Cheeks, Midface and Lower Eyelids

Whenever we plan facial enhancement or rejuvenation, it is important to recognize that the main goal of any procedure is an improved but balanced and pleasing look. Therefore, it is short-sighted to regard certain facial regions as isolated structures that need to be improved. For instance, the upper lids cannot be appropriately addressed without thoroughly assessing the eyebrows. Any observing and experienced facial plastic surgeon will assess the lower eye lids in conjunction with the cheek and midface region. And arguably so, no other region deserves a thorough, thoughtful and artistic examination than the lower lids and cheek complex. Whenever a lower blepharoplasty is performed without understanding the specific condition of the lid-cheek region, the outcome will be suboptimal.

Youthful Lower Lid and Cheek Complex

The youthful face is characterized by smooth and convex facial lines. Alternating “mounts and valleys” are signs of aging, volume loss or even poor health. The young face shows a soft arched transition line between lower lid margin and cheek. As aging and family traits advance, puffiness of the lower lids develops followed by deep troughs just below (“dark circles”). When then the cheek mount descends and cheek volume is lost, the classic “double-convexity” develops: two mounts (eyelid puff and cheek) with the “tear trough” in between. When we look at a person, we rarely zoom into his or her eyelid bags but the face as a whole resonates in our subconscious first. These facial features make us think if a person is tired, drawn, sad or even sick on one hand, or pleasant, energetic, fit and approachable on the other. Removing just the eyelid bags is a keyhole approach to the more complex midface region. The final goal of achieving a more youthful look requires more than just an eyelid lift.

The Tear-Trough Deformity (a.k.a. Naso-Jugal Crease)

When modern lower eyelid approaches and midface rejuvenations are discussed, the tear-troughs deserve special attention. As mentioned earlier, if just fat is removed from the lower lids, the eyes may look less puffy but not necessary much better. For the best improvement that lasts, the tear trough is softened. This is an area difficult to approach illustrated by the various techniques offered. Unfortunately, extremely few surgeons are experienced in all of these surgical and non-surgical approaches:

Implants: Tear trough implants can be placed during an eyelid lift through the existing incisions. Many plastic surgeons used them, some abandoned the use of them, some rediscover them and others have never tried them or even thought about them. This illustrates that they may be difficult to place (at least in inexperienced hands) and that they continue to hold some value. One advantage is that implants can correct significant deformities (tear troughs implants are available in various sizes and dimensions). In addition, they will provide benefits for the years and decades to come. Whenever implants are placed, one is concerned with infections (which may require removal of the implants). In addition, one is concerned that these implants could shift or move. Most surgeons believe that once an implant is in the right position, it will stay there. If it is not right, things will look worse with time rather than better.

Midface Lift/ SOOF Lift: This procedure is designed to elevate droopy cheek tissues. Distinct fat compartments of the cheek including the SOOF (sub-orbicularis oculi fat) can be elevated. One of the reasons that tear trough deformities get deeper with time is that midface tissues descend over the years. When the cheek is lifted the tear troughs are softened. Midface lifts (cheek lift) are performed either through a lower eyelid incision or through an incision within the temple hair. In addition, an incision is commonly used to completely free up the cheek tissues for effective advancement. Many surgeons combine it with a browlift. The improvement from a midface lift only is commonly subtle. Advantages include that what drooped will be lifted and restored. On the downside, that the recovery time can be relatively long (3 weeks or more) and that facial nerve branches are at risk. Experienced surgeons will understand how to minimize the risks, though.

Repositioning of Eyelid Fat: This fat-sparing eyelid lift procedure is considered an advanced blepharoplasty approach. Instead of just removing fat that is responsible for puffy under-eyes, the fat is placed into the tear-trough to soften that depression. Because the fat is left attached to its blood supply, concerns for spontaneous absorption are small and most of the fat will survive for a predictable benefit. Advantages include the use of tissues that are available during an eyelid lift. On the other hand, sufficient amounts of eyelid fat are not always present and the outcome varies with the cosmetic surgeon’s experience.

Facial Fat Grafting: Also know as fat transfer, fat can be harvested from other parts of the body (i.e., abdomen, thighs, and buttocks), prepared and injected into areas of concern including the tear trough. Fat grafting can be performed in conjunction with blepharoplasty or as a separate procedure. Advantages are that one uses the patient’s own material and that most people have enough fat available. In addition, other regions can be augmented at the same time. Disadvantages include the common need for two fat grafting procedures to achieve the desired result, the relatively high risks for bumpiness and unevenness of the tear trough region (very thin skin!) and the surgeon’s learning curve. The longevity is unclear: Re-absorption may be complete after 3 months and the enhancement may be good for a few years.

Dermal Fillers: Skin fillers that come pre-manufactured in vials and syringes can be used to fill in and improve the naso-jugal folds. Arguably, this is the face region where fillers are the least forgiving making it the most challenging filler treatment for your cosmetic surgeon. A thorough understanding of the anatomy and experience with injecting these regions is a pre-requisite. Although various compounds have been used in this area (Radiesse, Sculptra, Collagen), most expert doctors would agree that the hyaluronic acid fillers (Restylane, Juvederm) are superior for this delicate treatment. Longevity varies but may be better as for other facial regions. The treatment is commonly performed using topical skin anesthetic creams only.

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