Thank you for your question.
You submitted your question with several photos. And you describe in your question that you’ve
undergone 2 fractional laser procedures and undergone 5 MCD and Oxylight procedures and
yet you are complaining about persistence of puffiness under your eyes. And you want
to know what to do about the appearance and dark circles under your eyes.
Well, I can certainly share with you my opinion in what I see based on the photos alone in
the absence of a physical examination and give you some guidance as to how I approach
situations like yours 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 helping people with under eye puffiness has to be one of the most
common issues I deal with in my practice every day. So I can certainly appreciate the frustration
and I think what always has to guide any intervention is a clear understanding of anatomy and I
think is where there has been some type of either miscommunication or perhaps a limitation
on the choice of the practitioners who performed these procedures for you.
When I look at your photos and you describe so clearly this constant under eye puffiness,
what I see is an anatomical issue called lower eyelid fat prolapse. Lower eyelid fat prolapse
means that the fat that’s normally around your eye pushes forward and creates this bulge.
Very often, this is described as an under eye circle. So people very commonly go for
solutions that are commonly sold as treatments for dark circles. And this includes everything
from creams to procedures that have nothing to do with the true anatomic issue. The true
anatomic issue has to do with fat.
Now this being said, when we look at an area that has fat prolapse, at this stage of our
knowledge, we are able to actually offer the different options to help our patients improve
the appearance of the under eye puffiness. Very often, people who have a slight degree
of puffiness are well served by doing a procedure with injectable fillers. For example, we can
use a filler such as Restylane or basically in the hyaluronic acid family and place it
into the tear trough area and that can help camouflage that area of puffiness.
Many people are afraid of needles. And what I explain to them is that essentially through
a minimally invasive approach, we can actually just place using a special instrument called
a blunt cannula into this area the filler and minimize the risks of bruising. And this
way, they can feel like they can confidently have a procedure and not worry too much about
downtime.
That being said, the other option for people who have puffiness of varying degrees depending
on how it appears in the relationship of their eye, their eye socket and their surrounding
area, you an also do a procedure that is more definitive and that procedure is called a
blepharoplasty. What this means is a surgical procedure that involves reduction of the fat
as well as various techniques to reposition and contour.
Typically for a younger person like yourself with your skin type, I would do a procedure
called a transconjunctival blepharoplasty. This is a procedure where I do all the surgery
from the inside of the eyelid. Now as strange as that may sound, this avoids the risk of
any incisions on the outside. I find that it is very predictable in terms of retaining
the shape and character of the eyes and it has been a very successful approach for me
in my practice and throughout my career. And in fact, we have developed in our practice
an approach that allows for essentially somewhat comparable to just getting an injectable filler.
We do these procedures under local anesthesia with LITE™ sedation. So there’s a differentiation
of course in getting sedated in which you don't get when doing a filler. But it’s
done in our facility which is certified by the Joint Commission. So for the patient,
it’s kind of a nice thing not to have to go to a hospital or surgery center and to
have the procedure done without general anesthesia. Essentially, the down time is generally a
few days. We get patients back to work in a week and we are able to essentially resolve
the issue of under eye puffiness.
Now it doesn't mean that you wouldn't still be a candidate for other ways to improve the
under eye skin area whether it’s with PRP or platelet-rich plasma derived from your
own blood to stimulate the collagen and to improve discolorations as well as other skin
focused treatments. My impression from what you had done is essentially, everything was
pointing towards the top layer of skin which essentially can certainly improve with anything
directed in that area but you’re not dealing with the actual anatomic issue which is the
lower eyelid fat prolapse.
So I think it’s, like I said earlier, that it could be a communication issue or a diagnostic
issue. But I think that if you really want to address the puffiness, you need to go to
a doctor who actually performs surgery, who’ll actually be able to offer you solutions that
are not biased by limitation. Again, without knowing the specifics of your situation, I
could tell you that it is not uncommon for me to see patients who have gone to either
non-surgical physicians or non-physicians and practitioners who offer all kinds of modalities
and alternatives to surgery and essentially, wasted a lot of time and money doing things
that don't address the true underlying issue. So I think again, I’m speaking from a bias
as someone who is on top of the pyramid of where expertise matters. And I think that
you are best guided finding the right practitioner with the right qualifications and experience
to guide you appropriately. But again, it’s important, any procedure, people have become
so overwhelmed by messaging about procedures and one quickly forgets that the basis for
any procedure is always the anatomy and what is the situation that is the foundation of
the problem that the individual presents with and not what’s the latest greatest tool.
You have to use the right tool for the right job.
So I hope that was helpful, I wish you the best of luck and thank you for your question.