While fat injections or dermal fillers can serve as an alternative to lower eyelid surgery, not all patients with under eye-bags can benefit from them.
The appearance of under eye-bag or “shadowing” is caused by different or even a combination of factors. Excess skin, herniated deep fat, loss or “shrinkage” of superficial fat (beneath the skin), or a combination of these variables may contribute to this aesthetic issue.
Before and after photos of a patient who have had fat transfer in her lower eyelid.
Basically, a “true” or standard lower eyelid surgery uses incision positioned very close to the lash line so the eyelashes can conceal the resulting scar. Referred to as an external incision technique, this allows the surgeon to remove excess skin and fat and possibly reshape the muscle.
However, not everyone with under eye-bags has excess skin. If the extra fat primarily causes this appearance instead, dermal filler injection (e.g., Restylane and Juvederm) can conceal the unsightly bulge.
The main purpose of dermal filler (as an alternative to lower eyelid surgery) is to make the lower lid bulge the same level as the upper cheek. This is a rather straightforward approach and does entail no or very little downtime; hence, it appeals in patients with busy schedule and cannot afford surgery and its ensuing “social recovery.”
But there is one caveat when dermal fillers are used to conceal the under eye-bag caused by excess fat: Touch-ups are generally needed at 6-12 months interval.
Meanwhile, fat injection or fat grafting is a method that provides longer-lasting effects than dermal fillers, with studies suggesting that its results last an average of 12-15 years. The procedure starts off with the collection of superficial fat (beneath the skin) usually in the tummy; only a few teaspoons are needed since the lower eyelid is just a small area.
The collected fat volume is then put in tubes and processed through centrifugation; the idea is to discard the oil, red blood cells, and other biomaterials except the fat cells. Afterwards, the purest form of fat is injected to conceal the bags.
It is important to note that fat injection and dermal fillers are basically volumizers (they add volume) and so they can also address the deep tear trough and the abrupt lid-cheek junction that come with aging.
It is not uncommon to combine volumizers with excision-based lower eyelid surgery to achieve the best results possible. This is particularly true for patients with excess skin, herniated deep fat, and abrupt lid-cheek transition, as suggested by leading Orange County plastic surgery expert Dr. Tarick Smiley.
Due to the laxity of skin and other supportive structures, the deep fat along the lower lid becomes prominent (i.e., it bulges out) with aging. In contrast, the superficial fat “shrinks” and thus gives the appearance of deep tear trough or abrupt transition between the lid and cheek.
To address the aforementioned problems, a small linear incision is made within the lower lid that allows the surgeon to remove the excess skin and reduce the deep fat pad. For additional fine-tuning, fat injection is used to create a smoother lid-cheek junction.
A lower eyelid fat transfer is a powerful tool in facial rejuvenation procedure that can provide natural-looking results in the hands of a skilled surgeon, as suggested by leading Beverly Hills plastic surgeon Dr. Tarick Smiley.
While dermal fillers can also correct the hollowed lower lid or deep tear trough, which is the transition between the thin-skinned eyelid and the thick-skinned cheek, fat transfer is perceived to be superior particularly if the goal is to achieve near permanent results.
The fat graft that persists about a year postop is expected to last a lifetime (or at least 10 years). Most surgeons aim to achieve a survival rate of 50-70 percent; it is important to note that some of the grafts will “perish” in the first few months of injection and so it might be necessary to slightly over-correct.
Dermal fillers, meanwhile, typically require 2-3 touch-ups every year because they are made of biodegradable material that the surrounding tissue gradually absorbs.
Dr. Smiley has recently performed lower eyelid fat transfer in a female patient with deep tear trough caused by soft tissue atrophy or “shrinkage” caused by the aging process. The procedure entails proper handling and injection of fat to achieve smooth, near permanent results.
The patient described has been considered as a good candidate for lower eyelid fat transfer “as a stand-alone” procedure (without simultaneous skin excision) because she only had very mild tissue laxity.
However, some patients can benefit more if their fat transfer is combined with the “standard” eyelid surgery (blepharoplasty) particularly if there is noticeable loose skin; this is achieved by placing the incisions at the natural upper lid crease or very close to the lower lash margin so the resulting scars are inconspicuous.
The celebrity plastic surgeon says one of the challenges or caveats of lower eyelid fat transfer is the risk of lumpiness because it deals with an area whose skin is markedly thin. To achieve smooth result, he highlights the importance of meticulous injection in which very small amounts of grafts (less than 0.1 cc) are introduced, as opposed to dumping them all at once.
The aforementioned technique, which is called structural fat grafting, also ensures spaces between each graft and thus allows blood vessels ingrowth needed for its long-term survival. Without this vascularization process, the body will eventually absorb the fat.
African American facelift involves a unique set of challenges due to the patient’s susceptibility to keloids or aggressive scarring. For this reason, a more proactive scar treatment approach in the first few weeks becomes particularly important to prevent any reminder of plastic surgery.
Scar placement is the first step to hide any surgical stigmata. Fortunately, this is possible for the vast majority of patients who can choose from different incision techniques to produce their aesthetic results.
Before-and-After Photos of African American Facelift Patient
While shorter incisions might be perceived as better than longer incision techniques, patients who need extensive corrections—i.e., their mid and lower face has a significant skin and tissue laxity—may have to accept the standard facelift method in which the scar typically starts from the temple (in front or behind the hairline) that goes around the inside edge of the ears and then reaches the earlobe.
Sometimes, the scar is even extended into the nape still concealed by the patient’s natural hairline for optimal concealment.
