Should you take Arnica to prevent bruising after cosmetic surgery?

Arnica : a miracle bruising cure ?

After cosmetic surgery, filler treatments, or even Botox, many doctors recommend their patients take Arnica to prevent bruising.  One study in JAMA Facial Plastic Surgery journal showed that nearly 50% of rhinoplasty surgeons will suggest homeopathic arnica after surgery.  Here in NY I’ve seen my own patients pop an over-the-counter Arnica tablet in their mouth after an injectable cosmetic treatment.  What are they taking?

Arnica Montana is flowering plant also known as wolf’s bane.  It’s not safe for ingestion in its pure form, so most versions you will find in the pharmacy are either topical creams or homeopathic oral preparations.

Is there scientific evidence that Arnica works?

The majority of peer-reviewed articles that examined the effectiveness of homeopathic Arnica Montana after surgical procedures showed no dramatic benefit.  In fact most of them show no benefit.

One study in 2007 in Plastic and Reconstructive Surgery journal looked at 48 rhinoplasty patients and found that Arnica did not reduce bruising.

One study in in 2006 in Archives of Facial Plastic Surgery looked at 29 facelift patients and neither the doctors nor the patients could tell any difference in post facelift surgery bruising when taking A. Montana versus a placebo.

Arnica after blepharoplasty

Because Arnica use is so widespread in cosmetic and plastic surgery I conducted an investigation to see if it works.  In 2010, my study included 30 patients who underwent upper eyelid surgery (blepharoplasty).  I approached the largest post-cosmetic surgery homeopathic Arnica manufacturer in the country and they provided the Arnica tablets and identical-appearing placebos.

My patients had one upper eyelid surgery with either Arnica or placebo and then a month later they had the second eyelid done with either Arnica or placebo.  There was no noticeable difference between Arnica and placebo for the patients and for independent physician observers, and the size of the area of bruising was not reduced by the active ingredient.

I published the results in Ophthalmic Plastic and Reconstructive Surgery journal, and my research was funded by a grant awarded by the Cosmetic Surgery Foundation.

study arnica bruising

Homeopathic arnica supplements used in my study


Homeopathic safety and effectiveness

Homeopathic remedies tend to be very safe.  This is because they are so diluted that they don’t contain much active ingredient, if any at all.  The primary principle of homeopathy is that more dilute substances are more effective.  While these over-the-counter preparations fall under the umbrella of FDA jurisdiction, the FDA does not evaluate their effectiveness.

Why cosmetic surgeons sell Arnica

If there is no credible scientific evidence to support the use of homeopathy as a whole, why do doctors and manufacturers readily promote it?  Because homeopathy is a huge multi-billion dollar business. And for the most part, homeopathic “remedies” are safe because they are “watered down” to the point of being empty.  And because its easier for a doctor to give a patient a placebo than to say “there’s nothing I can do for your bruising”.

How you can prevent bruising

The best measures you can take to avoid bruising after a cosmetic surgery or a cosmetic injection is to discontinue medications and supplements that promote bleeding before your surgery.  Before you stop any prescribed medications, you should check with your doctor to make sure it is safe to do so.

For cosmetic injections, including Botox, Dysport, Juvederm, Restylane, and Sculptra, you can ask your doctor if ice is advisable before the procedure.  Cold compresses can temporarily shrink the blood vessels in the area, making them less likely to cause a bruise.  Cannula injections (instead of needles) are used quite often where I practice in NYC, probably because they have been shown to reduce the chance of bruising in certain facial areas and the typical client is averse to any downtime.

Bromelain, a form of pineapple extract is another popular supplement that is meant to reduce bruising.  Like Arnica, there isn’t a great deal of support in the scientific literature for its usefulness, but it probably isn’t harmful either.

The most popular Asian cosmetic surgery

Asian double eyelid surgery

More Asians have double eyelid surgery than any other cosmetic procedure, including rhinoplasty, liposuction, and breast augmentation.  It has become such a trend that non-medical personnel at salons have been found using “quick stitch” procedures, frequently with less than perfect results.

What is a double eyelid?

The vast majority of “western” or occidental people have a crease across the upper lid that divides the lid into two parts, thus the double lid.  Approximately 50% of Asians lack this crease or have a poorly visible crease, giving the appearance of a single eyelid, or a “monolid”.

double eyelid drawing

Double eyelid






Why is double eyelid surgery done?

