LAM FACIAL PLASTICS

Dr. Lam -

I have some questions regarding the purported "Tyndall effect" after the use of a hyaluronic acid filler in the tear trough under the eyes.

The first has to do with the effect/cause itself. It is claimed that the bluish tint that is sometimes seen after this procedure is due to the filler being injected too superficially (too close to the surface of the skin), which results in light being refracted in such a way as to produce the said discoloration. However:

QUESTION 1: Is this the actual cause of the anomaly? I have read comments from physicists that claim this is not possible. Obviously, there is a discoloration, and obviously it is caused by the injection. But is it actually caused by the "Tyndall effect", or something else? (Unfortunately, none of the physicists that denounced this explanation bothered to give another...)

Regardless of the above technicality, I am nonetheless curious why it occurs, given what I seem to understand about the anatomy around the eye. (I am not a doctor, so it is likely that my assumptions about this anatomy may be inaccurate.) It seems to me that the hollowing of the tear trough that apparently occurs with age is due mostly to the loss (or shift) of fat in that area as we age. Indeed, this is what the hyaluronic acid injections intend to correct. However, it also seems to me that this lost fat was originally located (at least in great part) above the muscle? Assuming this is correct, it leads me to the following question(s):

QUESTION 2: Why does the replacement of this fat above the muscle suddenly cause a blue tint that wasn’t there before? (Is this because the HA that is used, though naturally present in the tear trough, isn’t quite the same thing that was originally there? [If so, why not make the filler out of the same thing that is being replaced, instead of HA?] Is it because the tear trough hollows are caused by fat loss both above and below the muscle? [If so, why not replace it both above and below?] Is it due to thinner skin? Or is/are there a different reason(s)?)

Finally, in one of your forum threads on this subject (gaunt-face-thin-skin-around-eyes-solution-t961.html) you state that “the blue color there from the Tyndall effect should not happen with me even in thin skin”.

QUESTION 3: Why is this so?

Thank you very much for any clarification on these questions!

hi,
answers are in all caps:

QUESTION 1: Is this the actual cause of the anomaly? I have read comments from physicists that claim this is not possible. Obviously, there is a discoloration, and obviously it is caused by the injection. But is it actually caused by the "Tyndall effect", or something else? (Unfortunately, none of the physicists that denounced this explanation bothered to give another...)

I REALLY DO NOT HAVE A PERFECT SCIENTIFIC ANSWER EXCEPT TO SAY THAT A CLEAR FLUID PLACED UNDER THIN SKIN REFRACTS DIFFERENTLY THAN SOMETHING OPAQUE.

Regardless of the above technicality, I am nonetheless curious why it occurs, given what I seem to understand about the anatomy around the eye. (I am not a doctor, so it is likely that my assumptions about this anatomy may be inaccurate.) It seems to me that the hollowing of the tear trough that apparently occurs with age is due mostly to the loss (or shift) of fat in that area as we age. Indeed, this is what the hyaluronic acid injections intend to correct. However, it also seems to me that this lost fat was originally located (at least in great part) above the muscle? Assuming this is correct, it leads me to the following question(s):
FIRST, THAT IS INCORRECT. FAT LOSS IS BELOW THE MUSCLE. THE LAYERS ARE SKIN, THEN MUSCLE, THEN SEPTUM, THEN FAT, THEN BONE.

QUESTION 2: Why does the replacement of this fat above the muscle suddenly cause a blue tint that wasn’t there before? (Is this because the HA that is used, though naturally present in the tear trough, isn’t quite the same thing that was originally there? [If so, why not make the filler out of the same thing that is being replaced, instead of HA?] Is it because the tear trough hollows are caused by fat loss both above and below the muscle? [If so, why not replace it both above and below?] Is it due to thinner skin? Or is/are there a different reason(s)?)
THINNER SKIN PLUS THE CLEAR FLUID. FAT IS OPAQUE.

Finally, in one of your forum threads on this subject (gaunt-face-thin-skin-around-eyes-solution-t961.html) you state that “the blue color there from the Tyndall effect should not happen with me even in thin skin”.

QUESTION 3: Why is this so?
BECAUSE I DO NOT PLACE A LARGE VOLUME RIGHT UNDER THE SKIN. THAT IS THE MISTAKE.

hope that helps.
sml

Thank you, Dr. Lam, for your prompt response.

A couple follow-up questions:

Concerning my questions on the general anatomy of the under eye area (and location of fat in particular), you responded:

FIRST, THAT IS INCORRECT. FAT LOSS IS BELOW THE MUSCLE. THE LAYERS ARE SKIN, THEN MUSCLE, THEN SEPTUM, THEN FAT, THEN BONE.

This would seem to handily explain all the questions I had on that subject, however it seems to contradict many sources that explain "subcutaneous" fat as being beneath skin and ABOVE muscle, and "visceral" fat that exists beneath muscle. E.g., this excerpt from Wikipedia:

"visceral fat" is located within the abdominal wall (i.e., beneath the wall of abdominal muscle) whereas "subcutaneous fat" is located beneath the skin (and includes fat that is located in the abdominal area beneath the skin but above the abdominal muscle wall)

These sources always seem to reference the abdominal area, however, so maybe that is not a general definition. Are these definitions not applicable to the under eye area? Is it more accurate to label "subcutaneous" fat as that near the skin (above and below muscle), and "visceral" fat as that near the organs? Or perhaps such general definitions of fat vs. its relative location to other tissue are not really proper.

You also answered my questions about the main cause(s) of the blue tint after fat replacement with HA:

THINNER SKIN PLUS THE CLEAR FLUID. FAT IS OPAQUE.

This just leaves my inquiry "why not make the filler out of the same thing that is being replaced, instead of HA?". I may know this answer (fat is not easily obtained, synthesized, and/or injected), but I would only be guessing.

Again, thank you for your attention and sharing your expertise!

for almost the entire body the fat sits under the skin above the muscle except in the eye area. the opposite is the case. i do tons of fat grafting which is beautiful and also "free" (since you are not paying per syringe) but fat is a graft and can change with one's weight which is a limitation plus it involves surgery. as far as an off-the-shelf filler restylane is great so long as it is used properly.
best,
sml