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.
Eyelid surgery after care may differ from surgeon to surgeon, thus a prudent patient will only stick to her doctor’s specific advice. The main idea of postop care is to keep swelling and bruising to a minimum, ultimately resulting in shorter social downtime.
Leading Los Angeles plastic surgeon Dr. Tarick Smiley explains his eyelid surgery after care tips.
* Pain Control. Most patients will only experience minimal discomfort that can be easily managed through acetaminophen such as Tylenol for a few days. Others do not even require medications.
* Head elevation for a few days. The goal is to keep swelling to a minimum and thus promote shorter social recovery, which typically occurs after 1-2 weeks.
* Cold therapy. In the first 48 hours cold therapy can control the amount of swelling; however, it should not be applied for more than 15-20 minutes at a time to avoid cold burns and blisters.
* Avoid or at least limit the consumption of alcohol and salty foods during the initial healing stage (2-3 weeks). They can cause fluid retention and thus aggravate the amount of swelling.
* Never rush one’s recovery. A good rule of thumb is to avoid rigorous activities that can result in increased heart rate and blood pressure for a minimum of three weeks. Nonetheless, bed rest is not good because it can lead to lethargy and may even aggravate swelling.
* Avoid activities that can dry the eyes. In the first week postop, activities that may dry up the eyes—e.g., using computer, watching TV, reading, and wearing contacts—must be avoided.
* Wear large dark sunglasses. The idea is to protect the sensitive eyes from harsh elements such as the wind, sun, and small particles.
* Expect 1-2 weeks of social downtime. Some patients may return work a week after their surgery, although they will most likely need a camouflage make-up to hide the outward signs of their surgery. At 2-3 weeks of their recovery, meanwhile, they can go outside without wearing eye make-up.
* Avoid drugs and supplements with blood thinning properties. These are best avoided 2-3 weeks before surgery and about a week afterward to prevent bleeding and persistent swelling and bruising.
A lower eyelid fat transfer is a powerful tool in facial rejuvenation procedure that can provide natural-looking results in the hands of a skilled surgeon, as suggested by leading Beverly Hills plastic surgeon Dr. Tarick Smiley.
While dermal fillers can also correct the hollowed lower lid or deep tear trough, which is the transition between the thin-skinned eyelid and the thick-skinned cheek, fat transfer is perceived to be superior particularly if the goal is to achieve near permanent results.
The fat graft that persists about a year postop is expected to last a lifetime (or at least 10 years). Most surgeons aim to achieve a survival rate of 50-70 percent; it is important to note that some of the grafts will “perish” in the first few months of injection and so it might be necessary to slightly over-correct.
Dermal fillers, meanwhile, typically require 2-3 touch-ups every year because they are made of biodegradable material that the surrounding tissue gradually absorbs.
Dr. Smiley has recently performed lower eyelid fat transfer in a female patient with deep tear trough caused by soft tissue atrophy or “shrinkage” caused by the aging process. The procedure entails proper handling and injection of fat to achieve smooth, near permanent results.
The patient described has been considered as a good candidate for lower eyelid fat transfer “as a stand-alone” procedure (without simultaneous skin excision) because she only had very mild tissue laxity.
However, some patients can benefit more if their fat transfer is combined with the “standard” eyelid surgery (blepharoplasty) particularly if there is noticeable loose skin; this is achieved by placing the incisions at the natural upper lid crease or very close to the lower lash margin so the resulting scars are inconspicuous.
The celebrity plastic surgeon says one of the challenges or caveats of lower eyelid fat transfer is the risk of lumpiness because it deals with an area whose skin is markedly thin. To achieve smooth result, he highlights the importance of meticulous injection in which very small amounts of grafts (less than 0.1 cc) are introduced, as opposed to dumping them all at once.
The aforementioned technique, which is called structural fat grafting, also ensures spaces between each graft and thus allows blood vessels ingrowth needed for its long-term survival. Without this vascularization process, the body will eventually absorb the fat.