The eyelid crease frames the eye opening and makes the eyes appear to be more open, an often desired aesthetic feature for those without a crease.  The procedure is generally aimed at preserving the Asian shape and features of the eyes, so it is not meant to Westernize the lids.

 Is it only done in Asia?

The double eyelid procedure is extremely popular in China, Korea, Thailand, and Japan, but Asian-Americans have the surgery in the United States as well.  As an oculoplastic surgeon in New York, I see a relatively large Asian patient base who are interested in double eyelids.

asian eye surgery

Immediately after double eyelid surgery






How the eyelid crease is made

There are 2 main methods of creating an eyelid crease.

1. The suture method: Disintegrating stitches are passed through the desired crease location and the lid is compressed in this area, allowing a scar to form as the skin heals.  This method is less permanent than the second option.

2. The incision method: A fine cut is made across the eyelid crease and stitches are placed from the skin to the deeper eyelid and back to the skin.  This approach has a longer scar but the surgeon has more control over the result.

Does this procedure have anything to do with those large contact lenses?

No, the circle lenses that have become a trend in Korea, Japan, and Singapore make the iris look larger (and often change the color of the iris) were inspired by anime characters and don’t actually change the eyelid shape.  Circle lenses seem to be more of a pop-culture trend while double eyelid surgery has been around for decades and is unlikely to wane in popularity in the near future.

anime contact lens

circle lenses






What type of crease do you have?

I’ve compiled an ebook on double eyelid surgery that includes a section to help determine what type of eyelid creases you have. You can download the free pdf file here.



Under eye fat injections – do they work?

What are facial fat injections?

Fat is used as a natural filler to put back the fullness and suppleness in your face that is lost as you get older.  Small amounts of fat cells are suctioned from one part of your body- your belly, hips, thighs for example, and then this fat is placed where it is needed to make you look the way you did years earlier.

transfer fat

Where do fat injections go?

The earliest parts of the face that lose fat are the grooves under the eyes, the cheeks, and sometimes the temples and eyebrows.


This is one of my patients that didn’t like the look of bags and sunken-under eyes.

bags under eyes







I suggested a lower eyelid lift, with fat injections.  You can see she has sunken areas under her eyes where she is missing a roundness to her upper cheeks.

This is where I placed fat, by injecting tiny amounts with a thin tube (cannula) deep under the skin and muscles of the face:

under eye fat grafting







And this is what she looked like after recovering from the procedure:

before and after under-eye fat












In addition to fat injections, a minor amount of bulging fat was removed from behind the eyelid, also termed a scarless lower eyelid lift.  With these two procedures I eliminated her eye bags and the hollowing in her cheeks.

Another example of under-eye fat injections with scarless lower eyelid lift to reduce bags and hollowing:

fat grafting eyes

Fat injections vs. fillers

Much of what can be accomplished with fat under the eyes can also be done with filler injections. Fillers (like Restylane and Juvederm) are in-office procedures, performed in minutes, and often with little downtime.


The benefits of fat are:

1. Fat lasts longer (possibly permanent) when compared to the most popular fillers

2. Fat is a natural part of your own body

3. Fat is softer than fillers

4. Fat reserves tend to be plentiful


The drawbacks of fat injections:

1. Your body may absorb some of the fat requiring a second treatment

2. Fat injections have more downtime than fillers (about 1-2 weeks)

3. Fat injections tend to cost more than fillers


How to ensure fat injections will last

There are many ways to handle and process fat to be used for injections, or fat grafting.  Gentle handling with sterile techniques and meticulous injection practices help to ensure the best chance of long-term fat cell survival.  Many surgeons will quote a 50% – 70% rate of fat acceptance.  For this reason, slight over-correction is desirable immediately after the procedure.

I centrifuge the fat at low speeds after collecting it with low-force suction. This purifies and condenses the fat cells.

purified adipocyte






The final product is a golden slurry of your own fat. I inject fat in small amounts using a one milliliter tube (1/5 of a teaspoon) as depicted below.  Each injection layer consists of one tenth or one twentieth of this tube.  Very small fat deposits create a smooth and accurate fat placement.

injection fat grafting







So yes, fat injections under the eyes can effectively fill in hollow and sunken cheeks and under-eyes.  The combination of fat grafting with lower eyelid surgery, facelift surgery, or even brow lifting is a great way to look younger without looking “done”.



Brett Kotlus, M.D.

