Fat injections Under the Eye

What can one do for bags under the eyes?

For many years, patients would come to me asking to remove the bags under the eyelids, saying the bags made them look old and tired. I usually recommended a standard blepharoplasty or eyelift. That involves making an incision right under the eyelashes, lifting skin and the muscle that is right under the skin. I would then remove the fat. It was the standard solution but it had several drawbacks.

For one, the area under the eyelids would sometimes appear hollow. Sometimes the line separating the “bag” from the cheek skin would become a deep trough, highlighting the emptiness under the eyeball. On certain patients, especially those with shallow cheekbones the lower eyelid could hang lower, showing the white under the iris (the colored part of the eye). In some cases, the lid would pull away from the eyeball, causing excessive tearing and dryness.

For that reason, I started doing what is called subconjunctival blepharoplasty, where the incision is made on the tissue inside the eyelid, leaving the skin and muscles intact. I would then do a peel or laser to take care of the wrinkles. This solved the problems related to the lower eyelid, but did not help the hollowness under the eye. I accepted this, because it was the best we had.

As Restylane and other facial fillers gained popularity, I started injecting fillers in the trough under the eyelid on young patients. It helped camouflage or disguise the bag under the eyelid, and I started using this approach more and more. But what really struck me was the “WOW” moment after the patients saw themselves in the mirror. It changed their whole look! If you read my post on where people focus on the face (saccadic eye movements), you understand why a little thing like a smooth contour under the eyelids has such a big impact. As the saying goes, “The eyes have it”.

More recently, a patient who had had a face lift and blepharoplasty several years ago by another surgeon came to me requesting a “revision” facelift. Since traditional facelifts do not address the area under the eyelids, and the area under the eyelids appeared hollow, I thought that pulling again on her skin would make her look worse, tight and drawn. When I proposed fat injections under the eyelid, she was not interested. To show her how this could improve her look, I injected saline in the upper cheeks and under the eyelids. The purpose of this was to imitate what real fat injections could do.

Talk about a “WOW” moment! After seeing the results that the saline injections produced (temporary), she agreed to the fat injection surgery right away. She had a remarkable result for a procedure done under local anesthesia, at a fraction of the cost any of the other surgical alternatives. This was a “big bang for the buck”.

Ricardo L Rodriguez, MD

Posted by Dr. Ricardo L Rodriguez at 11:41 AM

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Dr. Ricardo L Rodriguez
Plastic Surgeon

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6 Comments

Dr. Ricardo L Rodriguez wrote
October 21, 2009 at 9:11 pm

Dear Linda:
Although I started injecting fat and/or fillers under the tear trough in young patients, the vast majority of patients who get this now are women who are getting facelifts, or are looking for a limited procedure, such as an injectable, that will make them look younger. The peak age group for these procedures is 45 to 65 years old.
I no longer feel this is a tricky area to treat with fat grafts or injectables, and as a matter of fact I recommend it to many patients my age (54, like you!).
The key thing to realize is that you are not treating the trough itself, but the loss of volume in the upper cheek that has made the tear trough empty out and descend. Thus I inject more volume at a deeper layer. The end result is more subtle, yet at the same time more youthful than just levelling the tear trough.
Linda Diefenbach wrote
October 21, 2009 at 1:58 pm

I’m a 54 year old female trying to come to a conclusion about whether or not to have dermal fillers placed in the tear trough below my eyelid when I happened across your discussion about fat injections in that area. You mentioned using fillers as an effective treatment, however, you said the magic words “…I started injecting fillers in the trough under the eyelid of YOUNG patients…”. Aside from the tricky nature of filling this area, is your feeling at this point that the dermal fillers are not the best option for filling tear troughs in older patients? Is the elasticity/thinness of the skin below the eyes that is the issue or is it something else?
Thank you,
Linda Diefenbach
Dr. Ricardo L Rodriguez wrote
May 26, 2009 at 7:40 am

Unfortunately, not knowing exactly what the surgeon did or how the postoperative course went makes these problems hard to analyze from across continents.
My best advice to you is to go see a Plastic Surgeon where you live and get an opinion from him. He will be able to see you in person and see and feel the eyelid and cheek area.
By the way, I would see one or two board certified Plastic surgeons, just to get an idea of what the range of possibilities is.
Let us know how the consults went.
By the way, I never make any decisions about revisions until 4 months after surgery, so in your case, we’d be talking about mid June at the earliest.
Donna Schae wrote
May 25, 2009 at 10:11 pm

Hi, I recently had fat injections under my eye, after firstly having a eye lid lift on the same day. Unfortunately I bled more than the surgeon expected, and my one eye remains puffy after having this procedure on the 13th of February 2009. I have tried putting ice on the eye every day and massage it so that it can go down, but nothing seems to be working. The procedure was done by a qualified cosmetic surgeon in South Africa, and I am not living in Melbourne Australia. Do you think he put too much in my eye, and now I will need to loose the weight to allow it to go down to its normal size. Please can you give me advise with regards to this as I am getting married in 6 months and hope it will have gone down. My surgeon advised that it will take time,but will go down in a couple of months and that I should be patient. I look forward to your response. Many Thanks Donna - Melbourne Australia
Dr. Ricardo L Rodriguez wrote
January 28, 2009 at 10:34 pm

hello Susan,

When properly harvested, processed, and injected the fat graft is permanent. I use very fine cannulae to remove the fat, centrifuge the fat to get the best fat cells, and do micro re-injections. However, the fat injection procedure is very technique dependent and not every surgeon uses proper technique. That is why this procedure gets a reputation for not working permanently and why some surgeons need to perform additional injections.

When done correctly , the fat graft is permanent and should not have to be repeated!
Susan Wilson wrote
January 28, 2009 at 9:12 am

Is the fat injection under the eye permanent? If not how often do you have to get it done?