Removal of Grafted Fat Under the Eyes, and Lower Eyelid Restoration by an Eyelid Specialist


Thank you for your question. You submitted several sets of photos of your
eye area. And you state that you had micro liposuction
done three times to address excess fat after undergoing fat transfer to the under eye area. And you’re concerned of a mound-like appearance
under the right eye. And that you state that you did have some
Belotero placed to help blend the area. And you show in the photos basically the eyes
at rest and the eyes with expression and you’re looking for some guidance as to how to proceed
moving forward. Well, I can share with you my experience and
my perception of this issue and how I’ve dealt with this area and issue in my 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. And this type of issue has presented itself
in multiple ways for a few reasons and I’ll explain as to what my position is about fat
grafting under the eyes. You see, the history of fat grafting has always
been for the surgeon the optimal filler, the natural filler that comes from your own body. And it is plentiful and certainly convenient
during surgery to take fat from one area and transfer to another area. It can certainly be effective in many areas
in the body including the face as well as for hand rejuvenation for example. But for a long time, I felt that fat grafting
under the eyes has unfortunately too many issues that make it problematic. When you look at the eyelid area, you’re
dealing with skin that is the thinnest skin of the body. You are dealing with an area that is relatively
unforgiving. In other words, basically, any irregularities
are very obvious. Now, before the modern day fillers, fat grafting
certainly potentially had a certain potential role given the absence of any great alternative. Now before there was Restylane introduced
in the US around 2005, the option was either to do fat grafting or a silicone tear trough
implant or nothing. So moving the clock forward, what I have been
seeing a lot is a variety of issues. Patients who have had fat grafting will either
have no results. In other words, the fat didn’t completely
make it at all or they’ll have irregularities because parts of the fat survived and parts
of it didn’t or they have an inflammatory response and the body forms a capsule around
the fat. Now, essentially the challenge with fat grafting
with its many advances in fat grafting remains essentially the same as it was more than 10-20
years ago. And what is that? If you want to place volume in any area, you
want safety, you want predictability and you want to have minimal downtime. So the challenge with fat grafting is really
for me is the predictability. When you place fat in this area, you are not
necessarily placing a uniform smooth substance like you are when you’re using an injectable
filler like a hyaluronic acid filler. You’re placing fatty tissue and this is
a combination of different fat cells and connective tissue. Now there are many ways to process the fat
and we have a lot of options in that way. But it still remains to be in my opinion to
be unpredictable. And thanks to the modern day of fillers, essentially,
my patients lean more towards to treat hollows rather than using fat in that particular area. Now that being said, I think part of the frustration
you may have had with the suctioning procedures is when fat is placed in this space, although
the surgeon wants to place it in a very particular way and in a very particular plane, things
may look good at the time of surgery. It is my experience when I have operated on
these patients to remove this fat that the fat ends up in multiple levels throughout
the tissue between the front and the back, in between the eyelid and the orbicularis
muscle within the orbicularis muscle, behind the orbicularis muscle and it’s essentially
like fat and scar tissue. It forms different nodules and planes. So it’s much more involved to actually remove
this. That being said, it is possible to address
this issue because you’re not really just removing fat. You’re removing the scar tissue and capsule
and everything else that goes with it. And it is important to also maintain the integrity
of the eyelid. So there’s never really an absolute when
you are planning this type of surgery. Generally speaking, this type of operation,
I will try to do from behind the eyelid, to preserve as much as the integrity of the muscle
and try to dissect out these nodules but never too aggressively to compromise the eyelid
muscular tone. In addition, there is the risk and the potential
need for additional surgery to support the lower eyelid should there be any type of loss
of integrity of the tissue. The eyelid is a deceptively complex structure. And the lower eyelid, the layers of the skin,
the muscle and the posterior layers are all in combination very strong. Individually, they’re much more weak. So they behave like columns holding up the
lower eyelid. So I think that in your situation, you should
mostly be focused on the appearance as it is when you are at rest. The appearance with movement when it comes
to dynamic motion is always going to be different because when the tissue has been operated
on and there’s all these irregularities, the muscle and the symmetry cannot really
be perfect when it comes to activity. But certainly at rest, to have this bulge
and elevation, it seems that it should be relatively isolated and probably can be addressed. But understanding the risks and benefits of
this type of surgery, it’s critically important and that should be done through a formal consultation. So I would recommend that you meet with an
oculoplastic surgeon and oculofacial plastic and reconstructive surgeon, someone who focuses
mostly on cosmetic who has experience in this area. And learn about these options and these risks. A proper exam requires also evaluating the
eyelid tone and the structure and actually to touch and feel and see what that amount
of area feels like so you actually kind of anticipate what to see when you are in surgery
and then take it from there. So I hope that was helpful, I wish you the
best of luck and thank you for your question.

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