It’s a really common complaint we hear from our community – how do i fix the area under y eyes? Recently I attended the Cosmedicon conference and heard Dr Ron Feiner speak on getting rid of your fat bags without surgery. I thought it was something we should share and was pretty excited to have a chat with him about how he helps to get rid of fat bags without surgery.
Trish: Good morning all you podcasters out there, or afternoon, or evening, or whatever it might be wherever you are. Today, I am having a chat with Dr Ronald Feiner. Dr Feiner’s a cosmetic physician who is based in Sydney, and he heads up the Cosmetica Clinic, which is in Castle Hill in New South Wales. So, Welcome Dr. Feiner.
Dr Ron Feiner: Thank you Trish.
Trish: Thank you so much for joining us today. Today we’re gonna have a bit of a chat about. . . I’ve heard you present at a conference recently about non-surgical aesthetic correction of lower eyelids fat bags, which is really, really exciting, and really, really topical. A lot of people do have those fat bags under their eyelids and you just don’t know what to do with them, and people don’t want surgery, so this sounds like this is gonna help them.
Dr Ron Feiner: Well, Trish, it’s a very interesting subject because we do see a lot of this in practise, and as you say taking the decision to have an operation is a significant decision. The operations entail risk, and complications, and you can entail some period in hospital, and time off work, and so it goes on.
So, anything we can do to improve these sorts of problems with noninvasive work, in this case with an injection of cheeks with a cannula which takes about 25 minutes, is really quite dramatic and something that we observed in practise a little while ago and started noticing the improvement in lower lid bags. So yes, I agree with you. It is an exciting finding.
Trish: Okay, so basically what you are doing is you’re injecting the cheeks which kind of fills up those fat bags, so it’s not about getting rid of the fat bags, it’s about getting rid of the crease I guess?
Dr Ron Feiner: Yeah, I’d call it instead of calling it…using the term collateral damage, I’d call it collateral benefit. So, when we found that we do a lot of injections to the malar and cheek area, because as we age we lose both bone and fat in that area, and the big fat pads. And what we found when we were using some of the contemporary fillers, that are volumising, when we injected into the right area, which are the deep fat bags, an area that we call the …, and the median-lateral fat bags, which lie deep under the skin. They are not the superficial fat, but the next layer down.
There are retaining ligaments, that demarcate those fat bags. And if you inject with the right filler into those areas, what we found was that we re-tensioned the ligaments, and re-set the fat bags, largely back into the anatomical space they should be. So, we found this collateral benefit if you like, that we just happened to note during the course of injecting people and comparing their before and after photographs and here was this lovely finding. That we actually had two benefits instead of one.
Trish: Okay and, so, is it becoming popular? How do people find out about it? So, someone will come to you and say, “Oh my God, the bags under my eyes are”. . .
Dr Ron Feiner: Trish often people come in with that complaint, but sometimes they don’t come in with that complaint, but when we put their photographs up, pre treatment photographs, they’ll note that there are some bags there that I didn’t relativise I had. So, in both those circumstances, where they’re presented with fat bags or that they happened to note there are fat bags there when we are looking at other things, I suggest to them that we can treat the cheek area and possibly improve their fat bags at the same time, rather than have an operation.
We started noticing just serendipity when we were looking at the general harmony of the face after injecting the cheeks. That this was much improved and it was an exciting finding. So, my finding I think is original. And I’ve presented this as you suggested in conference situation and I’ve actually presented in another talk last year. And people are taking some note of it. So, it was somewhat an original thought. It’s always nice to have an original thought in this field.
Trish: Yeah, totally. And that’s how developments happen and innovation happens. It’s by thinking outside the square I suppose for want of a better…
Dr Ron Feiner: And it’s very important to present those to colleagues, because it matches the whole field. I might say that when we do cheek injections we often improve the lower face. And we’ve always known that, but when we inject the cheeks, it supports the lower face. It’s like a coat hanger on the lower face. What we didn’t realise, or what I didn’t realise til I observed this collateral benefit, was they’re also improving the lower lid fat pad. Always exciting. And there are good anatomical reasons that I go into in my reports as to why that should occur.
Trish: Okay, so, say for example if someone wants to have this done. Is it something that you have to keep getting done all the time? Or does it kind of. . . does stuff build up over time? Or is this a commitment you make for the rest of your life? You’re gonna have to be getting…
Dr Ron Feiner: Yeah. So, it’s very interesting. In my talk I presented. . . the short answer to your question is yes there is maintenance required. Every 18 months, two years, injection to maintain the effect of course is necessary. But then it’s necessary anyway because as we age we lose our cheek proportion and contours. So it’s something that most people are doing, who are interested in their facial aesthetics, in any case.
