It is often said that the eyes are the windows to the soul. What would an aged periorbital appearance imply? It is no wonder that rejuvenation of the periorbital region is one of the commonest aesthetic requests. A youthful and aesthetically pleasing lower eyelid region consists of smooth and crisp lower eyelid skin without wrinkles or pigmentary blemishes, well-positioned lower eyelids, and blends smoothly into the cheek without grooves or bulges. When viewed from the side, the eyelid and cheek should form a gentle convexity from the eyelash down to the corner of the mouth. A youthful lower eyelid and cheek region imparts the image of an individual who is attentive, energetic, and confident.
The aging lower eyelid consists of a constellation of changes. The lower eyelid skin becomes thin, forms redundant folds and may have pigmentary changes. Wrinkles may be seen in the lower eyelid when the individual smiles or forcefully closes their eyes. The lower eyelid may descend, and with resulting exposure of the sclera and cornea. Eye bags start to protrude resulting in unnatural and unaesthetic bulges at the lower eyelid. Hollowing occurs beneath the eye bag, especially on the inner (medial) side, and an obvious junction forms between the lower eyelid and the cheek. This is known as the tear trough deformity.
The midface and cheeks lose their youthful projection and become flattened and descend. Lower eyelid descent leads to corneal exposure and the sensation of dry, gritty eyes. The ageing lower eyelid may exhibit both functional and aesthetic impairments. These changes add to the perceived age of a person and adversely affect body image and social functioning.
The processes underlying the aging of the lower eyelid and face are multifactorial and occur simultaneously. These include:
The lower eyelid and cheek appear to be one single unit in youth. With advancing age, the lower eyelid and cheek gradually become distinct and separate parts of the face delineated by bulges and grooves. The constellation of changes to the lower eyelid and midface brings about the most significant difference to an individual’s perceived age.
Lower eyelid rejuvenation is one of Dr Matthew Yeo’s key clinical interests. He is experienced in this area and delivers lectures in the Asia Pacific region on this topic. Picasso Plastic Surgery has an en suite operating facility that assures you maximal privacy and convenience, and keeps facility and equipment costs contained.
The optimal treatment for eye bags and tear trough deformities depend on their severity and the individual’s treatment goals. Attaining good results requires appropriate technique selection and precise execution by an experienced practitioner. Successful outcomes help individuals restore self-confidence and improve social functioning. The treatment options include filler injection, structural fat grafting, microfocused ultrasound, and eye bag surgery (lower blepharoplasty).
Tear troughs are reliably treated with filler injection and attain a high degree of satisfaction in most cases. Filler injection is a popular ambulatory procedure and is often used for restoring soft tissue volume in areas where age-related fat loss has occurred. There is a wide range of fillers with various different characteristics to suit each individual’s unique anatomy and help them meet their aesthetic goals. A detailed explanation of filler injection may be found here.
Individuals with shallow tear trough deformities, small eye bags and minimal skin laxity are good candidates for tear trough deformity correction with filler. Filler injection is a camouflage procedure that reduces the prominence of the eye bags by effacing the tear trough depression, but the eye bags themselves are not removed. Repeat treatments are necessary for maintenance of the result.
We frequently see or hear of people who look unnatural following aesthetic treatments. This is often due to practitioners who attempt to reverse all the signs of aging by using revolumization techniques alone, resulting in a puffy periorbital appearance or an over-filled “pillow face”. Filler injection does not reverse skin and muscle laxity or ligament lengthening. Choice of the incorrect filler type will also result in irregularities that become more prominent when an individual animates the face. The eye bags and tear troughs are adjacent to each other and incorrect filler administration results in an increase in size of the eye bag. Attaining bespoke and attractive results that retain an individual’s expressivity is frequently possible and requires accurate assessment, appropriate product choice, precise administration by an experienced practitioner.
The anatomy of the tear trough region is complex and contains important nerves and blood vessels that should be avoided when delivering filler injection. The skin overlying the tear trough is also thin and is prone to irregularities following filler injection if it is not performed correctly. Injection of the tear trough is a fine art. We use a proprietary technique of filler injection in the tear trough region that will deliver beautiful and elegant outcomes.
The effects of filler injection may be observed almost immediately following the procedure. Most of the filler will be resorbed in 6 to 9 months and repeat treatment is required to maintain the result.
Individuals are advised to avoid vigorous massage or rubbing of the treatment area for 2 hours following filler injection to minimize the potential for bruising. Individuals may resume their usual activities immediately following the procedure.
Structural fat grafting involves harvesting fat from areas of excess, purifying it, then grafting it in volume-deficient areas. A high proportional survival of fat cells may be attained with the use of specialized fat grafting cannulas available at Picasso Plastic Surgery. Structural fat grafting delivers elegant and long-lasting results. Structural fat grafting is a camouflage procedure that reduces the prominence of the eye bags by effacing the tear trough depression, but the eye bags themselves are not removed. Structural fat grafting is a minimally-invasive ambulatory surgical procedure performed under local anesthesia, with optional intravenous sedation if requested.
