Fat Grafting Eyelid Series Part 2 of 2:  Rethinking the Lower Eyelid

This second article in the series focuses on techniques for lower eyelid rejuvenation.  The traditional way to manage the lower-eyelid aging was through a cutting procedure that involved either a skin cut or involved taking fat out from inside the eyelid without an incision.  This article will focus principally on understanding how fat grafting can be used in lieu of or in conjunction with other procedures to attain the safest, most natural long-term results for the lower-eyelid area.

First, it is important to understand how the lower eyelid ages.  Besides wrinkles and changes in skin quality (which will be discussed separately in a moment), the principal method of aging is fat loss along the bony orbital rim.  In over 80% of lower eyelid aging, there is not a protrusion of fat, known as an eyebag, but rather hollowness under the so-called eyebag that makes one appear to have an eyebag.  Think of this analogy:  the water at high tide covers any rocks along the shoreline but as the water recedes the rocks become visible.  The water is the fat that we have in youth, and the rocks are the eyebags that we attain when we get older.  So instead of removing the rocks, we should look at raising the shoreline to cover the rocks that are there.

This woman underwent only a fat transfer to her face including her lower eyelid area. Instead of seeing the lower eyelid area as an eyebag that needs removal, more often than not it is too hollow that would benefit from filling with fat to achieve the desired results for rejuvenation.

As emphasized in the first article in this series, it is important to see “negative space”, i.e., the area of hollowness (the area along the bony eye rim), rather than the area of perceived bulge (the fat bag).  When one can see that raising the water back to high tide, i.e., filling with fat grafting, can oftentimes be enough to manage the aging in a durable and natural way.

Now is there no role for fat removal then?  No, I do remove fat bags in about 1 in 15 people whose fat bags are simply too big to be covered with fat grafting.  In some people, fat bags can become bigger as one ages but in almost all cases there is hollowness below it that needs to be addressed.  So even in the 1 in 15 people that has there eyebag removed, I almost always still add fat below it where there is hollowness.

Now how do I prefer to remove fat bags?  I prefer the non-incision technique known as transconjunctival, which can easily be combined with a fat transfer.  However, more than that, I believe that this no-incision technique is the safest method.  I think that the external approach that requires a skin incision carries risk:  not risk of a scar which I think is almost negligible but the very real risk of changing the shape of one’s eyes in very unfavorable ways.  Too often I see that when the eyelid skin is tucked back up the outer corner of the eyes are changed in such a way that the person looks slightly to significantly different and in many cases unnatural.  For that very reason, if I approach the lower eyelid my goal is almost never to make an incision if I can avoid it (which I almost always can).

I believe wrinkles need to be managed with Botox to help soften the movement, which after about a year or two of consistent usage truly helps erase the skin aging.  This combined with skin peels and skin care products can manage the lower eyelid skin aging.  I think that these wrinkles and sun-damaged skin are issues of skin aging and should not be cut out or removed through surgery, as you will still smile and cause more wrinkles to occur over time.  Treating surgical problems as surgical problems and non-surgical problems (skin problems) as non-surgical problems is the way to go.

Rethinking the lower eyelid area (and the rest of the face for that matter) by seeing it as a problem of deflation can help one understand why fat grafting can be the ideal way in many cases to rejuvenate the face durably and naturally.

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