So, the fillers that we have today are, the rheology or the physics of fillers, is such that they can last a long time. And we’ve had patients even last three years. They’ll come back at one and a half years and say look do I need anymore and we find that the effect still is maintained.
Now the reason for that is that when we inject fillers, we also stimulate the inherent collagen of the patient in the region that we are injecting. So there’s not only a filler effect, but also a stimulatory effect with the fillers that we use. And the common ones that we use are hyaluronic acid fillers, which there are many brands these days.
That’s an effect that’s actually been recognised in subject studies. So, it’s quite exciting. Often the effect is much longer than the expected durability of the filler itself.
Trish: Mm-hmm (affirmative). And I know, with the fillers there’s different types isn’t’ there? There’s one that last for. . .there’s different lengths of, or thickness, or whatever. There’s different types of fillers on the market.
Dr Ron Feiner: There are indeed. I think that the vast majority of the market is serviced by hyaluronic fillers, because they got a great safety record and they have these various rheologies and that’s another study. Physical properties that can make them last longer and in some ways be more elastic. In the cheek area, once in the vastidity, the filler set so the face moves naturally. In areas where we inject, the jawline for instance, we want fillers that are actually less elastic, more viscous. Because there’s not a lot of movement around the mandible, the jaw area.
So there are different fillers for different reasons. There are also some fillers that actually can last a lot longer, they’re another type of filler, which are based on calcium for instance, where you have a longer duration, and sometimes a stimulatory effect as well. So, yeah, there are some choices. We have a toolbox and the issue is to choose the right tool, that you know how to handle, in the toolbox for the task.
Trish: Mm-hmm (affirmative).
Dr Ron Feiner: There’s a little bit of that experience in this and a little bit of a learning curve as to what to use where. And of course Trish, paramount is safety. So, how you inject, what you inject, the delivery. I like to use cannulas for instance because they’re very safe, compared to just putting a needle in. Of course we’re very frightened of vascular complications these days in the process, and even blindness. So you have to be very very careful, the way we deliver a filler. And use the safest method and the least traumatic method for the patient.
Trish: Yeah. I’ve heard some horrific stories lately, so it’s not only looking at which surgeon you go to for surgery, but it’s looking at which practitioner you’re going to for the non-surgical procedures as well these days.
Dr Ron Feiner: Very much so. We’re very concerned about the side effects that have been reported in Asia. And I think the number at the moment that’s actually reported of unilateral blindness, monopolar blindness, so actually becoming blind in an eye from a filler being injected into a vessel that can anaesthetise join other vessels that supply the retina. And that’s a tragic thing to happen for a non-invasive procedure. So I think you have to choose very carefully, the person you’re going to. . . chose somebody with a good occupation, good education, it’s terribly important. Very important in this work. Very underestimated indeed.
Trish: Yeah. I think it’s actually the most important decision, apart from the decision to have it done, it’s the most important decision you make, is who you go to.
Dr Ron Feiner: Yeah, it’s a combination of getting good workers, using good product, using good techniques, and having the aesthetic eye, and understanding the anatomy. All these ingredients go into making the product or the practitioner if you like for the procedure too.
Trish: Totally. And can I ask you, so what kind of patients is it suitable for? Would it work for someone who’s got dark circles under their eyes, ’cause often patients with fat bags under the eyes, they might also, or they might not actually, have dark. . . would it work for that?
Dr Ron Feiner: That’s a good question Trish. It varies. Now we actually treat people sometimes in their twenties with this problem. And sometimes it’s actually dark circles without fat bags. And sometimes dark circles with fat bags. Dark circles are probably due to a lot of vascularity in the area of the ocular lower orbit. And that can be there without fat bags or with fat bags.
But because we are filling the cheeks, the tissue of the skin and the soft tissue is actually lifted off the bone and off the vascularity and can improve. It’s not a definitive treatment for dark circles. I don’t think there is a definitive treatment. But everything that you do, can help.
Cheek insufficiency, or a lack of cheek projection and contour can happen from a very early age. It can be genetic, but certainly it’s exacerbated the biology. We lose bone and deep fat unfortunately as we age. And it’s a great treatment. Really at all ages. But you have to identify the right age.
Trish: Yeah. Exactly, like someone’s going to think “Oh I’ve got fat bags, I should go and have it done.” But that’s not necessarily the case. You need to go and have a consult with someone like you who does it exceptionally well. And say it might not be the right thing for them.
Dr Ron Feiner: It certainly can fail. In a case of very excessive fat bags, it might improve the situation but not sufficiently. Every case is different. Every case that walks into our office is a custom case.
Dr Ron Feiner: There isn’t a fixed menu. Everything as one of my great cosmetic surgeons from Paris, one of my mentors said “You know everything here is a la cart.” No fixed menu.
Dr Ron Feiner: So every case is new and you have to assess them in that fashion.
