Dr. Sam Lam Plastic Surgery Forum

I do hundreds of periorbital fillers and I have only seen 1 case of Tyndall effect in my hands. Now, occasionally in 1 out of 20 I see a tiny bump that is barely perceptible. I take care of that with a Vitrase dissolver. Good thing Juvederm and Restylane can be reversed easily. The reason that I don't see a lot of Tyndall effects is that I use a cannula to place Restylane very deep on bone so that it sits below skin, fat, and muscle. That reduces the Tyndall risk. In the eye area, it is much better to place the product below muscle.

I tend not to use Juvederm around the eyes, even though I have not had problems, because a lot of my colleagues who are very experienced injectors have had a lot of problems with it around the eyes like excessive and prolonged swelling, spreading of the product, and uneven results. Because my trusted colleagues have had problems, I have moved exclusively to Restylane around the eyes.
best,
sml

You do not want to put fat grafting or fillers all the way up to the eyelid margin. That is unsafe and unattractive. What your physician did was correct by staying along the bony rim. However, either too much was placed or it was placed too close to the skin causing your problem. If you need two syringes of Restylane, I charge $1000 ($550 for the first syringe and $450 for the second syringe).

You cannot make a direct comparison between fillers and fat grafting. I generally place about 1 cc of Restylane per side but that would be a zero result with fat. You will start to have bulges with Restylane after 1 to 1.5 cc per side (because it is a hard material) plus it is too expensive to do much more than that. If I put 1 cc of fat a side, you will see no difference. I generally use 3 to 4 cc of fat per side but I have a lot of experience with putting fat in those volumes. If you don't, you should not because it is a difficult area to fill safely and well at those volumes. However, I have never had a lump under the eye that I have had to remove in 100s of cases.

As far as discounting fat for just under the eyes, I generally don't. The reason is that your aging has as much to do with the brows, upper eyelid, tear trough, anterior cheek, lateral cheek, buccal transition, canine fossa, and jawline as the lower eyelids even if the lower eyelids are the most obvious to you. Here are the reasons that I do not do just lower eyelids:
1. Your result is very poor because you will still look older and tired without facial balance.
2. If you lose 20% of your lower eyelid fat graft, you will think you paid too much for too little gain. In fact, you really won't see the result because the aging process has so much more to do with the entire face than just the lower eyelid region.
3. It costs me a fortune to open the room, staff it, process the fat, etc. for just a lower eyelid treatment. It takes me only a short more time to "finish the picture". Also, I really am an artist. I can't paint half the picture and make it look good. That being said, in a rare younger twentysomething individual, I could conceivably just do the lower eyelids with a price break. That is pretty rare though. If I think you need more than just lower eyelids, I won't just do the lower eyelids for you. Trust my judgment.
Best,
SML

Wow, don't scare me here my man. Don't know how you got your hands on Restylane if you are not a physician. That is very dangerous. Please read my section on my blog about fake Restylane. I have been helping a lady from overseas who came here to have fat grafting but could not because she has been having a chronic reaction to FAKE RESTYLANE. I have a lady from South America who had "Restylane" injected into her lips and I had to cut out half her lip to fix the problem and now I have been injecting 5-FU into her upper lip for the past year.

As far as injecting up to the eyelid, that is a bad idea. Yes, I know you like the swelling. That is closer but not exactly what fat grafting looks like. The reason you were swollen for 3 days is that restylane is hydrophilic and needs to equilibrate with water over a 3 day period. Listen to my lecture on Restylane that I gave in Boca a few weeks ago under my Video Lectures section to understand the basic science of hyaluronic acid better.