Individuals with any degree of tear trough deformity, seeking long-term improvement and short recovery period are good candidates. Structural fat grafting may be simultaneously performed in other areas of hollowing and volume loss such as the face, neck and hands, and deliver benefit in multiple sites in one single procedure. Individuals with severe hollowing will benefit from significant cost saving in the long term as compared with recurrent treatment using large volume filler injection. Individuals with the other accompanying signs of lower eyelid aging, including significant eye bags, lower eyelid skin laxity, and lower eyelid malposition may obtain better benefit from lower blepharoplasty surgery.
Common sites for fat harvest include the inner thighs, hips, flanks and lower abdomen. Small incisions are made near the areas of intended liposuction, and local anesthetic is infused for optimal intra- and post- operative pain relief. The fat is broken up and aspirated under negative pressure. It is purified before being grafted into the tear trough deformity using purpose-made fat grafting cannulas for optimal survival. Grafting is performed through 1-mm incisions that are well-concealed.
Many individuals are able to return to work on the day after the surgery. Depending on the extent of fat harvesting performed, most of the swelling and bruising will resolve by the 7th postoperative day. Stitch removal is usually performed on the 5th postoperative day.
Individuals are advised to avoid pressure on the grafted areas to optimize graft survival. Face washing is possible on the 2nd postoperative day. Postoperative swelling is reduced by remaining upright during the daytime and by elevating the head of the bed with extra pillows when asleep at night. Bruising may be minimized by avoidance of strenuous activity for the first 2 weeks. Individuals may return to their original exercise and gym routines after 2 weeks.
After structural fat grafting is performed, blood vessels grow into the fat grafted area (neovascularization). The degree of neovascularization determines the proportion of fat graft survival. In general, 60 to 80% of the grafted fat will survive and the appearance at 2 months postoperatively is normally representative of the long-term result. The body absorbs the non-surviving fat during the first two months. The fat grafts that survive persist for many years.
There is an increasing demand for non-surgical facial rejuvenation and microfocused ultrasound (MFU) has emerged as one of the effective and safe technologies for tightening the skin and subcutaneous tissues. This is a popularly requested procedure for rejuvenation. In appropriate individuals, MFU cheek lift elevates the cheek tissue and blunts the transition from the tear trough to the cheek. The MFU cheek lift is an ambulatory procedure performed under local anaesthesia nerve block and intravenous sedation for optimal effect.
Individuals with early cheek descent, good skin quality and minimal laxity are good candidates for MFU cheek lift for correction of the tear trough deformity. These are usually individuals in their thirties or early forties.
MFU uses microfocused sound waves that generate vibration and heat at specific points in tissue. This creates discrete areas of controlled thermal injury zones at predetermined depths, leaving the surrounding tissue undamaged. At these areas of thermal injury, the collagen contracts and is eventually absorbed by the body, and new collagen production stimulated, resulting in skin renewal. A detailed explanation of MFU treatment may be found here.
Administering effective and safe treatments are the cornerstones of our care delivery philosophy at Picasso Plastic Surgery. Effective MFU treatment requires repeated delivery of high doses of energy, which may sometimes render the treatment slightly painful. Utilizing our detailed knowledge of anatomy, MFU treatments are performed under regional nerve blocks with local anesthesia for maximal comfort, with optional intravenous sedation if individuals request for it. This allows individuals to tolerate higher doses of treatment to obtain a visible clinical effect in a safe and comfortable manner. Individuals who do not receive optimal analgesia often receive suboptimal treatment doses and may attain less satisfactory results. Our clinic uses the Ulthera (Ultherapy) system, which is the most extensively studied MFU device and was approved by the United States Food and Drug Administration in 2009 for non-surgical skin tightening.
The effects of MFU may be observed almost immediately following the procedure. The treated areas continue to undergo collagen production, subcutaneous remodelling and tightening up to 3 months post-procedure. In most cases, the effects are sustained for 6 to 9 months, and repeat treatment is required to maintain the result.
There are no wounds and no special post-procedural care is required. Individuals may resume their usual activities following the procedure.
Transconjunctival lower blepharoplasty effectively reduces eye bags and tear trough deformities and treats many of the signs of lower eyelid aging. The scar is concealed on the inner side of the lower eyelid. It produces elegant, natural-looking and sustained results and is a popular aesthetic procedure. It is performed as an ambulatory procedure under local anesthesia, with optional intravenous sedation if requested.
Individuals with mild-to-moderate eye bags or tear trough deformities with minimal loose skin are the good candidates for transconjunctival lower blepharoplasty. Those who have obtained suboptimal correction with non-surgical methods may also benefit from transconjunctival lower blepharoplasty. Individuals with lower eyelid skin laxity, lower eyelid descent, and large eye bags or deep tear trough deformities may obtain better benefit from lower blepharoplasty surgery.