135 E. 71 street

Phone: 212-882-1011

This is what happens when you get an eyelift: part 2

Getting back to work (and life) after eyelift surgery

In the last blog post entitled “This is what happens when you have an eyelid lift“, I shared the video chronicle of my 37-year-old patient who wanted a cosmetic upper eyelid lift because she saw her lids getting droopier and heavier after having 2 children.

At the end of the video, she talks about how happy she is that her family noticed her eyes look brighter and she can finally see her eyelid makeup.

I’ve received a few emails asking about the upper eyelid lift recovery.  More specifically:

When can I go back to work after a lid lift?

This depends on the type of work and how you want to be seen.  There is a restriction on heavy lifting and strenuous activity for 1 – 2 weeks.  In terms of looking your best, that can take a few weeks as well.

Most people have their worst swelling at 24-48 hours.  Look at this photo series that my patient shared:

eyelid surgery recovery










After the initial 1-2 days when things look very puffy and strange , swelling gradually subsides over a period of days and weeks.

Some people get back to work after a long weekend..

Others will want to wait 7-10 days before “presenting” themselves in social situations.  This will partially depend on if there was any bruising after the eyelid lift and how you feel about others seeing you with some minor signs of having something done.

At the one week point, if you were to walk around the streets of New York City without sunglasses, you probably wouldn’t turn heads.  If you went to dinner with a close friend one week after eye lift surgery, they would probably notice something but they may not know exactly what was done.

After recovery most people forget.

Because the healing process is relatively quick and painless, most people tend to forget that it even happened.  I think my patients seem to be focused on the results rather than the recovery phase and they are happy with their new look.

Sometimes, it’s nice to have an imposed “rest time” in our lives to enjoy a book or two and then emerge bright-eyed and refreshed.

Here’s my patient after the eyelid swelling disappeared and life returned to normal:

after eye lift ny




Brett Kotlus, M.D.

135 E. 71 street

Phone: 212-882-1011

This is what happens when you get an eyelift

What happens during eye lift surgery?

Eye lifts are done to make the eyes look younger, less tired, less heavy, and less baggy.  It’s what I do the most of in my cosmetic practice in NYC.  So what does the eyelift involve?


It’s an outpatient procedure

You don’t have to stay overnight, and it’s done in an accredited surgical suite.  The total operating time for just the upper eyelids is under an hour, longer if the upper and lower eyelids are done together.

To make the upper eyelids look younger, a thin strip of skin is removed and the eyelid is sculpted on the inside by shaping the fat and muscle.  Then stitches are used to close the skin and to improve the contours of the eyelids.

Downtime can be 1 – 2 weeks

Some people look great after a week (which is usually when any stitches are removed), but others may have bruising and swelling that lasts longer than a week.  The vast majority of my patients use only Tylenol for some mild discomfort during the first week of healing after their eyelift.

Will an eyelift make me look strange?

A natural-looking eyelift surgery will only make you look strange during the early healing time- so perhaps a few weeks.  Over-done eyelid lifts when too much skin or fat was removed can make your face look different.  A key is finding a surgeon you trust and has specialized eyelid training.  Their before and after photos should provide examples of results that match your goals.  And they should be able to tell you if your expectations are realistic.  These are issues I focus on when I see prospective clients in my offices in NY.

The goal of cosmetic eyelid surgery is to rejuvenate the eyes without calling attention to the fact that something was done.  The results can be nothing short of amazing.  Click here to see what I mean.





Cannula tear trough filler under eyes for dark circles and eye bags

Cannula tear trough filler

Eye bags and dark circles may be present from birth or can develop with age.  They make us look older and more tired.

In my NYC practice I fill the so-called tear trough to minimize hollowing under the eyes and to soften the under-eye contour.  Filling this area makes the eyes look less tired.

Here is what a tear trough is: it’s a valley under the eyelid that contributes to shadows, dark circles, and the appearance of under-eye bags.  I describe it at more length here.  It is caused by the tight attachment between the eye closure sphincter muscle (orbicularis oculi) and the rim of bone under the eye.

The cannula tear trough filler treatment is a way to minimize or eliminate eye bags without surgery.

See this example:

filler under eye

Another example:

How is cannula tear trough filler done ?

An injection delicately and precisely places a biocompatible material under the skin to lift the sunken area.

There are a few filler types available (Restylane, Juvederm, Restylane Lyft, Belotero, Volbella, Vollure,  etc.), and these consist of gels that are packaged in a syringe or a tube.  At the tip of this tube is a needle or a cannula that delivers the gel in the right place.

