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UNDEREYE SOLUTIONS New York plastic surgeon Andrew N. Kornstein, MD, FACS, agrees and adds, "Any ongoing inflammation affects melanocyte production and deposition, and can lead to dark circles. In addition, bone loss in the area can change the angle of inclination of the lower lid, leading to shadowing. Prominent eyelid fat pads can compound the strain to this area leading to progressive dysfunction of the skin, darkening it in response to chronic stress." The undereye area is complex and there are usually multiple factors involved in the sagging, bagging and discoloration. "It is the physician's job to detect the factors and then to work backwards to tease out any environmental, genetic or behavioral causes," says Lisa A. Zdinak, MD, chief surgeon and medical director, Precision Aesthetics, New York. She questions patients thoroughly to uncover any medical conditions, possible allergic reactions or injuries that might be causing circulatory outflow interruption. "Outflow disturbances must be dealt with first or other treatments will fail," adds Dr. Zdinak. "If I suspect a nasal obstruction, I send the patient to an ENT for endoscopic evaluation. If not, I generally give the patient a trial of nasal steroids plus antihistamine. I see the patient back after about a month. Most are feeling better already so we proceed to address any other factors in play." Discovering the factors involved in creating undereye complaints is just the first step. Deciding which treatment to use is equally challenging. Treatments and outcomes vary and there is no consensus on the best approach to diminish wrinkles, discoloration, volume loss and hollowing under the eye. Filling Out Hollows "Aging of the lower lid compartment and cheek is generally acknowledged to be a process of bone and soft tissue atrophy, which can start as early as the late 20s," says Dr. Kornstein. "My preferred treatment is autologous fat transfer, which creates volume and actually reduces bone atrophy due to its inherent stem cell 48 SEPTEMBER/OCTOBER 2013 | MedEsthetics effect. I also use soft tissue fillers; they don't arrest the aging process but they do slow the descent of the overlying soft tissues as can After noninvasive skin tightening, such as Ultherapy (Ulthera, ultherapy.com)." Dr. Kornstein extracts the small amount of fat needed for the undereye area with hand-held This patient received 12 carboxytherapy injections to diminish her undereye circles. liposuction, centrifuges it and then reinjects. "The key is in amounts of the fat under the skin all the reinjection process. It is important not across the lower lid, adding more in the to traumatize the area, to keep tissues tear trough to soften any herniated fat and blood flow intact while shaping the pads. Building the cheeks a little biginjected fat aesthetically. In my opinion ger provides a structure to support the fat grafting is the only reliable means of necessary fat pads under the eye," Dr. treatment that has persistent, long-term Coleman adds. benefits for undereye dark circles and Simon Ourian, MD, Epione, Beverly bags," he says. "The only question we are Hills, California, has a different point of still studying is whether fat grafts can be view. "I used to use fat transfer instead of improved by multiplying the stem cells in synthetic fillers, but in my experience the a transplant graft." results were not reliable," he says. "You Sydney R. Coleman, MD, TriBeCa never knew how much of the fat would Plastic Surgery, New York, is equally enbe absorbed so there was a tendency to thusiastic about fat grafting for volume loss overcorrect. The size of the fat cells harunder the eye. "The injected fat immedivested from other areas of the body can ately provides an optical barrier, hiding the vary and cause pillowy, unnatural results. circulating blood that is often the cause of All in all, I found fat transfer more cumberdark circles. It fills the tear trough, supsome and less reliable than synthetic fillers; porting any undereye pouches, which can it caused more bruising and was more excause shadows, and over the following pensive for the patient than newer fillers." Cost is certainly a factor for many months, it gradually thickens the skin," patients. A fat transfer procedure to he says. "Results can be seen within one correct the undereye area can cost month but the real effect won't be visible $5,000 to $10,000, and there is a until about six or seven months later." higher risk of complications. Dr. Coleman began developing his Dr. Ourian prefers Restylane (Medicis, procedure, known as Lipostructure, in restylaneusa.com), Perlane (Medicis) or 1987. "It involves harvesting the tissue Radiesse (Merz Aesthetics, radiesse.com) under low pressure, using a syringe, for undereye corrections. "The Radiesse then placing it in a centrifuge to isomust be injected deep into the skin belate and concentrate the living fat. We tween bone and muscle to avoid lumps, use only the densest fat in lower lids, bumps and granulomas," says Dr. Ourian. which has more regenerative cells. Dr. Chasin also prefers dermal fillFinally, we use a 1mL syringe and two ers for correcting undereye hollows. or three tiny cannulae to place minute PHOTOS COURTESY OF LISA ZDINAK, MD. Before