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.
The degree of arm lift pain after surgery greatly varies from patient to patient due to individual pain threshold, physical fitness, and extent of surgery (short vs. long incision technique).
Dr. Tarick Smiley, a prominent Orange County plastic surgery expert, says it is expected to experience temporary pain, numbness, tingling sensation, skin sensitivity, and tightness following an arm lift surgery, or medically referred to as brachioplasty.
During an arm lift, Dr. Smiley says the excess skin is removed with incisions made within the armpit fold; however, patients who require extensive correction will need their scar extended into their elbow to achieve the most natural, smoothest results possible.
(Note: Aside from skin excision, the operation also involves reshaping and tightening the fascia, which connects the skin to the muscle. This additional step also contributes to the amount of arm lift pain after surgery.)
The perpendicular scar from “full” or standard arm lift is generally positioned on the inner aspect of the arm so it remains hidden most of the time.
In the first few days, most patients will need narcotics painkillers to help them cope with the discomfort. However, these can be minimized with the use of Exparel injection, which can numb the surgical site for up to four days.
Dr. Smiley, who regularly posts educational videos on Snapchat, often uses Exparel in body contouring surgeries. This medication is injected directly into the muscle before closing the incisions with sutures and has eliminated the need for pain pump, a balloon-like device that slowly releases numbing drugs for several days.
Most patients are “back on their feet” about a week postop and may choose to return to work provided it is only a desk job. Meanwhile, it remains prudent to avoid heavy lifting, rigorous exercise, and stretching the arms for at least six weeks.
Dr. Smiley says that most bruising and swelling will resolve 2-3 weeks. At this period, the use of compression garments might help with their resolution and to some extent even control the pain.
While bruising and swelling tend to resolve easily with time, this may not always be the case with the “lingering” pain or discomfort, which could emanate from sensory nerves starting to “wake up”.
It is important to note that during surgery, some small nerves are injured and can take months to recover fully. While the pinprick sensation or shooting pain is rather inconvenient, this is actually a good sign that the nerves are gradually repairing themselves.
Should the discomfort remain persistent, some patients may take Tylenol and anti-inflammatory drugs, or massage the affected area, provided their surgeons give them permission.
While neck lift with liposuction is a highly individualized procedure, it generally refers to excess fat removal combined with platysma muscle repair. However, older patients (i.e., 60 years and above) may need additional contouring in the form of lower facelift, which basically lifts up the skin.
It is important to note that the success of any facial plastic surgery boils down to meticulous physical or anatomical examination. The idea is to determine the underlying cause/s of the problem to come up with the best solution.
Dr. Tarick Smiley, a renowned Orange County plastic surgery expert, has explained the basic components of neck rejuvenation surgery.
- Liposuction-alone surgery
This is only reserved for patients with good skin elasticity, meaning it can snap back without any problem after removing the excess fat responsible for the appearance of “double chin” or excessive fullness of the neck. Hence, the vast majority of patients are relatively young (late thirties and forties).
It involves a small round incision beneath the chin, precisely made at the natural skin crease for optimal scar concealment.
- Neck lift with liposuction
Some patients have a poorly defined neck contour due to excess fat and loose platysma, which is a muscle that extends from under the chin all the way down to the neck and collarbone.
This approach starts with the creation of small incision beneath the chin to remove the excess fat. Then, the same opening is used to access the splayed muscle so it can be tightened in the midline with the use of internal sutures.
Basically, a lower facelift elevates the sagging skin (and remove any excess) that contributes to the appearance of jowl. In doing so, the patient can expect a tighter and more defined neck and jawline, and possibly improvement in the corners of their mouth.
As a more extensive approach, this favors older patients who typically require more correction. This may also serve well massive weight loss patients who are left with redundant skin, which not just affects their body but also their face and neck.
BBL surgery, also referred to as Brazilian butt lift or buttock augmentation via fat injection, can serve as a permanent solution for improving the appearance of flat buttocks and hips. However, it is a rather complex procedure because it entails different processes that must be done meticulously to achieve great results.
