Simultaneous rejuvenation of the lower eyelids and the cheeks is a winning combination.
This image shows an actual surgery patient of Dr. Niamtu. The aging midface (left) is rejuvenated by lower eyelid surgery and cheek implants (right).
Facial aging is an interesting multi factorial phenomenon. Many things contribute to an aged midface including sun damage to skin, atrophic and gravitational changes to fat, muscle and bone. Two of the biggest things that make us look old and tired occur in the lower eyelids and cheeks.
The lower eyelids can undergo aging changes as early as the third decade. The skin becomes crinkly and sags, fat can protrude from around the eyeball and produce sausage shaped fat bags on the lower eyelids. This protruding fat also causes a shadow from overhead light which contributes to the dreaded “dark circles” under the lower lids. In addition, due to the aforementioned changes, the “tear trough” (technically the nasojugal groove) becomes accentuated. This produces a deep grove under the eye from the side of the nose across the cheek.
Extremely related to midface aging is volume loss in the midface. Young patients have full, plump and rounded cheeks. This good fat in good places produces a smooth, continuous contour under the eyes and around the cheeks. Gravitational and atrophic aging changes causes volume loss in the cheeks and gives us a drawn, gaunt and hollow appearance. This is also very related to the lower eyelid aging as the lower lids are the upper cheeks. The combination of aging produce an old and tired look and the only means to address this aging comprehensively is to address both the lower eyelids and cheeks at the same time. I find it rare that patients with lower eyelid aging don’t need attention to the cheeks (midface). I would say that 95% of my lower lid patients that are over 40 would benefit from simultaneous midface augmentation. Fortunately, many of these patients understand this and combing procedures.
My approach to the healthy lower lid is pretty simple. I remove conservative fat with a laser incision from the inside of the lid (transconjunctival blepharoplasty). This means no external scar and no bleeding due to the laser. No bleeding means faster surgery and recovery with less bruising and pain. I am always very careful to only recontour the excess fat as not to produce further volume loss. The second step of lower eyelid rejuvenation is addressing the aging skin of the lower lids. Although some surgeons still cut off lower eyelid skin, I think that is a bad idea. It only stretches the skin; it does nothing for rejuvenating the skin. The skin will return to its normal wrinkling in a short time. More of a problem is the fact removing skin from the lower eyelid can also contribute to lower eyelid malposition. Due to the scarring that can occur inside the lower lid, the eyelid can be pulled down which looks unnatural and can cause problems.
To truly rejuvenate the lower eyelid skin, it needs to be resurfaced. I prefer CO2 laser resurfacing or chemical peeling. These modalities actually remove wrinkles and brown spots and makes new, younger skin. That is truly rejuvenation!
Since the aging does not stop at the lower lid, this is an excellent time to also address the midface. The patient is already sedated and will be taking a week off of work, so why not be comprehensive with the rejuvenation? My most common method of augmenting the aging midface is the use of silicone cheek implants. (Click here to view a video about cheek implants and facial aging). There are many reasons that I like cheek implants. Among them is the fact that they are inserted from the inside of the mouth so there is not visible scar. They are held to the cheekbone with a micro screw, so they are permanent, but they can be changed or removed in 30 minutes if the patient desires. Not many things in cosmetic surgery are permanent but reversible!
By placing cheek implants, the youthful contour of the midface is reestablished and many times the tear troughs and even the nasolabial folds are also improved. Alternatively, the cheeks and tear troughs can be volumized with injectable fillers. This is non-surgical and is also reversible. The downside of midface filler augmentation is that it is a temporary fix.
Simultaneous rejuvenation of the lower eyelids and the cheeks is a winning combination. If a patient seeks lower eyelid rejuvenation and the surgeon does not discuss the midface aging, a second opinion may be in order.
To find out more about cosmetic facial surgery by Dr. Joe Niamtu, III in Richmond, Virginia visit www.lovethatface.com
Joe Niamtu, III DMD