While fat injections or dermal fillers can serve as an alternative to lower eyelid surgery, not all patients with under eye-bags can benefit from them.
The appearance of under eye-bag or “shadowing” is caused by different or even a combination of factors. Excess skin, herniated deep fat, loss or “shrinkage” of superficial fat (beneath the skin), or a combination of these variables may contribute to this aesthetic issue.
Before and after photos of a patient who have had fat transfer in her lower eyelid.
Basically, a “true” or standard lower eyelid surgery uses incision positioned very close to the lash line so the eyelashes can conceal the resulting scar. Referred to as an external incision technique, this allows the surgeon to remove excess skin and fat and possibly reshape the muscle.
However, not everyone with under eye-bags has excess skin. If the extra fat primarily causes this appearance instead, dermal filler injection (e.g., Restylane and Juvederm) can conceal the unsightly bulge.
The main purpose of dermal filler (as an alternative to lower eyelid surgery) is to make the lower lid bulge the same level as the upper cheek. This is a rather straightforward approach and does entail no or very little downtime; hence, it appeals in patients with busy schedule and cannot afford surgery and its ensuing “social recovery.”
But there is one caveat when dermal fillers are used to conceal the under eye-bag caused by excess fat: Touch-ups are generally needed at 6-12 months interval.
Meanwhile, fat injection or fat grafting is a method that provides longer-lasting effects than dermal fillers, with studies suggesting that its results last an average of 12-15 years. The procedure starts off with the collection of superficial fat (beneath the skin) usually in the tummy; only a few teaspoons are needed since the lower eyelid is just a small area.
The collected fat volume is then put in tubes and processed through centrifugation; the idea is to discard the oil, red blood cells, and other biomaterials except the fat cells. Afterwards, the purest form of fat is injected to conceal the bags.
It is important to note that fat injection and dermal fillers are basically volumizers (they add volume) and so they can also address the deep tear trough and the abrupt lid-cheek junction that come with aging.
It is not uncommon to combine volumizers with excision-based lower eyelid surgery to achieve the best results possible. This is particularly true for patients with excess skin, herniated deep fat, and abrupt lid-cheek transition, as suggested by leading Orange County plastic surgery expert Dr. Tarick Smiley.
Due to the laxity of skin and other supportive structures, the deep fat along the lower lid becomes prominent (i.e., it bulges out) with aging. In contrast, the superficial fat “shrinks” and thus gives the appearance of deep tear trough or abrupt transition between the lid and cheek.
To address the aforementioned problems, a small linear incision is made within the lower lid that allows the surgeon to remove the excess skin and reduce the deep fat pad. For additional fine-tuning, fat injection is used to create a smoother lid-cheek junction.
Makeup after eyelid surgery can be used to conceal the swelling and bruising, although most patients are advised to wait at least 7-10 days postop before starting the use of cosmetics.
Patients who wear eye makeup too soon after surgery run the risk of infection and permanent “tattooing” particularly when the cosmetics get into the incisions. Just to be on the safe side, leading Beverly Hills plastic surgeon Dr. Tarick Smiley says prudent individuals should always ask for their doctor’s consent.
Photo Credit: marin at FreeDigitalPhotos.net
Once the surgeon gives his permission to use makeup after eyelid surgery, the use of brand new tubs of concealers, creams, foundations, applicators, and sponges is ideal to further reduce the risk of irritation and infection.
In the first few weeks following eyelid surgery, the skin is usually delicate and so the most ideal eye makeup is mineral based, which is known for being gentle but nonetheless effective. Water-based cosmetics are also okay.
Oil-based cosmetics, meanwhile, are ideally avoided in the mean time because they could irritate the still sensitive skin and are more challenging to take off as they require a special remover, which may also cause irritation.
Lighter skin-tone concealers are a great way to hide bruising, which may appear asymmetric (i.e., one side has more prominent “black eye” than the other). However, regular foundation is usually enough to conceal light discoloration, although a thin colored cream may need to be applied to the “adjacent” area to make a smoother, more natural transition of color.
Once all the swelling and bruising are gone, applying eye makeup becomes a breeze.
Dr. Smiley, who regularly performs eyelid surgeries and posts them on his Snapchat to spread patient safety awareness, says the procedure not just addresses the excess skin, but also the glut of fat that contributes to the tired appearance, and the “excessive” fullness that may affect the lower or upper eyelid, or even both.
