LAM FACIAL PLASTICS

Hi Dr. Lam,

I had Juvederm to fill in tear trough areas below the eyes. The places of injection look darker at certain light angles. I was hoping this was bruising so got treated with low settings of V-beam but it didn't resolve it. I think it's called 'Tindal effect' - the filler scatters light in a certain way beneath the skin and creates that dark-circle impression.

Does such problem occur in your practice using Resty or Juvederm below the eyes?

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

I am contemplating coming to you the next time I need filler below the eyes. Could you give me details like a price quote for a total of 1cc or 2cc Resty below the eyes. Do you use general anesthesia or just local?

Also, do you deposit the filler only on the orbital bone or over the whole lower eyelid to the level of eyelashes? My injector just injected over the orbital bone where there is no much depth to hide the filler and no wonder I can see it. I even had ridges of filler there so I had to press it over the orbital bone to flatten it out and push it upwards inside the lower eyelid. That resolved something like 70% of the ridges.

Although I am very lean, I think I have enough fat for fat grafting just below the eyes, it needs something like 2cc fat total. Do you do fat grafting just below the eyes, not full face and if yes, could you give me a price quote on that too.

Thanks and happy new year to you.

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

I once self-injected Resty under eyes - I know, I know it's dangerous. I injected very little but it was bumpy because I wasn't sure how to inject it at all. For some reason it caused a 3 day swelling which was totally the result I wanted to achieve - the eyelid was completely smooth without any transition line to the cheek. Unfortunately the swelling went down.

When I said, filling to the eyelashes, I meant imitating the swelling that takes the whole eyelid not only the orbital bone line. Filling just along the orbital rim won't do that. One has to go at least a little up, inside the lower eyelid or the result would be a ridge like in my case.

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.

The swelling was caused by some kind of irritation - the restylane I used was very little quantity, only a few dots in the eye corner, but the whole eye lid swell. I think it wasn't a crosslinked Resty, just hyaluronic acid in water for cosmetics applications. I haven't experienced such kind of swelling from Juvederm and it was much more in quantity.

When I say to inject over the whole eyelid I mean simply to fill in the well so that the whole eyelid is lifted not only the rim, basically imitating swelling. One doesn't have to place the filler at the very rim below the eye lashes, just have to fill in the well below the eyelid, like filling a bowl with water.

I know you use canulla to place filler under eyes, does that cause less bruising than needles or you can't say for sure?

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.

I know that there is this new variant of lower eyelid surgery (blephoplasty?) where they cut the baggy fat and then add a blob of extra fat to restore the volume, otherwise the lower lid will look flat but hollow.

I have no idea where exactly is the extra fat blob placed but I believe it restores the volume of the whole lower eyelid, not only the orbital rim (tear-trough). Is that correct? If that is the case, why the same can't be done with fat grafting cannulas?

I've read of cases of blindness from using syringes in the eye area but I believe there isn't a single case with cannulas. Most practitioners injecting in the tear trough use syringes, why would that area be safer than the whole lower eyelid? If the tear-trough line is as risky as the whole lower eyelid, not not inject the whole eyelid instead?

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

[quote]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 ([b]I inject the whole lower eyelid every time[/b]) 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. [/quote]

I am getting confused here. First you said that you fill in only the tear-trough line which is just a segment of the orbital rim. In the above paragraph, by saying you 'inject the whole lower eyelid all the time' did you mean filling the whole orbital rim line, and nothing higher? Injecting 'the whole lower eyelid' means going higher than the orbital rim for me so you don't do that neither with restylane nor with fat correct?

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

I learned a lot from these posts, Dr. Lam.

Is it possible to fill the entire eyelid region by injecting restylane
at the orbital rim. Couldn't one manuevre, aim, mold, massage, the product in the entire eyelid/tear trough region by only injecting at the rim bone and preventing any transitions from lower eyelid to cheek?

I am fine with a little hollowness, but as I have said in previous posts, my eyes look deep set and I want to bring them out a bit.
I have seen some people with very high cheek bones that have no transition hardly, but they are actresses and I wonder if they have had plastic surgery.

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