Eye bags may either be removed or they may be advanced downwards to fill up the tear trough deformity. The technique chosen is tailored to the severity of the deformity and the individual anatomical characteristics. The result is elimination of the eye bag bulge and improvement of the tear trough hollow. This surgery is performed using an incision that is concealed on the inner side of the lower eyelid and has a short recovery period.
Individuals are advised to stop herbal supplements and traditional medicine and start special medications 7 days prior to surgery to minimize bruising and swelling.
Local anesthesia is infused to the lower eyelid and cheek for optimal intra- and post- operative analgesia and comfort. The incision is made on the inner surface of the lower eyelid. The lower eyelid structures are delicate and careful dissection is performed to expose the eye bag fat. Eye bag surgery is a fine art and strikes a balance between removal of an optimal amount of eye bag fat whilst preserving sufficient fat to prevent a hollowed-out look. In some cases, the eye bag may be advanced downwards to fill up the tear trough depression for synergistic effect. The wound is closed up using self-dissolving sutures.
Mild bruising and swelling is expected, which will mostly resolve by the 7th postoperative day. Stitch removal is not required as the stitches used are self-dissolving. Most individuals are able to return to work after the first week.
Postoperative swelling is reduced by remaining upright during the daytime and by elevating the head of the bed with extra pillows when asleep at night. An optional electromagnetic field device may be used for the first 5 days to accelerate wound healing and reduce swelling. Strenuous activity should be avoided for the first two weeks to minimize bruising. Contact lens use is best avoided during the recovery period. are able to return to work after the first week.
Transcutaneous eye bag excision is the most comprehensive method of rejuvenating the lower eyelid and upper cheek region. It addresses the signs of lower eyelid and upper cheek aging and produces exquisite, bespoke and long-lasting results. The scar is well-concealed at the lower margin of the eyelashes. Successful outcomes help individuals regain self-confidence and improve social functioning. Transcutaneous lower blepharoplasty is performed as an ambulatory procedure under local anesthesia, with optional intravenous sedation if requested.
Individuals with any degree of eye bag or tear trough deformities and seeking long-term improvement may undergo transcutaneous eye bag excision. Individuals who benefit most are those with significant eye bags, deep tear troughs, loose lower eyelid skin, and lower eyelid and cheek descent. Individuals who have obtained suboptimal correction with non-surgical methods may also benefit from transcutaneous lower blepharoplasty.
Transcutaneous eye bag surgery is the most effective and comprehensive method of elimination of the bulge resulting from the eye bag and filling up the hollow lying immediately beneath caused by the tear trough deformity. The eyelid may be tightened to correct age-related drooping, and a gentle upward tilt seen in youth may be recreated. Excess skin is trimmed off to restore smooth, crisp and wrinkle-free skin in the lower eyelid. In selected cases, a mini-cheek lift may be performed through this incision as well. The incision is made below the lower margin of the eyelashes of the lower eyelid, heals well and is well-concealed.
Individuals are advised to stop herbal supplements and traditional medicine and start special medications 7 days prior to surgery to minimize bruising and swelling. Smoking needs to be stopped for at least 2 to 4 weeks prior to surgery to minimize the occurrence of complications.
Local anesthetic is infused into the wound for optimal intra- and post- operative analgesia. The incision is performed just below the lower eyelid eyelashes and the skin and muscle lifted off. The lower eyelid structures are fine and delicate, and careful dissection is performed to expose the eye bag fat. Eye bag surgery is a fine art and strikes a balance between removal of an optimal amount of eye bag fat whilst preserving sufficient fat to prevent a hollowed-out look. In some cases, the eye bag may be advanced downwards to fill up the tear trough depression for synergistic effect. The tear trough is more comprehensively corrected with the transcutaneous technique as compared with the transconjunctival (“scarless”) technique. The lower eyelid is then tightened and anchored upwards onto the eye socket to recreate a beautiful, gentle upward tilt. The excess skin and muscle is excised and wounds closed meticulously to deliver the best possible postoperative scar and aesthetic outcome.
Mild swelling is expected after the surgery. Stitch removal is usually performed on the 5th postoperative day. Individuals undergoing transcutaneous lower blepharoplasty may expect most of the swelling to resolve by the 10th postoperative day. Most individuals are able to return to work after the 10th postoperative day.
Postoperative swelling is reduced by remaining upright during the daytime and by elevating the head of the bed with extra pillows when asleep at night. An optional electromagnetic field device may be used for the first 5 days to accelerate wound healing and reduce swelling. Strenuous activity should be avoided for the first two weeks to minimize bruising. Contact lens use is best avoided during the recovery period. Meticulous scar care is important in the immediate postoperative period to ensure optimal scarring and to achieve ideal postoperative results.