Regardless of one’s race or gender, the vast majority of facelift patients will require some type of internal reinforcement in which the soft tissue and muscle are reshaped as well, as opposed to relying solely on skin, which over times settles and droops due to the effects of gravity.
Simply put, most facelifts today are not a skin-only operation. To achieve stable results that can last for many years, experts at the California Surgical Institute suggest that all soft tissue must be taken into account during surgery.
In the past, facelifts relied on excising and tightening the loose skin, without giving much thought about the facial volume loss. This approach resulted in gaunt cheeks, upper cheek crescent, and/or hollowed lower eyelids, which could present themselves immediately or years after the surgery.
To avoid these aforementioned reminders of plastic surgery, surgeons at the California Surgical Institute address facial volume loss at the same time; this is either performed through fat transfer or dermal fillers.
Fat transfer uses the patients’ own fat cells, usually collected from their tummy, to smooth out their laugh lines, correct the deep tear troughs, and plump up their hollowed cheeks. Typically, this is performed simultaneously with facelift.
Dermal fillers such as Restylane and Juvederm, meanwhile, also work like fat transfer, although their results can only last between four and six months.
Whether fat transfer or dermal filler is used at the time of surgery, addressing soft tissue shrinkage during African American facelift means the surgeon relies less on skin pulling, thereby possibly obviating the need for longer scars.
Restylane vs fat transfer injection: This is arguably the most common dilemma of patients seeking facial rejuvenation procedure, as suggested by leading Beverly Hills plastic surgeon Dr. Tarick Smiley.
Both materials are also referred to as volumizers since they fill in hollowed facial regions (e.g., flat cheeks and gaunt lower lids) and certain types of deep creases.
Photo Credit: Restylane.com
Restylane is a hyaluronic acid-based dermal filler, a naturally occurring material that gives the skin its youthful “plump” and glow, hence there is almost no risk of allergic reaction.
In essence, Restylane is derived from tissue cultivated in a laboratory, with its entire DNA removed to further eliminate risk of allergic reaction. A few comprehensive clinical studies have demonstrated its impressive safety profile, making hyaluronic acid-based volumizers more popular than collagen and other filler materials.
Fat transfer, meanwhile, also boasts impressive safety profile in the hands of a skilled injector. But compared to Restylane or any other type of dermal fillers, the technique has a higher technical difficulty due to the processes involved.
In this technique, donor fats are collected, then processed to eliminate impurities, and injected back into the body. As of this writing, there is no standardized procedure thus the survival rate of grafts may differ from doctor to doctor.
Proponents of fat transfer suggest that it provides more natural and softer results than most types of fillers because it adheres to the principle of replacing “likes with likes.” For this reason, it has become a common routine to combine this technique with facelift surgery.
The effects of fat transfer are expected to be near permanent, or at least 8-10 years, while Restylane or most types of hyaluronic acid-based fillers can only last 4-6 months. Simply put, the patient who resorts to dermal fillers must take into account the cost of maintenance.
However, fat transfer has its own caveat such as longer downtime—i.e., it will take about two weeks for most of the swelling to subside. As a result some doctors recommend dermal fillers to most of their patients unless they will have a simultaneous facelift surgery.
Dermal fillers, particularly hyaluronic acid-based products, are also ideal for first-time patients who are contemplating about the possibility of more permanent solutions like fat transfer or facial implants.
Hyaluronic acid-based products are reversible should the patient is not happy with the results. They can be immediately broken down by an injectable enzyme; however, this is not an option in fat transfer.
The issues involving Restylane vs fat transfer can be resolved by honest and transparent communication between a patient and her doctor.
All efforts must be done to avoid the facelift telltale signs such as windswept or overly tight look, gaunt cheeks, hollow eyes, lumpy neck and jaw line, visible scars, and hairline/ear deformity.
The list below explains the fundamental strategies utilized by surgeons from the California Surgical Institute that allow them to deliver natural-looking facelift results and to prolong its rejuvenating effects.
- Deeper facial muscle methods
The goal is to create a strong, stable support and elevation of the face by going deeper, as opposed to stretching the skin alone, which is an antiquated technique that is linked to the windswept appearance, overly tight or flat cheeks, hollow eyes, poor scarring (migration), pixie ear deformity (elongated appearance), and short-lived results.
Simply put, elevating the deeper muscle and fascia layer can help surgeons avoid a myriad of facelift telltale signs.
- Use of ancillary procedures
Soft tissue laxity is not the only sign of facial aging. It is important to address the loss of volume or fat as well to achieve a more balanced, youthful appearance. For this reason, volumizers usually in the form of fat transfer and dermal fillers are often considered as good simultaneous procedures.
Simultaneous neck lift is also warranted in many cases. Bypassing this procedure could make the aging neck look out of sync with the more youthful face.
Other possible ancillary procedures include brow/forehead lift, eyelid surgery, and cheek implant.
- The issue of fat and volume
While others require volumizers to correct the gaunt cheeks and hollowed eyes, some patients may need liposuction along their jaw line and neck to correct the “fleshy” appearance. However, this should be done sparingly; there should be some layer of fat left behind under the skin to preserve its smooth surface.
- Preservation of the natural hairline and the ear’s contour
While it might seem always ideal to hide the incisions behind the hairline, some patients’ anatomy will warrant them to be positioned in front lest their natural hairline might be disturbed. With proper wound closure, they are supposed to fade into a scar that is almost invisible.
Facelift may also entail incisions in front of the ear. Some doctors suggest that placing the scars in front of the tragus, as opposed to inside the ear, is less likely to disturb the natural shape of the ears. Despite varying views on the “best” scar placement, the consensus is that eliminating or minimizing tension on the wound is of critical importance to promote favorable scars.