Restylane is arguably the best filler for the under-eyes.

Read this article to hear more about why Restylane is the best for under eyes based on my experience with thousands of treatments over more than 12 years.

Needle vs. cannula

A needle is the traditional way of performing filler treatments.  It has a sharp tip and works with a high degree of accuracy.

A cannula is similar to a needle but the tip is not sharp, it is blunt and rounded.  The cannula eye lift has a few benefits:

1. Cannulas can be less likely to cause bruising after filler treatment

2. Cannulas may be less painful than needles

3. Cannulas may require less entry points because they tend to be longer than needles

4. Cannulas may be safer than needles because it is less likely to puncture a blood vessel and inject filler where it doesn’t belong

Which one do I use?

I use cannulas for the tear trough, mainly because of the improved safety and reduced risk of bruising.  Here in NYC, my patients want to be able to return to their busy lives with minimal recovery time.  The cannula makes that much more likely than needle treatments for eye bags.

However, I don’t use cannulas for every filler treatment I perform because certain situations are better suited for needle injections (e.g. shallow fine lines, acne scars, surgical scars).

Example of cannula eye lift with Restylane immediately after one side was completed:

eye bag cannula

How long does the cannula eye lift last?

After under-eye Restylane treatment, you should expect a year or more of improvement in the appearance of eye bags.  If the upper cheeks are filled at the same time, the results can last longer due to the improved volumetric support.

Surgery or filler for eye bags?

Aside from the cannula eye lift, there are both surgical and non-surgical ways to improve the under eyes- I created an infographic that helps you decide if fillers or surgery are a better option for you.  You can find it by clicking here.

Before and after cannula eye lift with Restylane

eye bags filler

eye cannula
 under eye filler

cannula eye lift

Getting the cannula eye lift in NY

When patients come in for the cannula eye lift, they often have their initial consultation and their treatment on the same day.  The entire procedure takes about 15 minutes.  I highly recommend you see a cosmetic eyelid surgery specialist (oculoplastic surgeon) for the procedure.  A good portion of my practice is devoted to correction of eye procedures performed elsewhere by non-eyelid specialists (revision procedures) and this includes correction of under-eye fillers that were incorrectly administered.  It’s best to get it right the first time but if you do encounter an issue a fix is usually possible.

Phone: 212-882-1011

What are festoons ?

Festoons, cheek bags, and malar mounds

These are all part of the same aesthetic problem. They are bags or bulges found on your upper cheek, below the eyelids and below the bony circle under your eyes called the orbital rim.  They are seen in both young and old people, yet they tend to get worse with age.

Festoons and eye bags are not the same things

Eye bags are the puffy areas within the eyelids that are caused by bulging fat orbital fat pads, the fat that lives around the eyeballs.  Festoons occur lower on the face, at the upper cheeks.

cheek bags





One side looks worse than the other- why?

It’s not uncommon for one cheek to look worse than the other.  Facial asymmetry is noticeable in almost everyone, and festoons follow this rule.  Here’s an example of a severe festoon on one side:

uneven cheek bags


Why do we get cheek bags?

Festoons are caused by several conditions happening at once.  The location of the folding skin and creasing is formed by the connective tissue bands that provide structural support between the skin, fat, muscle, and bones in your face.  These bands or “ligaments” dictate the position of creases and folds on your face.  With age, you may lose structural support and volume in your face.  Volume loss combined with gravitational effects leads to aging signs such as jowls, sagging eyebrows and eyelids, and you guessed it, festoons.

Is there a correction for festoons?

Yes.  Treatment involves a combination approach that addresses each of the underlying causes of the problem.  Laser skin resurfacing, volume replacement (fat or filler injections), and lower eyelid lift surgery are often used to minimize or eliminate the festoon.

Here is an example of my patient who underwent lower eyelid surgery, fractional laser skin resurfacing, and fat injections to reduce both eye bags and festoons in a single procedure.

eyes fat grafting

Lower eyelid lift with fat grafting





















I routinely see clients who are concerned with festoons in my NY office and I’ve noticed that the festoon page on my website is one of the most frequently visited.


Brett Kotlus, M.D.

135 E. 71 street

Phone: 212-882-1011

How do you put ointment in your eyes after surgery ?

Putting ointment in your eyes

It sounds tricky but there is an easy way to apply ointment in your eyes after surgery.  After a lower eyelid lift (blepharoplasty) when the incision is created behind your eyelid or the transconjunctival approach, Dr. Kotlus prescribes an ointment containing antibiotics or a combination of antibiotics with steroids. These ointments are safe for contact with the surface of the eye.

