Thank you for
your question.
You are asking what is the better option, surgery or fillers to deal with hollows under
the eyes.
And you submitted two photos that show this area very well.
I think that, certainly, your question is very relevant and you describe in your question
that your skin is very thin over these areas.
And you're looking for, you're asking if the blepharoplasty would be more permanent
or will it sag over time.
Well, I can certainly help you understand my perspective when I help patients like yourself
who come to my practice with very similar scenarios and questions.
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 eye rejuvenation is the foundation of my practice.
We do so much and customize so many different solutions to help patients who come to us
from around the world.
So to begin with, it's very important for you to have a basic understanding of the principles
that guide what the solutions are.
So in your photo, what I see is the under eye puffiness.
I also see the relative hollows that are below the eye.
I also see relative volume loss in the cheek area.
And the skin quality is consistent with your type of skin.
It's relatively thin underneath the eyes.
So when you ask about permanence and this is something that people always want, they
want something that's a long-term, long lasting solution.
But understanding that facial aging and especially with the genetics as well as the environmental
factors makes long-term solutions variable in their potential as far as longevity is
concerned.
So let's begin with the basic issues.
We'll start with the under eye fat pockets.
The under eye fat pockets have prolapsed forward.
We refer to it as lower eyelid fat herniation.
And so, for that area, I would consider, this is in the absence of a physical examination,
I would consider a procedure like a lower eyelid blepharoplasty.
Now this is a procedure where I would go in from the inside of the eyelid which is a transconjunctival
approach, from the inside of the eyelid, to address the fat pockets and reduce and reposition
as is appropriate.
This way, the under eye area will not have the bulge of the fat pockets which I feel,
contributes to the hollow that is perceived.
The bulge is like a mountain, the hollow is like a valley.
Another question comes up, what about tightening the skin?
Well every often, it's a misinterpretation that skin quality thinning or thinning skin
quality is best treated by pulling and tightening the skin.
A lot of times, my colleagues will have done a transcutaneous approach where they go from
the outside and take away skin with the intention of trying to make the skin tighter and what
ends up happening is that the lower eyelid retracts or everts, a condition called ectropion
which means that the eyelid now there's a skin shortage.
So I think that, from my perspective, I take the approach that the lower eyelid skin especially
in a lighter skin person is very thin and should have minimal, unnecessary manipulation.
So what I would typically do in a situation like yours, I would do something called PRP
injection which is called platelet-rich plasma or PRP which is the concentration of the wound
healing and growth factors that stimulates collagen, stimulate blood supply and improve
skin quality.
On the surface point-of-view, with the fine lines and wrinkling, I would use something
like a fractional CO2 laser or fractional Erbium laser to help improve the quality on
the outside.
Now the challenge comes to the relative hollows.
Now the relative hollows are best addressed with volume and by using fillers.
So essentially, my thinking would be is that I would evaluate the under eye tear trough
area after surgery and see if there's any indication of there being some volume loss
opportunities to treat with the filler such as Restylane or something that's in the
lighter hyaluronic acid family.
Now, one thing that's often overlooked when people focus on the under eye hollows is the
areas of the cheeks.
And when I look at the eyes, I don't just look at the eyes.
I look at the eyes in combination with the relative cheek projection.
So when I talk to my patients about this, I often suggest that we do something called
structural volumizing.
Structural volumizing means placement of fillers that are longer lasting.
These are fillers like Juvederm Ultra Plus or Juvederm Voluma placed at the bone level.
And at that level, the material actually creates a better structure, creates more definitive
angularity and structure to the cheekbones.
And it balances out the area of the eye.
A lot of times, people focus on the area that bothers them the most but they missed the
forest for the trees.
They missed the whole picture.
So I think that there is a value there especially with the long lasting fillers to help with
the eye aesthetics.
Now when I say long lasting, we're talking about 1-2 years to have this full correction
and the longevity that goes with it.
Something to really understand is that permanence, when it comes to soft tissue is something
that is really difficult to achieve.
I look at the skin quality and the challenges with dealing with genetics and environmental
factors, whether it's sun exposure or the breathing environment such as smoking or secondhand
smoke.
We're dealing with issues or factors which ultimately cause breakdown and causes aging.
So in a way, there's always a benefit to a maintenance process whether it's getting
PRP injections every 3-6 months, whether it's doing some kind of either ablative or non-ablative
lasers such as Q-switch laser to stimulate collagen or radiofrequency.
But basically, looking at skin quality, there is a downward direction if you don't do
anything and there's mitigating those changes and getting enhancements if you do something.
But it's not like surgery to always be a definitive one type of procedure.
So I think that you have to consider this as embracing a plan besides having a single
item solution.
Certainly, a surgical procedure such as lower eyelid blepharoplasty, PRP, fractional CO2
laser will be an improvement.
But to try to reach the maximum potential to look good as possible, something like structural
volumizing and the strategic placement of fillers and the use of PRP in a schedule that
makes sense to you both in terms of logistics and financially, will probably give you the
best long-term outcome.
I always say like it's kind of like going to the gym.
You can't go to the gym once and expect to be in a good shape forever.
These treatments that require things like PRP or non-ablative laser are basically pushing
your body to generate collagen and without some kind of stimulating, it will only go
in one direction.
So meet with qualified, experienced cosmetic surgeons.
Learn about your options and try to look at this perspective of looking at the eye, not
in isolation, but at the eye as it relates to the cheek and I think it will give you
a sense of what I'm describing.
So I hope that was helpful, I wish you the best of luck and thank you for your question.
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