Why Under Eye Hollows are More Safely Treated with Cosmetic Filler Rather than Fat Repositioning


Thank you for your question. You submitted your question with a photo. And you’re asking are you a good candidate
for transconjunctival blepharoplasty with fat repositioning. And in the details of your question, you state
that you’re 25-years-old and that you are bothered by the hollows under your eyes and
you’re looking for some guidance. Well, I can certainly share with you how I
discuss options with my patients every day who come with very similar concerns. 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. Helping people with their under eye area whether
it’s for under eye bags, bags with hollows, hollows alone, discolorations, wrinkles, essentially,
the aesthetics of the eye area has been the foundation of my practice throughout my career
and has continued to evolve thanks to a lot more tools that we have and customizing a
strategy. So I can certainly understand your concerns
about hollows and the attraction of a surgical procedure where you can reduce what is the
fat pocket that is present and to try to fill the hollow which is your primary area of concern. Now of course, a proper physical examination
would involve taking pictures and examining the three dimensional aspect of the level
of the prolapse of the fat and the relative impact on the under eye tear trough area. I would say that fat repositioning, although
it is a reasonable concept when it comes to trying to move fat from one area into a trough
area, I would be cautious about using that as a first-line of therapy. I can tell you that the goal for most people
who have any type of aesthetic issue is to have a procedure that is predictable, that
is safe, that is not likely to have any kind of untoward complexities beyond the procedure. I think the tolerance for variability and
outcome is becoming essentially almost zero. But beyond that, I would say that the tools
that we have in front of us that we use routinely also change the hierarchy in which recommendations
are made. So in a situation like yours, I would probably
not do a surgery, again, based on just a photo alone, for a limited amount of fat prolapse
where the hollow is the more dominant issue for you. I would, in your situation, consider a, first
for the hollow area, I would use an injectable filler such as Restylane and I would place
that in the tear trough area. That would help with the transition between
the fat pocket and the area where it’s hollow. And further, discoloration which is also an
important variable in the perception of under eye dark circles and hollows, I have found
a lot of value in using something called platelet-rich plasma (PRP). Now of course, when someone is relatively
young, a 25-year-old, I would make that decision based on examination looking at skin quality. But at the same time, there has been value
in using platelet-rich plasma (PRP) for discoloration if it’s from environmental causes as well
as just as a general skin improvement concept. Basically, your platelets are concentrated
in plasma after the blood is spun. And the growth factors and healing factors
help stimulate collagen, stimulate vascularity and improves the skin quality. Now when we deal with someone who is relatively
young, it still seems to have a value when done in conjunction but it is evaluated in
an individual basis. A lot of times, I take little steps and I
start with just a filler and see how much an improvement we can achieve. It’s always important to always manage the
cost of doing things with the outcome. And I generally lean towards using PRP for
people who have history with sun exposure that is significantly aging the skin as well
as other issues that would require an improvement or there would be a more significant benefit
to skin quality. But when it comes to the anatomy of the under
eye area, essentially if the fat prolapse is minimal, then I would suggest considering
filler as a first-line therapy. Now you may not be excited about doing this
as a maintenance type of basis but generally speaking, a filler under the eye can last
up to a year and it is not unusual for it to last longer. I think that in a way, both the predictability
and the convenience and the relative expense makes it an attractive first-line option. I think that without going into unnecessary
details, that would not be my first-line. I would be concerned that any type of surgery
where you’re taking fat and trying to move it in an area can be problematic in terms
of swelling, lumpiness, irregularities. And so, I think that’s a variable that you
should be aware of before just doing something that may be attractive because you may perceive
it has having a long-term benefit in comparison to a filler. So I think it’s very important that you
meet with qualified, experienced surgeons who perform both injectable filler and surgery
such as lower eyelid blepharoplasty and learn what options makes sense to you. As an oculoplastic surgeon who has no real
limitations and has extensive experience, I would say that it has been tremendous to
have the tools and the techniques to do things for patients like yourself with less invasive
approaches than surgery because ultimately, our goal is to help our patients look their
best in the safest and most predictable way possible. And it’s always a balance of relative risk. So I hope that was helpful, I wish you the
best of luck and thank you for your question.

3 thoughts on “Why Under Eye Hollows are More Safely Treated with Cosmetic Filler Rather than Fat Repositioning

  1. Hi Respected and my favourite loveliest doctor,

    I always prefer to get your opinion before starting any treatment, as you always give an unbiased and educated opinion so the things becomes more clear that a person can make right decision.

    Kindly guide me if semi permanent fillers are right for me around eyes and one side cheek area as my one side is little affected by bell palsy since my infant age before 40 years ago.
    Could these fillers become lumpy after some time? (my doctor said, fillers never create lumps)

    My one eye is also lacking fat pad in inner corner, in an attempt to remove xanthalasma through the procedure of upper lower blepharoplasty.

    I'm sending you the link, my surgeon's PA suggest these fillers. https://goo.gl/images/9Zut3c

    My surgeon also remove some fat(xanthalasma) from inner corner of upper lids which was left untreated by mistakenly (before 6month ago during blepharoplasty)
    My new stitches will be removed by Monday (6th day). And fillers will be injected the same day.

    Kindly give me your best opinion as I am not wanting any risk (if I could physically approached you, you are my best choice but I can't, because of very very far away from your country but at least I can get your opinion)

    Live Long I pray as there are few people who really educate people without any biasis.

    Thanks in advance

  2. Hello Dr Prasad. Are you saying that including the platelet rich plasma in with the injections
    can (over time) have a healing affect to where the tear troughs would look better than when you started, even after the injection has lost it's effectiveness? Not as good as with an active
    injection, but better than in the beginning?

    Also, are you the only doctor who includes platelet rich plasma in with the injections? Thank you.

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