All of my results in the before and after galleries for fillers and fat are only injected at the rim. Even if you have some hollowness left, leave it alone. You are only asking for misery by injecting anything that close to the eye. The skin is too thin and will not tolerate an injection there.

hi summertan,
1. as you probably know, cross-linking or the lack thereof does not lead to more swelling. the higher concentration of HA to water content leads to a hydrophilic response in which water is rapidly absorbed into the product, which takes about 3 days to balance out. you probably had a product that had very little water in it, leading to your response. or it was simply idiosyncratic. cross-linking percentages lead to greater longevity of the product. a totally uncross-linked product is gone in 2 to 3 days. however, uncross-linked HA helps with minimizing viscosity and aids in product flow.
2. as a repeat warning out there to you guys, please do not be injecting anything out there that is not from Medicis or Allergan. This is dangerous stuff, and only an experienced and trained physician should be administering FDA approved product.
3. i fill the rim and that is the extent of it. if you find a doctor that is willing to go anything higher than the rim and can show you safe before and after results great. i won't do that for two reasons. the skin is too thin to tolerate the product. second, if you start going deep with the product that high up, you can go behind the orbital septum and hit a vessel that can risk blindness. am i kidding? no. that is another reason that i use cannulas. it is pretty hard to get into a vessel without a needle.
4. as far as bruising with cannulas, my bruising is much much much less than with a needle. most get no bruising. some get a small amount.

A few things here. First, I can't speak of your technique since what you mentioned is very vague. However, you might be talking about lower eyelid fat transposition in which the fat bag is partially removed then sewn over the orbital rim. If that is the case, the reason that I do not perform that procedure is several fold: 1) I do not cut the lower eyelid skin (see vlog video) if the procedure is performed in this fashion (it can be done through a no-incision approach, 2) there is only limited fat to be transposed so once you move the fat bag over the rim, the story is over (WHAT IF YOU NEED A TOUCHUP?), 3) this technique is technically very difficult and can create a lump if not perfectly performed, 4) the fat transposed ONLY corrects the tear-trough (HOW ABOUT THE REMAINING 80% OF THE HOLLW RIM). Now, I don't believe that this technique really hollows out the eye but if we use your thinking, the fat is oftentimes unnecessarily "removed" to be translocated inferiorly so you have to imagine how much hollower the upper portion of the eyelid is with this technique.

Now compare that with my method in which I remove fat from the lower eyelid WITHOUT an incision and ONLY do so when I need to (about 1 in 10 cases) then I have unlimited fat from the belly or elsewhere to replace the loss of fat along the orbital rim.

The other technique that you may be referring to is simply cutting out pearls of fat and inserting it as free grafts. This in my opinion is a problem too since you are putting big lumps of fat compared to my fat particles that are 1/100th of a cc per microdroplet. Which method do you think will lead to a smoother result and which method do you think has a higher chance of fat take and which method do you think does not require any incision whatsoever? Of course, fat grafting with cannulas.

Yes, blindness has been reported with needle injections (but extremely rare). Why do you think all of my periorbital injections are performed with blunt cannulas? Safety is first but also reduces the bruising profile and increases the chance of smoothness. The tear trough is just as risky with needles as the whole lower eyelid. The reason that physicians who use needles only inject the tear trough (I inject the whole lower eyelid every time) is several reasons: 1) a lot of bruising around the eyes with needles (compared with my cannulas), 2) trying to conserve product even though aesthetically the whole lower eyelid needs to be done, and 3) technically it is very laborious and you must be very careful to inject the entire lower eyelid with a needle. With a cannula, I can fill an entire lower eyelid with Restyane in less than 15 seconds. Because I use 3 to 4 cc of fat, it takes me about 3 to 5 minutes per side.

Okay, here's the real answer to your question: I do not believe that it is safe to inject near the eyelid with fat or fillers. If you want this done, you need to find another surgeon not me. I don't take risks in this very highly sensitive and difficult to correct area. I am not offended if you do not come here. I simply stop at the orbital rim. period. Read my previous entries for more detailed answers about the risk profile associated with injecting superficially and high in the lower eyelid. I don't want to convert something that only you see as a problem into something everyone and his brother can see. Safety first.
best,
sml

Okay, sorry for the semantic confusion. The "tear trough" refers specifically to the inner part of the orbital rim near the nose not technically the entire lower eyelid orbital rim. So, I do fill the entire lower orbital rim (and the upper for that matter). However, I do not fill up to the eyelid margin where the eyelashes are. Sorry for the confusion. Tear trough is a very specific term medically speaking. That is why I was confused when you used it.
sml

you cannot inject the lower eyelid and one spot and spread it. you can do that more effectively in the cheek but not in the deeply adherent and thin lower eyelid. that at least is my opinion.
best,
sml