Thank you for your question.
You submitted several sets of photos of your eye area.
And you state that you had micro liposuction done three times to address excess fat after
undergoing fat transfer to the under eye area.
And you’re concerned of a mound-like appearance under the right eye.
And that you state that you did have some Belotero placed to help blend the area.
And you show in the photos basically the eyes at rest and the eyes with expression and you’re
looking for some guidance as to how to proceed moving forward.
Well, I can share with you my experience and my perception of this issue and how I’ve
dealt with this area and issue in my practice.
A little bit of background, I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial
plastic and reconstructive surgeon.
I have been in practice in Manhattan and Long Island for over 20 years.
And this type of issue has presented itself in multiple ways for a few reasons and I’ll
explain as to what my position is about fat grafting under the eyes.
You see, the history of fat grafting has always been for the surgeon the optimal filler, the
natural filler that comes from your own body.
And it is plentiful and certainly convenient during surgery to take fat from one area and
transfer to another area.
It can certainly be effective in many areas in the body including the face as well as
for hand rejuvenation for example.
But for a long time, I felt that fat grafting under the eyes has unfortunately too many
issues that make it problematic.
When you look at the eyelid area, you’re dealing with skin that is the thinnest skin
of the body.
You are dealing with an area that is relatively unforgiving.
In other words, basically, any irregularities are very obvious.
Now, before the modern day fillers, fat grafting certainly potentially had a certain potential
role given the absence of any great alternative.
Now before there was Restylane introduced in the US around 2005, the option was either
to do fat grafting or a silicone tear trough implant or nothing.
So moving the clock forward, what I have been seeing a lot is a variety of issues.
Patients who have had fat grafting will either have no results.
In other words, the fat didn’t completely make it at all or they’ll have irregularities
because parts of the fat survived and parts of it didn’t or they have an inflammatory
response and the body forms a capsule around the fat.
Now, essentially the challenge with fat grafting with its many advances in fat grafting remains
essentially the same as it was more than 10-20 years ago.
And what is that?
If you want to place volume in any area, you want safety, you want predictability and you
want to have minimal downtime.
So the challenge with fat grafting is really for me is the predictability.
When you place fat in this area, you are not necessarily placing a uniform smooth substance
like you are when you’re using an injectable filler like a hyaluronic acid filler.
You’re placing fatty tissue and this is a combination of different fat cells and connective
tissue.
Now there are many ways to process the fat and we have a lot of options in that way.
But it still remains to be in my opinion to be unpredictable.
And thanks to the modern day of fillers, essentially, my patients lean more towards to treat hollows
rather than using fat in that particular area.
Now that being said, I think part of the frustration you may have had with the suctioning procedures
is when fat is placed in this space, although the surgeon wants to place it in a very particular
way and in a very particular plane, things may look good at the time of surgery.
It is my experience when I have operated on these patients to remove this fat that the
fat ends up in multiple levels throughout the tissue between the front and the back,
in between the eyelid and the orbicularis muscle within the orbicularis muscle, behind
the orbicularis muscle and it’s essentially like fat and scar tissue.
It forms different nodules and planes.
So it’s much more involved to actually remove this.
That being said, it is possible to address this issue because you’re not really just
removing fat.
You’re removing the scar tissue and capsule and everything else that goes with it.
And it is important to also maintain the integrity of the eyelid.
So there’s never really an absolute when you are planning this type of surgery.
Generally speaking, this type of operation, I will try to do from behind the eyelid, to
preserve as much as the integrity of the muscle and try to dissect out these nodules but never
too aggressively to compromise the eyelid muscular tone.
In addition, there is the risk and the potential need for additional surgery to support the
lower eyelid should there be any type of loss of integrity of the tissue.
The eyelid is a deceptively complex structure.
And the lower eyelid, the layers of the skin, the muscle and the posterior layers are all
in combination very strong.
Individually, they’re much more weak.
So they behave like columns holding up the lower eyelid.
So I think that in your situation, you should mostly be focused on the appearance as it
is when you are at rest.
The appearance with movement when it comes to dynamic motion is always going to be different
because when the tissue has been operated on and there’s all these irregularities,
the muscle and the symmetry cannot really be perfect when it comes to activity.
But certainly at rest, to have this bulge and elevation, it seems that it should be
relatively isolated and probably can be addressed.
But understanding the risks and benefits of this type of surgery, it’s critically important
and that should be done through a formal consultation.
So I would recommend that you meet with an oculoplastic surgeon and oculofacial plastic
and reconstructive surgeon, someone who focuses mostly on cosmetic who has experience in this
area.
And learn about these options and these risks.
A proper exam requires also evaluating the eyelid tone and the structure and actually
to touch and feel and see what that amount of area feels like so you actually kind of
anticipate what to see when you are in surgery and then take it from there.
So I hope that was helpful, I wish you the best of luck and thank you for your question.