BBL surgery always starts with liposuction to collect donor fats from multiple sites. Renowned Orange County plastic surgery expert Dr. Tarick Smiley said he almost always treats the lower back and flank as donor sites because treating the adjacent areas of the buttocks can further improve their shape and projection.
Before and After Photos of a Patient Who Asked for a Conservative Fat Volume for Natural Results
In his recent Snapchat posts, the celebrity plastic surgeon said that liposuction should not be done too aggressively—i.e., remove too much fat in the donor area—due to risk of skin irregularities. The general rule of thumb to achieve smooth results is to predict how much skin shrinkage will occur, he added.
Moreover, the skin in the buttocks “should also be respected,” he warned, and thus “over-injection of fats” can lead to sagging appearance and unnatural results.
“It is important to preserve the strength of the fascia system. This thread-like anatomy holds the skin and determines the final shape of the buttocks. However, too much fat volume can weaken them, resulting in buttock sagging,” said Dr. Smiley.
He cited Kim Kardashian and Nikki Minaj’s “backside” as a poorly done BBL surgery because their buttocks look hugely disproportionate to their body. Furthermore, he mentioned the lack of smooth transition between the posterior thigh and the buttock.
“My strict rule is to create a nice transition between the thigh and the buttock. We don’t want a buttock in which the leg appears hanging from it, just like in the case of Nikki Minaj,” he said.
To avoid over injection of fat graft, Dr. Smiley said he always takes into account the patient’s body frame and her skin elasticity as well.
“Too much fat injection or too much weight can stretch out the skin and affect the stability of the fascia system that holds the buttocks shape. This is the key to achieve natural-looking, long-lasting results from BBL surgery,” said Dr. Smiley.
The use of breast implants on skinny women has certain challenges that stem from the lack of soft tissue coverage, making them susceptible to rippling, increased palpability, and less natural breast shape that is often described as too “globular.”
However, there are several ways to compensate for the lack of soft tissue coverage, as suggested by leading Orange County plastic surgery expert Dr. Tarick Smiley.
The celebrity plastic surgeon has explained all the things to avoid when breast augmentation involves patients who are naturally thin or have little soft tissue coverage.
Saline implants are filled with sterile saltwater solution once propelled and positioned into their pockets. While women with sufficient soft tissue coverage (they’re wearing B cup bras at the very least) can achieve good results from them, patients with a skinny frame may end up with visible implant edges or a breast shape that is too globular.
Meanwhile, silicone implants are suitable for women who have little soft tissue coverage or low body fat percentage because their filler material closely resembles the breast fat and tissue.
- Avoid over the muscle position (subglandular)
Placing the implants over the muscle that the only thing supporting their weight is the tissue and skin can spell disaster for thin patients. Using saline implants can further aggravate the risk of rippling and palpability.
Under the muscle position, meanwhile, favors breast implants on skinny patients because this strong anatomical layer not just gives additional coverage but also more support that prevents bottoming out or any other type of inadvertent implant displacement.
- Avoid low profile implants
Low profile implants have a wider base dimension that could occupy too much horizontal space when used by thin patients. For this reason, they may end up with unusually flatter and “bubble-shaped” breasts that give them a heavy top look.
In general, thin patients are suitable for moderate profile implants especially if they want just the right amount of lateral bulge and mid cleavage; or high profile implants if they like a fuller upper breast pole (because it offers the most forward projection and has a relatively narrow base, which is the complete opposite of low profile).
To prevent unnatural breast contour and other surgical stigmata, a good rule of thumb is to use implants whose dimension is within the chest and breast measurement.
- Avoid hugely disproportionate implants
Arguably, this is the most influential factor. When implants are too large for the underlying anatomies, they will cause overstretching of the breast tissue and skin, which of course can spell disaster.
Small-framed women who want to achieve natural-looking results are generally advised to stick to 300-400 cc breast implant size range.