More than Meets the Eye

Created on 15th January 2012

Consultant plastic surgeon Mr James McDiarmid FRCS (Plast), explains the potential of periorbital surgery in transforming our appearance

As our faces age changes occur in the periorbital region at different rates depending on our ethnic background and lifestyle. Smoking in particular can accelerate ageing changes in the soft tissues of the periorbital region.

Generally what happens as we age is that the brow descends and we develop lateral hooding of the upper eyelid.  In addition to this the upper eyelid skin can frequently become stretched and excessive (dermatochalasis). In the lower eyelid the orbital fat can start to be more visible as the membrane which holds it in place becomes loose and baggy and the lower lid can lose its elastic recoil. The lower eyelid skin can also become stretched and excessive.

Surgical efforts were originally aimed solely at removing this excess skin from the eyelids as the skin excess is the easiest part to correct but the genuine causes of the problem are far more technically challenging to treat. However, excessive skin removal can frequently result in scleral show (being able to see the whites of the eyes) and more severe forms of lower eyelid malposition.

The 1970s and 1980s saw orbital fat excision coming into vogue as the answer to 'eyebags', but this removal of fat from underneath the eye often led to long-term hollowness and loss of volume. The next step was the development of fat repositioning techniques (fat redraping blepharoplasty) which preserved fat and connected it to fat pads in the mid-face. These procedures required extra reinforcement of the lower eyelid, so canthopexy (retightening of the lower lid) techniques also evolved to support the lower eyelid.

No discussion of canthopexy would be complete without mentioning my close friend and colleague Martin Kelly, the plastic surgeon who I believe brought canthopexy into the twentyfirst century and who was fast becoming recognised as a world leader in this field prior to his untimely death last year.

Any discussion on the subject of eyelid aesthetics would be incomplete if it did not touch on aesthetics of the brow and mid-face (cheek) areas. Vital aesthetic relationships exist between these regions and the aim of surgical intervention should be the restoration of aesthetic harmony. For this reason the surgery must be tailored to suit the precise requirements of the individual patient and the procedure choice can range from browlift, blepharoplasty, canthopexy (lid tightening), mid-face lift and insertion of cheek implants.

The holy grail of genuine periorbital rejuvenation in many patients presenting to my practice is achievable only through fat redraping or repositioning. This approach does not risk hollowing as tissue is almost never removed and also there is a very low risk of producing lower eyelid malposition. Additionally it offers the only way of permanently correcting the 'tear trough', a hitherto unfillable hollow between the cheek and the lower eyelid.

In case 1 a transconjunctival laser blepharoplasty has been performed. This patient had significant fat pockets which have benefited from reduction and is the exception to the rule of fat preservation in lower eyelid blepharoplasty. The CO2 laser has reduced the fat pads in the lower eyelid as well as tightening up the skin of the upper and lower eyelids with no external scar on the lower lid and a far more rapid recovery than other types of blepharoplasty. This technique is applicable  to many younger patients with significant fat excess and minimal skin excess and produces subtle but definite results.

In case 2 there is significant skin excess preoperatively as well as a contour break between lower eyelid and cheek. This patient had 4-lid blepharoplasty with canthopexy. Performing a simultaneous canthopexy has enabled significant retightening of the lower eyelid to be performed.

In case 3 as well as having significant skin excess this patient had prominent fat pockets preoperatively. A 4-lid fat redraping blepharoplasty was performed along with canthopexy to dramatically smooth out the underlying soft tissue contour. The after image shows the situation when the orbital fat has been redraped and connected to the mid-facial SOOF fat (SOOF means sub-orbicularisoculi- fat). The surgical access required to join these fat pockets together creates a temporary loss of tone in the lower eyelid and a canthopexy is absolutely essential to retighten the lower lid.

The lady shown in case 4 initially presented requesting a lower facelift. At consultation we discussed how performing a lower facelift would have had only a minimal effect since the majority of the changes which were making her appear tired were in the upper third of her face most notably her upper eyelid and eyebrow. She therefore underwent endoscopic browlift, 4-lid blepharoplasty and fat transfer to her midface and lips. This combination of surgeries has removed the 'tired' look and investing in regular Botox treatment has maintained the beneficial effects of surgery.

The oriental lady shown in case 5 desired westernisation as well as rejuvenation of her eyelids. The oriental eyelid differs in several ways from the Western one. She underwent 4-lid fat redraping blepharoplasty (with formation of a symmetrical upper eyelid creases) and canthopexy. In certain patients the effects of mid-face lifting are far greater in conjunction with fat redraping eye surgery and can really be breathtaking.

So what is the mid face? The mid-face is the area of the cheek immediately below the lower eyelid, to the side of the nose and above the nasolabial fold. The soft tissues here are partly fatty and partly fibromuscular. When the soft tissues have drooped downwards exposing the 'tear trough' or gap between prominent under eye fat pads and drooping mid-facial soft tissues a mid-face lift is absolutely essential for effective rejuvenation.

Simply correcting orbital fat prominence will not correct a tear trough and the mid-face lift provides support to the lower eyelid by pushing the mid-facial soft tissues upwards and filling out the 'tear trough' from below. The bony foundation that provides projection for the mid-facial tissues is the maxilla, the upper jawbone. Sometimes the maxilla may be retrusive or under developed compounding the problem. This can make the lower eyelid fat pockets look particularly prominent with an increased overhang (as in case 7). In these cases it is not the lower eyelid fat pockets that are especially prominent but rather that the cheek tissues immediately below them are under projecting. If lack of bony projection is the cause of the problem then the answer is a cheek implant in addition to mid-face lifting and fat redraping blepharoplasty.

Case 6 shows a lady with significant mid-facial drooping preoperatively who underwent high lamellar SMAS facelift as well as fat redraping blepharoplasty with canthopexy (and hairline lowering foreheadplasty). Unlike almost every other kind of facelift, high lamellar SMAS facelift incorporates a mid-face lift. In case 6 elevation of this patient's mid-face has allowed the midface fat to be joined to the orbital fat completely effacing the 'tear trough' and producing a dramatic improvement in the contour here.

Case 7 shows a male patient desiring periorbital rejuvenation but with a very challenging preoperative anatomy. He had a lack of mid-facial projection (known as a negative vector cheek) as well as significant prominence of his lower eyelid fat pockets and drooping of his mid-facial soft tissues. He  underwent 4-lid fat redraping  blepharoplasty with canthopexy as well as midface lift/ insertion of large cheek implants (andrhinoplasty). This kind of dramatic improvement in the lower eyelid in patients with a negative vector cheek is unachievable using conventional blepharoplasty. The additional lower eyelid support afforded by elevation and augmentation of the mid-facial soft tissues has made the surgery more effective and far lower risk.

As is clear from the different case studies I have described above, each patient has very different needs and often will need a combination of different surgical procedures to achieve the desired outcome. The success of surgery depends on a highly detailed knowledge of the underlying anatomy as well as experience of the entire repertoire of rejuvenative procedures mentioned above so that an individualised treatment plan can be tailored for each patient.