The tube

The ointment tube will read “ophthalmic use” and it should not be confused with other medications in your house, and special care should be taken to keep it separate from any tubes of super glue!

Using the tube

The tip of the tube should not touch your skin or the surface of the eye.  In a mirror, use your index finger on one hand to gently pull downward on your lower eyelid.  With the tip of the tube near the edge of the eyelid, very carefully squeeze and allow a thin strip of ointment to reach the eyelid; approximately 1/4 inch long.

If the ointment is on the eyelid margin or very close to it, you can then blink several times and it will work its way over the surface of the eye including the incision area.

It is common to use this ointment after cosmetic lower blepharoplasty.  In his Manhattan and Westchester offices in NY, Dr. Kotlus routinely  uses the transconjunctival approach to the lower eyelid fat pads.

The video above shows exactly how the ointment can be applied.

Amazing facts about eyelids

People like to send me unusual medical links.

As a fellowship-trained cosmetic and oculofacial surgeon, I routinely receive articles and YouTube links from patients, friends, colleagues, and family members that would fall under the heading of strange and unusual medical stories.  The stranger the subject, the more eager they seem to share their intrigue.

The eyelids are unique parts of your body.

I collected several facts and links about the eyelids, which are one of several focal points of my cosmetic surgery practice.  Did you know the eyelids have the thinnest skin in the entire body?  Did you know that you can get a tattoo on the surface of your eyelids?  I edited these links into a video of 5 facts which I find astounding- the way that people push their physical limits in this montage speaks for itself…




Under eye creases of youth

The lower eyelid crease

When we are born, many of us have a crease on our lower eyelids.  This crease is a horizontal line below the eyelashes that is more noticeable when looking downward.  I like to call this the lower eyelid crease of youth.

Not every crease is a wrinkle

I recently answered a question on Realself about lower eyelid creases of youth.  These creases can persist into adulthood but they shouldn’t be considered as wrinkles that need erasing.  Taking away a youthful-looking feature will not necessarily make you look better or younger.

What the eyelid crease of youth looks like

Below is an image of my 2-year-old son’s eyelid.  Notice the line on his lower eyelid that is rather deep when looking down.

eyelid crease of youth

This crease is made by the extension of the lower eyelid retractors, the muscles that pull the eyelid down when you gaze downward.  See the large blue arrow in the diagram below (image borrowed from a book chapter I co-wrote in Clinics in Plastic Surgery).

eyelid retractors


If you have these creases…

Consider yourself youthful-looking and lucky.  Removing or softening them can be done with surgery or Botox, but is not recommended in most situations.



What is a laser eyelift ?

laser eyelift advertisement

What does the term Laser Eyelift mean? Is it used by cosmetic eyelid surgeons purely for marketing or does the laser truly improve cosmetic eyelid surgery results?  The answer is both.

The word “laser” added to any procedure makes it sound more modern, cleaner, and better.  And it is used to market medical and surgical procedures including laser facelift, laser liposuction, laser toenail fungus removal, and laser teeth cleaning. Here in NY the word laser is thrown about quite frequently in medical advertising- I’ve seen all sorts of laser procedures on billboards on the NYC subway.

Lasers are used in cosmetic eyelid surgery in 2 ways:

1. Creating an incision and dissecting tissue: A focused laser cuts the skin and vaporizes tissue with pinpoint accuracy.  This can be better than using a scalpel because it theoretically gives the surgeon more manual control and seals blood vessels as it cuts.  On the other hand, stitches often need to remain longer after laser upper eyelid surgery and studies have shown similar end results when laser versus scalpel was used to make the upper eyelid incision.

2. Resurfacing the upper eyelid and surrounding skin: Laser energy is used to remove the eyelid skin surface, leaving room for new skin to replace sun-damaged skin.  This can be done on its own or at the same time as eyelid skin removal.  Laser resurfacing improves the quality of the skin, reducing wrinkles and brown spots.  This approach does improve on traditional upper eyelid lifts that didn’t commonly include resurfacing.  Last year, I presented my upper eyelid skin laser resurfacing technique to a large group of surgeons at an oculoplastic surgery conference in New Orleans and it was received with much interest.  Lower eyelid skin resurfacing is quite common and I expect upper eyelid skin resurfacing to become more popular in the next 5 years.