Eye Bags – How a Doctor Experienced with Surgery and Under Eye Fillers Decides on Treatment


Thank you for your question. You submitted your question with a photo.
You blocked out your eyes to try to hide your identity. You’re asking what is better for
the bags: Restylane or Dysport? And you can’t tell if you have hollowness or bags or both.
And you state also that you are mid-20s and you want these gone now. Well, I can certainly share with you how I
counsel patients like yourself in our practice. 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 under
eye hollows and bags or both has been something that has been a big part of my practice for
over 20 years. And we live in a very good time where we have a lot more tools and options
to really customize a treatment plan that is ideal. So I think it’s important to also understand
certainly in the way you asked the question that there is no “either/or”. There is
really a strategy. And I think what gets confusing for people when you do your research is that
there is often bias by practitioners or instrument providers whether it’s laser or non-surgical
or whatever what someone wants to sell, they’ll always lean to their particular bias. And
I think a proper evaluation should at least inform you what are the anatomic issues as
well as what are the optimal strategies to maximize the appearance of your eyes. So let’s begin with analyzing your eyes
just with the photos. So there are under eye bags. What are under eye bags? Well under
eye bags mean that there is something called lower eyelid fat prolapse. Lower eyelid fat
prolapse means that the fat that’s normally around your eyes has pushed forward and created
a bulge and that bulge results in these puffy under eye bags. Now many times people don’t always appreciate
the bags because they are also bothered by what they perceive as the hollow areas. Now
typically the hollow area means that the patient or the individual’s concern is bothered
by the area just below the bags. That area is referred to as the tear trough. And the
tear trough is a relative hollow because the valley which is the tear trough is deep because
of the relative projection of the mountain, the under eye fat pocket. Now years ago, we would have a straightforward
discussion where I would simply say, “Well, you have lower eyelid fat prolapse and that
you should undergo a cosmetic surgical procedure.” Now many times people in their 20s are aghast
about that idea and say “Well, I’m much too young to have surgery.” And the reality
is that that’s not really the case. You do surgery when it’s appropriate. However, when we see a lot of our patients
who come in with a similar situation, I try to determine whether or not it is a potential
value in doing a procedure such as an injectable filler such as Restylane as you asked in your
question which is a filler and using a filler to fill part of that deficit that is perceived
which is filling the area in the tear trough. And we can essentially help our patients look
better even though not definitively treating the under eye bags. And a lot of times, what
we basically say is, you’re essentially buying time, you’re getting an improvement
and lot of times our patients say, “Well, I would love to do the surgery and I realize
these bags are really significant but I’m not going to have time off from work for at
least another year so maybe we can just do the filler for now. ” A lot of times, the
filler can be a good strategy for years. So, placement of filler in this area can potentially
be a benefit. What is the limitation? Where is the line?
Well, the line is when the relative projection of the fat pocket exceeds significantly the
area that can be filled with filler. We see patients all the time who have come from other
practices because they got filler but the patient feels that their under eye bags are
actually worse. And you can see how that can happen. A doctor who either doesn’t do surgery
or is trying to accommodate the desire of a patient may place a filler and end up creating
a double bag by creating so much volume. And a lot of times, this area can swell significantly.
So we end up using hyaluronidase to dissolve the filler and see what the actual anatomy
is and then either come up with a strategy using alternate fillers or doing surgery. The surgery involved with the lower eyelid
fat prolapse, just for the idea, is a procedure we do in our practice called transconjunctival
blepharoplasty. Transconjunctival blepharoplasty means basically addressing the fat pockets
from the inside of the eyelid. And by doing that, I’m avoiding any external scar, I’m
retaining the natural shape of the eye and I’m doing something that is more definitive
and of course long-term. A lot of patients are afraid of surgery because
they are afraid to go under general anesthesia. They’re afraid of the potential complications
and of course those are important. So, in our practice, what we do is we do these procedures
under local anesthesia with LITE™ sedation which is avoiding general anesthesia. There’s
no tube in the throat. And we are able to do this in our office in our Joint Commission
approved facilities. That way the safety and quality is there, the avoidance of hospital
and surgery centers and the convenience is also very nice. And pretty much in a week,
most people go back to work. So it’s not always an “either/or” situation
also. Sometimes what we also recognize is that the tear trough area and the cheek area
which is very important in the relationship of eye aesthetics, I always say we look at
both the eye and the cheek to have true balance and harmony to get the optimal appearance.
Again, for someone in their mid-20s, very often, they’re really not ready to do fillers
as someone who is more ready in their mid-30s and later. But nonetheless, it is important
to recognize that there is volume that is genetically maybe considered to be somewhat
deficient that could be addressed in the cheek area. This is where a procedure we call Structural
Volumizing has a potential value. Structural Volumizing is using a filler that
is on the thicker side such as a Juvederm Ultra Plus or Juvederm Voluma and placing
it in the cheek area below the eye so that the area between the eye and the cheek is
more balanced. And when you have volume in the cheek that’s just right, not overfilled
but just right, then it looks really nice and it really blends well with the under eye
area. So I think it’s important that you meet
with a cosmetic surgeon, a doctor who is able to do both surgery and injectable fillers
and who has a lot of experience in this area. And I think it’s very important to get a
realistic understanding of what is an optimal strategy for you and what works for you in
terms of your needs. So I hope that was helpful, I wish you the
best of luck and thank you for your question.

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