Some patients even require a simultaneous fat injection to correct the deep tear trough or to create a smooth, natural transition between the lower lid and cheek.
In Dr. Smiley’s previous Snapchat video, one patient has mentioned that after surgery makeup application becomes much easier, or sometimes she “skips it altogether” because of the impressive results.
Before surgery, the patient had hooded upper lids due to excess skin and fat that her eye makeup easily smeared. Also, her concealer or cream settled into the fine lines below her eyes, further contributing to her aged appearance.
A lower eyelid surgery for puffy eyes is a highly individualized procedure, which entails meticulous physical examination to determine the factors causing the problem. Excess deeper fat, loose skin, abrupt transition between the lower lid and cheek, cheek descent, or a combination of these might be the culprit.
It is important to note that factors such as lack of sleep, allergies, and fluid retention and other causes of intermittent swelling must be ruled out prior to surgery.
Simply put, eyelid surgery for puffy eyes only applies when there is a true excess skin and/or fat around the lower eyelid.
California Surgical Institute medical director Dr. Tarick Smiley says that some patients have lower lid puffiness caused by deep fat, with no or very little loose skin. For these individuals, a transconjunctival approach in which a small incision is made inside the lower lid, thus the risk of visible scar is almost zero.
The incision allows the surgeon to remove the deeper fat, which becomes herniated due to aging (i.e., tissue laxity/weakness). But for a more rejuvenating and natural result, Dr. Smiley says he almost always complements it with fat injection to create a smooth transition between the lower lid and upper cheek.
Unlike the deeper fat along the lower lid that becomes more prominent with aging, the superficial fat “shrinks,” a condition referred to as soft tissue atrophy, thus resulting in an abrupt transition between the lid and cheek. Further contributing to the problem is the cheek fat pad descent.
Dr. Smiley says fat injection or transfer involves collecting just a few teaspoons of unwanted fats in the tummy area, which are then processed before injected around the lower lid.
Most patients will only need small amounts of purified fat (less than 1 ½ cc) to correct the abrupt lid-cheek transition and eliminate the appearance of deep tear trough.
Meanwhile, some patients have puffy eyes that are not just caused by excess fat, but also by loose skin. In this scenario, a small linear incision is made very close to the lower lash margin to remove some excess skin and thus achieve a tighter, more youthful appearance.
The resulting scar from the external incision technique is expected to fade into the background, particularly when it is hidden by the patient’s lower eyelashes.
Lower eyelid surgery with fat transfer is primarily used to create a smooth, youthful transition between the lid and the cheek. While it can work as a stand-alone procedure, this approach will only suit patients with no or very little excess skin.
Leading Beverly Hills plastic surgeon Dr. Tarick Smiley has recently posted a series of Snapchat videos to demonstrate how lower eyelid surgery with fat transfer is performed.
In the video, the patient had a deep tear trough and a crepe-like skin adjacent to the lower eyelid. To correct these aesthetic issues, Dr. Smiley collected fats from the tummy area through gentle liposuction.
The celebrity plastic surgeon injected about 1 ½ cc of “purified, golden,” fat—i.e., all the impurities have already been removed with the use of centrifuge. This meticulous process ensures that most of the fat grafts can persist long term, said Dr. Smiley.
Dr. Smiley explained that the use of centrifuge allows surgeons to separate and remove biomaterials based on weight. The oil, which is the lightest, floats above the processed fluids and is discarded.
The red blood cells, meanwhile, are the densest and so they settle to the bottom after centrifugation. These are also discarded, leaving the “middle” part, which consists of fat and stem cells, to be later injected into the area that needs to be plumped up or rejuvenated.
Dr. Smiley said fat injections work like a “carpet” to create a smooth and nice transition between the patient’s lower lid and upper cheek.
Meanwhile, the celebrity plastic surgeon said that some patients who require lower eyelid surgery with fat transfer will need a simultaneous removal of their deep fat pad, which is responsible for the unsightly bulges or the appearance of under eye-bags.
“We remove or at least reduce the deeper fat pad right beneath the lower lid. Then, to create a smooth lid-cheek junction we inject superficial fat into the area,” he explained.
In the past, many surgeons relied on over-aggressive removal of the deep fat pad, which typically resulted in the gaunt or “done” look. But with simultaneous fat transfer, Dr. Smiley said this aesthetic-related complication can be avoided.
