How Tired -Looking Eyes can be Treated Surgically or Non-Surgically, and Choosing Approach


Thank you for your question. You submitted your question with two photos.
And you stated in your question that you are not happy with the dark color under your eyes.
And that no matter how much you sleep, you are not happy with the under eye appearance.
And you submitted the photos to help explain your situation. Well, I can certainly share with you my perception
of what I see with the photos and how I advise our patients who have similar concerns 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. Helping people with the under eye area to help not look tired
has been a central significant part of my practice. The entire time I’ve been in practice,
often patients come in saying essentially the same thing and in not so many words, they’ll
say that they’re tired of looking tired. We live in a time when there’s a lot of
variables that we can actually address and customize the treatment plan for our patients
based on certain anatomic aspects of their situation. Essentially to begin with, the analysis should
begin with anatomy. A lot of times, people look at themselves and they diagnose what
they call or refer to their condition as dark circles. And it’s kind of a broad term and
naturally, the first thing that people do is go to the store and buy creams for dark
circles. And essentially, they figure out that they’re not getting what they want
because the creams doesn’t do anything specifically for what they want. Essentially, it might
moisturize the skin, it might help tint the skin. So when we look at the under eye area, we’re
basically looking at it in a systematic way. First we want to look is there something called
lower eyelid fat prolapse. What that means is that the fat pockets that are normally
around the eyes have prolapsed, pushed forward and they create a hill. What’s fascinating
is that a lot of these people don’t notice the hill but rather the sunken appearance
so they think they have hollow eyes. And so, right below that hill of fat is an area called
the tear trough. And the tear trough is this area where it looks very sunken. It can also
look dark. Now part of the explanation for this has to be with variables that include
skin quality, skin pigmentation, the vascularity or the blood vessels under the skin. So the strategy with addressing this issue
has to do with the relative projection and prominence of the under eye bags and I’ll
explain further. For many years, the gold standard for anyone having under eye bags
was to do some kind of surgical procedure because essentially the underlying issue is
a hernia, a hernia of fat. So routinely, for a situation like this, we would consider surgery.
However, we also now have an option which many people are exercising and actually, a
lot of people are getting this done in situations where it really doesn’t meet the criteria
for optimal management and that is a procedure such as the use of an injectable filler usually
in the hyaluronic acid family. And what we do, I place into that tear trough area the
hyaluronic acid filler with minimal trauma using blunt cannulas to help soften the transition
between the tear trough and the puffiness. So what’s the threshold as to when you do
one procedure versus another? Well, as a surgeon of course, I am not limited by any procedure.
I do all these procedures and so I basically advise my patients as follows: If the under
eye area puffiness is so prominent that if you’re adding filler that it can actually
make it look worse, then that’s the time when you don’t do that. If the puffiness is
actually extending past the tear trough and the eyes are too puffy, then you’re not
going to have a place to actually place the filler. And there are those patients who are
kind of in the in between stage. A lot of times what we’ll do first is we’ll
say, okay, you understand that surgery is probably a critically a strategic approach
to helping your issue. It’s not even considering the other anatomic issue such as the cheek
volume but let’s just focus in that area. Then what we can do is we can try placement
of a hyaluronic acid filler in the tear trough area and then we follow our patients and we
see our patients two weeks after and see how they look. Generally speaking, in the right
patients, you can get a pretty nice result. Now there are patients who come to us who
have had this approach done elsewhere and they end up with tremendous puffiness under
their eyes from the hyaluronic acid filler or from just the volume of the filler. And
we end up using hyaluronidase to actually dissolve the filler and actually see what’s
the underlying anatomy. And then we discuss options with those patients. Sometimes options
include an alternative hyaluronic acid filler or to move forward with the surgical procedure. One doesn’t really negate the other. When
someone has relative hollowness, you can also think of the eye and cheek volume relationship.
And so, it’s really a combination of two. You can reduce the puffiness, reevaluate and
then add volume in the tear trough to try to balance and improve the appearance. There’s
an area called the V deformity that can sometimes also benefit from volume and as well as the
projection of the cheek. So you can imagine, there are a lot of different scenarios. To speak towards the surgical scenario, when
this puffiness like what you have, it’s pretty common for me to do a procedure called
a transconjunctival blepharoplasty. This is a procedure where I address those fat pockets
from the inside of the eyelid that way you avoid an external excision and you are able
to, more definitively, address the puffiness. And when patients are afraid of surgery because
they’re afraid of general anesthesia and the potential complications of surgery, well
I explain to them that the procedures are done in my office operating facilities as
opposed to going to a hospital or surgery center. And it is done under local anesthesia
with LITE™ sedation. So in many ways, it has so many comparatively similarities to
an injectable procedure. And it is, in so many ways, one can argue, invasive as an injectable
but of course it is a little more involved. But that being said, if that’s the procedure
that’s optimal then you want to do it in the safest and most predictable way and that’s
what we’ve been able to show our patients for over 20 years. That for me is an optimal
approach. So I think beyond that, if you are talking
about color, you can also address the area with things to help skin quality. But I think
skin quality whether it’s improved with laser or platelet-rich plasma (PRP) is a secondary
issue compared to what is the primary which is the dual balance of a hollow or the valley
next to the mountain. So meet with qualified, experienced cosmetic
surgeons who do a lot of lower eyelid surgery and are very comfortable with the injectables.
This way, you avoid the bias. What I find is the bias is that, there are so many more
doctors who offer injectables because there are fewer doctors who are actually surgeons,
just proportionately, that a lot of patients who would otherwise benefit from surgery are
ending up getting fillers because the doctor simply just doesn’t want to refer them for
surgery and just the harsh reality of the business of medicine. So meet with a surgeon who does all these
and this way, there is no bias one way or the other but rather, more comprehensive solutions
to be provided and what’s right for you. Three dimensional evaluation is what’s necessary
in order to get a more definitive answer and of course the experience of the doctor also
determines what they would recommend for you. So I hope that was helpful, I wish you the
best of luck and thank you for your question.

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