Trish: Yep. Alright. Now I wanna ask you one more thing. Is this something that people can have done as a quote “Lunchtime procedure?” Or is it something that you need to have a bit of down time? Or can you give us-
Dr Ron Feiner: That’s a very interesting question. With the use of cannulas and the single entry point on each cheek, which is something I do now, the procedure takes about 25 minutes, 30. It is a lunch time procedure. I wouldn’t have said that once, but it is now. And most of our patients can put on makeup and go out to dinner that night.
So it’s quite atraumatic these days. The single entry point, using a cannula, and doing the entire unit of the cheek, very pleasing and, yeah. . . as I said most people can put on makeup and go out tonight if you wish. There are the exception where you might get a little bruising. But more often than not, there’s very little bruising.
Trish: Okay. So, it depends on the person. If they’re someone who bruises easily, they might. . . ’cause I’ve had injections. Sometimes I bruise and sometimes I haven’t. So it kind of –
Dr Ron Feiner: You’ve got to know what’s under the skin when we put a needle through. And sometimes you can be a bit unlucky. But if we see bleeding, we immediately put compression on, and stop the bleeding as we would after a blood test. Put some pressure on vein and then usually it’s not a problem.
So I would say 80% of our patients, after this procedure are pretty much ready to go and enjoy life and get on with their existence. And the patients, they should look natural. They should look like a slightly younger version of themselves. It’s a very pleasing procedure. I have to say, if you’ve ever got off the couch, looked in the mirror, and maybe actually done a count, about 90% would look in the mirror and go “Wow, I love it. This is wonderful.”
Dr Ron Feiner: And that’s very pleasing for us because we love seeing results that people are happy with and technically it’s pleasing for us too.
Trish: Yeah of course. And actually talking about looking natural, there was definitely. . . you want to make sure you don’t get that pillow face look, which was out a few years back. People are changing now as well.
Dr Ron Feiner: Very much so.
Trish: Because sometimes, that pillow face, where it was just a bit overdone, ’cause people wanted more and more fillers, but it wasn’t being done properly. That’s-
Dr Ron Feiner: So true, so true. Today we don’t think of just filling an area, we think of the proportions, the aesthetic, we think of contour, we think of a natural outcome that suits the person, the harmony of the patient, face. All these factors have to come in and cheeks can be placed, when you use a filler in the wrong area, and we do still see some people with pillow face outcomes. Which are unnatural.
But again it’s all due to technique and it’s how you approach the harmony of the face, and the proportion of the face. That’s another topic. The ratios that are aesthetic, we understand these days. And one should be cognizant of that when you’re treating a patient. So we try to educate our doctors and our college of cosmetic surgery. We try and educate registrars to understand these facets. Good teaching, good books, good videos, and good course are all important.
Trish: Yeah. And that’s a topic for a podcast on its own as well. So you’re involved with the Australian College of Cosmetic Surgery?
Dr Ron Feiner: Yeah. I’m the medical dean. I’m in charge of teaching of basically minimally invasive and non-invasive cosmetic medicine. And I’ve been doing that for some years now. And our course is very very popular. We have a waiting list of people who want to do our course, which is from 18 months to two years. And it’s a very big commitment. But I think we turn out some very very good doctors in this field. And we are very proud of that and we enjoy doing that.
Trish: Yep, and that’s great. I love it when someone’s a cosmetic physician, and they’ve got the ACCS behind their name as well. It’s always reassuring and gives you that extra little level of confidence.
Dr Ron Feiner: We’re very proud of the college and very proud of the way we’re moving forward with that and. . . you know we’ve been around for 20 years now as a college?
Trish: Oh wow.
Dr Ron Feiner: Yeah. So it’s really matured into a great organisation. And I’ve been very proud to be associated with them in the capacity that I am.
Trish: Oh no, that’s great. I’m so happy to hear that. And look, I just want to thank you so much Dr. Feiner for taking your time out of your busy day to chat with me today, because it definitely piqued my interest when I heard you speaking about it. I thought “Oh, we need to share this, we need to share this.” So.
Dr Ron Feiner: It’s an interesting finding. And I’m delighted to be interviewed on the topic. Thank you Trish. Thank you so much.
Trish: Oh that’s great. Thank you so much. So, ladies and gentlemen out there, if you’re looking at having this procedure done and you’re new and about Sydney, definitely look up Dr. Ron Feiner whose based, as I said in Newcastle. Sorry, sorry, in Castle Hill. If you want you can drop me through an email. You can google him online. It’s F-E-I-N-E-R. Or, otherwise you can drop us an email to email@example.com. And we’ll send it on. Thank you so much for joining us today Dr. Feiner.
Dr Ron Feiner: My pleasure. Anytime. Thank you.
Trish: Thank you. Bye.
Dr Ron Feiner: Cheers now.