques that come up when you do that
kind of search.
And certainly, a lot of my colleagues do what they feel comfortable with just the way I
do what I feel comfortable with.
Now here is my perspective on what I will do for you and of course it’s going to be
a little bit different than what you might have been considering and I’ll explain to
you what the thinking is.
When you are dealing with fat prolapse under the eyes then the goal is to reduce that fat
prolapse and so I do a procedure typically called a transconjunctival blepharoplasty.
By doing this procedure, I do this procedure from the inside of the eyelid, I reduce the
fat pockets and I’m able to reduce or reposition and shape and sculpt the fat pockets so that
the contour looks better.
Now typically, when I evaluate the patient, I point out to them the cheek area as well
as the position and relative elasticity of the outer core of the eyes.
So if someone needs the outer corner lifted slightly or reinforced, that’s a procedure
that’s done concurrently.
If they need volume in their cheeks, they’re done at the same time usually with an injectable
filler or done later with an injectable filler.
Now where does fat transfer and this muscular sling procedure or suspension procedure come
into play?
Well, there’s a school of thought that, if you were to add fat to fill the volume
deficit that is in continuity with the lower eyelid, then there is a value with creating
an area that restores volume and camouflages the puffiness and that technique is basically
called fat grafting.
Now the problem I have with fat grafting is actually several fold.
In my experience, when patients have extensive fat grafting under their eyes to try to hide
the under eye bags, they end up with kind of a swollen appearance and unfortunately,
because of the techniques used with grafting, the muscle called the orbicularis oculi muscle
can become fairly traumatized.
And to counteract that trauma which can compromise the position of the eyelid causing lower eyelid
retraction, a lot of my colleagues would do some kind of muscle suspension procedure to
try to keep the eyelid from sagging.
I feel that patients, and this is from direct experience, that patients have come to me
from around the world to have actually fat removed from their eyelid because of fat grafting
and having this chronic swelling and this instability with the eyelid requires a lot
of work for revision surgery and this is an area that I specialize in.
So I think that my recommendation would be different from a colleague’s recommendation
where I would approach this as, and the basis again is, you want a procedure, and this is
something that is very much important these days, you want a procedure that’s likely
to be satisfactory that’s predictable and that is less likely to have problems or a
prolonged healing process.
Fat grafting by nature takes a longer period of time for healing and for swelling to resolve.
Our patients want to get back to normal life and get back to work and back to their activities
in a week.
And so I think that my approach would be something that’s different doesn’t make someone
else’s approach wrong but it’s important for you to understand the perspective and
the pluses and minuses.
It is very important to also understand and really have a handle of what is the ideal
outcome for you.
No matter what, facial aging is a change and what we want to do is to help people look
their best for their age.
So I think that as you are learning more about these procedures, you need to take good notes
and really understand the pluses and minuses of each procedure and then ultimately make
a decision and go with it.
But that’s my opinion on what I would do for someone with just the focus of the eyes
and the photo you submitted.
So I hope that was helpful, I wish you the best of luck and thank you for your question.