Blepharoplasty surgery, or more commonly referred to as eyelid lift, is believed to be a rather straightforward procedure—just removing the loose skin and excess fat is enough to address the aging upper or lower eyelid. However, this is far from the truth, says leading Beverly Hills plastic surgeon Dr. Tarick Smiley.
The list below shows the most common blepharoplasty surgery tips and traps, as explained by Dr. Smiley.
Before-and-After Photos of a Patient with Impressive Results from Blepharoplasty
* Placement of the scar in upper eyelid. In an attempt to raise the corner of the eyelid, some inexperienced surgeons commit a grave mistake of carrying the incision too high and lateral, which of course results in visible scar.
Dr. Smiley believes that the upper eyelid scar should follow the natural curve of the lid fold and then stop there. If the scar lies precisely at the natural skin crease, patient satisfaction tends to be high.
* Conservative fat removal. In the past, the fat pads were removed entirely in an attempt to eliminate the under eye bags or “heavy” upper lid. However, this aggressive maneuver almost always results in disaster—the eyes look skeletonized. To avoid this problem, Dr. Smiley will always leave a little fat; sometimes, he even perform fat injection particularly if the patient has deep tear trough or abrupt transition between the lower lid and cheek.
* Conservative muscle resection. When done judiciously during an upper eyelid surgery, this technique can contribute to a more youthful, natural appearance.
However, some doctors have tried to replace muscle resection with “multiple pinpoint” cauterization technique (“burning off” the tissue) in an attempt to create a lifting effect. But this method has a serious caveat—it may create a thick band of scar tissue in the muscle that can pull the edge of the eyelid, leading to unnatural contour. For this reason, muscle resection remains the most predictable and safest approach.
* Meticulous physical exam. Dr. Smiley says that great surgeons put a high value on precise anatomical evaluation in which the “rebound” of the lower/upper lid skin, the length of the lid’s border, and the amount of loose skin and fat are scrutinized.
Dr. Smiley says that blepharoplasty is a highly meticulous procedure that it is often referred to as surgery by millimeters.
Some patients may even require vision tests (and other similar modalities performed by ophthalmologists). This is particularly true when health insurance requires proof that upper blepharoplasty is going to be used to improve a person’s peripheral view affected by loose skin or eyelid ptosis (drooping).
Modern Asian eyelid surgery is focused on achieving natural Asian appearance (about half of the population inherently have visible upper lid crease), as opposed to Caucasian imitation. The goal is to deliver results that look ethnically consistent and so the eye shape and even the entire face must always be taken into consideration.
The height of the eyelid crease is one of the key elements that will dictate how natural or “done” the results appear. All efforts are made to prevent too much height (i.e., more than 7 mm from the upper eyelash) because of the westernizing, incongruous effects. The consensus is to create just 2-5 mm height to achieve ethnically consistent results.
Photo Credit: vudhikrai at FreeDigitalPhotos.net
While the underlying anatomies must always be respected to achieve natural results and reduce risk of complications particularly relating to asymmetry and eyelid ptosis (drooping), it remains important to establish the patient’s cosmetic goals to achieve satisfying outcome. For this reason, the right candidate for Asian eyelid surgery should be able to describe her aesthetic expectations in details.
For instance, some patients want the medially tapered crease, i.e., the fold begins very close to the inner eye and gradually curves; the “tail end” of the crease is ideally positioned marginally higher than the “beginning point” of the fold.
Others desire for a more parallel eye crease, i.e., the medial crease starts parallel to the eye.
Another critical issue is the shape of the eye crease. It is important to note that Asian eyelid surgery was first performed on a patient with only one natural eyelid; hence, the Japanese surgeon made sure that he created a new eye crease whose shape and height was almost the same as the other side.
The consensus is to avoid a semilunar eyelid (when viewed from the front) because of the westernizing effects, which of course look ethnically inconsistent. But as with any rule, it may not apply to everyone seeking Asian eyelid surgery. For instance, patients of mixed race or Southeast Asians may tolerate this deep inverted U look without the risk of looking “done.”
Another critical guideline to create natural- Asian eyelid surgery results is to avoid high fold, which generally favors patients with large eyes and strong levator muscle (which elevates the eyelid). Too much height is known to increase the risk of ptosis or eyelid drooping in Asian patients, particularly those with weak eye muscles, according to the California Surgical Institute website.