The technique I use in every case for eyebag removal is known as transconjunctival, meaning that there is no external incision. The reason for performing this technique is not so much to avoid an incision but instead to ensure the shape of the eyelid remains untouched and unchanged. The lateral canthus (the outer joining of the upper and lower eyelids) can be altered when performing an external lower-eyelid blepharoplasty because the lower-eyelid retractors, the support mechanism to the lower eyelid, are violated and must be restored. The problem is that restoring the integrity to this system does not predictably result in a consistent eyelid shape and thereby the eye shape may be altered leading to both an unnatural result a change of identity, and potentially a functional problem like dry eyes and eye-closure issues. Although this is not always the case following an external lower blepharoplasty, the inherent risk in my opinion does not justify the technique. In 23 years of clinical practice, I have simply never had a patient who had a change in the eye shape, an inability to close the eyes, or other functional issues.
I have also been asked the question whether I believe in fat repositioning of the eyebag. The simple answer is no. The reason is that fat repositioning can only really be accomplished in someone with a large eyebag, which is inconsistently observed. In addition, the amount of fat that I transplant to achieve a favorable result is significantly more than the repositioned fat. For example, on a typical eyebag I will remove about 0.1 to 0.2 cc of fat, whereas I inject about 5-6 cc of fat. It is not even close in terms of the two numbers. Further, the eyebag usually only sits in the inner half of the eyelid in the region known as the tear trough. How about the outer eyelid hollowness? How can you address that area with fat repositioning? The answer is you typically cannot. I only remove an outer eyebag in less than 10% of the eyebag cases I perform. However, I inject fat into the outer lower eyelid in 100% of cases. I also only remove eyebags in about 50% of the cases of lower blepharoplasty, whereas I perform fat grafting in 100% of the cases because I believe the principal issue of under eyelid aging has to do with volume loss.
Another question I have received is whether I perform a skin pinch to remove skin to help with sagging or crepey skin. The short answer is no. I used to do this procedure over 20 years ago when I first started my practice and saw no differences. A skin pinch only removes about 2 to 3 mm of skin along the border of the lower eyelid, which cannot affect the wrinkles and texture for the remaining lower eyelid. In fact, I simply do not see any measurable change whatsoever following a skin pinch. For crepey skin and wrinkles I perform a mixture of procedures depending on what is the problem. In lighter-skin individuals (from Irish to Asian) I can perform a fractionated CO2 laser to improve the texture and to tighten the skin. However, I always try to explain skin is like a shirt. If you iron a shirt and then wear it, you will have a wrinkled shirt shortly thereafter. That is why I believe MesoBotox which in summary is dilute Botox used to permanently improve skin texture (minus further sun damage), plus regular, concentrated Botox can help control the sun damage and skin aging with excellent results to limit “the shirt from wrinkling again” so to speak.
Fat grafting has gotten a bad rap due to poor techniques and poor understanding. Let me address some of the negative stereotypes and ideas that have plagued the airwaves. First, I will say that I have been performing fat grafting for over 20 years and there are not a lot of procedures that I can say I have done so for that long a time. I have simply abandoned techniques that have fallen away either due to the inability to withstand the test of time or due to the advent of newer technologies and better techniques. Fat grafting is not one of them. It simply has withstood the test of time for me. The first myth is that fat grafting is unsafe around the eyes due to the risk of lumpiness. I have had consistently safe outcomes due to proper technique, which I have lectured extensively about through hands-on cadaver workshops and which I have published extensively in my textbook, Complementary Fat Grafting (Lippincott, Williams & Wilkins, Philadelphia, PA, 2006) as well as many scientific articles and book chapters.
A second argument against fat grafting is that it is not permanent and goes away after a few months. That argument does not hold water and is due to two principal reasons. First, if fat is not processed well, then the survival is definitely less. For the first decade of fat grafting, I used centrifugation to clean up the fat. I still attained favorable results but in the past decade I switched over to PureGraft processing, which is an ultrafiltration device that gets me much more sustainable results. In the past, if I harvested 20 cc of fat, I would have a usable 10 cc of fat. Today, if I harvested 20 cc of fat, I will most likely have 3-5 cc of usable fat. The difference is most likely that the older method of processing was filled with impurities including lidocaine, lysed fat cells, blood, etc., that were not entirely removed through centrifugation. That causes more inflammation and less long-term viability of fat cells. The second reason people argue that fat grafting is not permanent is that there will be some loss of the transplanted fat. I liken it to planting flowers. If you plant 10 flowers you will have probably 7 that grow. Unlike flowers though, initially it looks like all 10 flowers grew because there is more volume. You go through what I call three phases: 1-2 weeks the fat looks too full, then at 6 to 8 weeks the result looks too perfect, then around 6 to 12 months you feel as if the result is not as good or may not have survived. However, when I show photos to you will see you actually still look amazingly better. I call these “right-brain results”, meaning you still look great when someone sees you but when you stare close up at your face you may still see a tear trough or some residual hollowness (left-brain perfection is unattainable).
How about fillers? Fillers seem to be an expedient option, and it was my go to procedure for individuals who didn’t want fat grafting or wanted a touch-up after fat grafting. I have stopped doing fillers under the eyes for several years now. Unfortunately, I have seen migration issues even years later following old filler placement that was supposed to be gone in 6 to 12 months. The dirty secret in the industry is that fillers simply do not go away. I have had patients 15 years after using “temporary fillers” with me who still have fillers visible in MRIs they have taken years later. I also have a hard time dissolving completely fillers under the eyes despite using ultrasound guidance to do so. In short, I no longer use fillers under the eyes of any kind. Are fillers safe and effective? Yes, I use them to manage folds and lines around the mouth and eyes, which fat does poorly to correct, where I do not see migration issues, but to fill the lower eyelid with volume is now a no go. Only fat grafting to me is safe, effective, and long-term.
Even though this blog does not talk about the upper eyelid, I think it is worth commenting that to me the hollowness under the eyes is mirrored by hollowness of the upper eyelid. If you think you need an aggressive browlift or excessive skin removal during an upper blepharoplasty, you do not understand the aging process. All you have to do is to go back to look at your youthful photos and you will see that your upper eyelid/brow complex was actually fuller when you were younger. I use the analogy that the brow is like a balloon that deflates so what may appear as if you need a lot of removal, you may actually benefit instead from fat grafting to re-inflate the sagging eyelid. Do I perform upper blepharoplasties? Absolutely. Just like removal of some lower eyelid fat that I perform in 50% of cases, I would say that I need to remove upper eyelid skin in about 50% of cases. Or in cases where someone simply wants a small office-based procedure to remove extra skin, I can perform an isolated upper blepharoplasty, skin-only excision, without sedation. However, I believe the level of rejuvenation is still lacking when compared with the power of fat grafting. Do I perform browlifting? Absolutely but less often than fat grafting and upper blepharoplasties and only in the outer edges of the eyelids to avoid the startled, unnatural appearance.
I hope this blog helps you understand how I envision aging around the eyes in a comprehensive manner and how I surgically and non-surgically approach eyelid rejuvenation through a combination of techniques. Only through a consultation (whether in-person or virtual) can I get a better sense of the best routes to achieve your desired level and type of rejuvenation.