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    Filler theorem: In the deliberation to cut or fill, eyelid traits guide selection for eye rejuvenation

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    60-year-old patient (left) before and (right) three months after a single treatment of 2 cc Restylane to the lower eyelids. Photo credit: Marc Cohen, M.D.
    Surgeons are cutting less and filling more when it comes to eye rejuvenation. While fillers provide patients with an alternative to blepharoplasty, there are four eye conditions that should make cosmetic surgeons wary, according to Marc Cohen, M.D., an oculoplastic surgeon who practices in Bala Cynwyd, Penn., and serves as associate professor in the Department of Ophthalmology at Thomas Jefferson University Medical School, Philadelphia.

    "We used to think that the best ways to fix people's aging changes around the eyes were to tighten, lift and remove bags," Dr. Cohen tells Cosmetic Surgery Times . "We've since learned that faces do not fall — they sink inward. Young people have long, smooth curves on their faces that go from their eyelids down to their cheeks. Older people have hills and valleys. So rather than taking out the hills, you have to fill the valleys."

    Dr. Cohen estimates that it's more common in his practice to use fillers to rejuvenate the eyes versus lower eyelid blepharoplasty. "I would say half of the patients who used to have surgery are now having fillers instead," he says. "Having said that," he cautions, "there are four eyelid types that surgeons should think twice about filling."

    INJECTOR BEWARE When faced with puffy, saggy, swollen or thin eyelids, surgeons should be wary, Dr. Cohen says. A "puffy" eyelid has excessive fat, which is different than a baggy lid.

    "What's happened [in patients with bags] is the eyelid fat in their face has atrophied and the fat that was always there becomes visible. So we use fillers to replace the fat around the bag and that makes [for] a much more youthful rejuvenation," Dr. Cohen explains. "But some patients really do have too much fat, and if you try to fill around that, you get an unnatural curve in the face. Those patients do not do as well with filler."

    "Saggy" eyelids are caused by structural eyelid defects, so the tendon loosens and the orbicularis muscle sags. These people, according to Dr. Cohen, need a surgical tightening of the eyelid, not added volume with a filler.

    "Swollen" eyelids come and go and are often the result of allergies. Patients with swollen eyes might wake up in the morning to find much puffier eyelids than they have during the day.

    It's critical, he says, to differentiate between "swollen" and "puffy" eyelids. Surgeons can do that easily: If the patient looks upward, fat comes forward; therefore, puffy eyelids look worse when one looks upward, but swollen eyelids do not. Another differentiation between swollen and puffy: In puffy eyelids, swelling does not come and go.

    "Swollen eyelids are the trickiest of all. People with swollen eyelids do not do well with fillers," Dr. Cohen says. "The fillers we use most commonly around the eyes are hyaluronic acid fillers, which work by absorbing and holding fluid in that area. When we use these on patients that swell a lot, the fillers make them swell more."

    However, nor is surgery the answer for patients with swollen eyelids, according to Dr. Cohen, because surgery will also cause additional swelling.

    The trick with swelling, he says, is to get it under control. Dr. Cohen recommends eyedrops that combine antihistamines with mast cell stabilizers to treat allergies, if that is what's causing the swelling.

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    Lisette Hilton
    Lisette Hilton is a writer in Boca Raton, Fla., who heads up her company, Words Come Alive.

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