Lower Eyelid and Upper Cheek

Lower Eyelid and Upper Cheek or Mid-Face Surgery

When considering surgery of the lower eyelid, also consider the upper cheeks since the two areas are in continuity with each other.  Aging conditions of the lower eyelid that can be corrected may include puffiness of the lower eyelid, wrinkling or even folds of excess skin and looseness, or horizontal laxity, of the lower eyelid margin.  The upper cheek fat tends to descend and thin with age.  This can leave a hollow immediately under the lower eyelid.   Laterally, the cheek fat drops and the skin may bunch over the cheekbone, sometimes even collecting a pocket of fluid where it bunches.  Each of these problems may require a different procedure to correct them.

Lower Eyelid Transconjunctival Blepharoplasty with Fat Repositioning

This is a very good procedure used to treat puffy lower eyelids with hollows below.  In many patients, the upper cheek fat has dropped and thinned, leaving a hollow that accentuates the appearance of puffiness in the lower eyelids.  This surgery is performed from the backside of the eyelid without a skin incision.  The fat is repositioned in to the hollow filling it out and flattening the eyelid contour.  Because the fat is still connected to its original blood supply, it does not tend to lose volume after surgery, unlike free fat transfer procedures.

Due to loss of his cheek fat, his lower eyelid fat “bags” became obvious. The bags were flattened with lower eyelid fat repositioning.
This man had a left upper eyelid posterior ptosis repair to make it match the right side, as well as a bilateral lower eyelid fat repositioning to fill in the hollows below.
This Asian lady’s lower eyelid fat “bags” were repositioned and hidden in the cheeks below. She also had upper eyelid posterior ptosis repair.
His puffy lower eyelids were improved with lower eyelid fat repositioning, with no skin incisions.

Filler (To Fill In Hollows Below Lower Eyelid)

If there are hollows below, but no puffiness or fat prolapse in the lower eyelids, it is better to inject filler to fill out the hollows.  In this location, hyaluronic acid fillers can last two to three years.

This woman’s under eye hollows were filled in with Restylane filler.

This woman’s fat loss and hollowing under her lower eyelids was nicely filled in with Restylane filler.
This woman did not want to have surgery. Her lower eyelid fatty “puffs” were disguised by filling in the hollows below with filler (Restylane and Voluma). She also had Botox injected in her forehead to reduce the frown lines, and slightly raise and soften the eyebrows, (a botox brow lift.)

Lower Eyelid Transconjunctival Blepharoplasty with fat removal

This surgery is used to remove puffiness, or bags, of the lower eyelid.  This puff, or orbital fat, is fat which has prolapsed forward due to a weakening of the septum of the eyelid; a membrane that normally holds the fat back.  The fat is removed with no skin incision, from the backside of the eyelid.  No sutures are needed.  Due to volume loss, the skin might be slightly looser and need a tightening procedure.

Lateral Mini Mid-Face Cheek Tuck

This procedure is used to treat the drooping fat of the upper cheek. The cheek fat pad is normally at the upper edge of the cheekbone; due to time, gravity and loosening of tissues, the tissue down over the lower part of the cheekbone, often bunching and sometimes collecting fluid in it.  This fat pad and some of the tissues that support it can be surgically lifted, smoothing out the bunching and moving that fat of the upper cheek upward.  This is done through an incision in one of the pre-existing smile lines at the outer corner of the eye.  If it is done in conjunction with upper eyelid blepharoplasty, the upper eyelid incision can be continued in to one of the smile lines and then the cheek tuck can be performed through that incision.

Full Mid-Face Cheek Lift

This procedure has also been called SOOF Lift (a sub-orbicularis ocular fat pad lift) and is used to lift a drooping upper cheek and lower.  Often, there is no excess lower eyelid skin, sometimes because of previous blepharoplasty or from some other skin tightening condition.  Therefore, when the cheek drops it pulls the eyelid down with it.  To correct this, an incision is made through the back side of the eyelid and the upper cheek fat pad is pulled up.  This elevates the cheek and takes its weight off the eyelid, allowing the eyelid to return to its normal position.

Canthoplasty (tightening At The Outer Corner)

A normal, healthy eyelid margin rests at the lower edge of the cornea, or colored portion of the eye.  With time, most eyelids stretch horizontally, lose their elasticity and get loose.  The outer corner of the eye, the lateral canthus, may slip away from its normal attachment to the bone.  In its normal healthy position, the eyelid is best able to protect the eye, keep the cornea moist, and help the tears drain in a normal fashion.  If the eyelid is horizontally loose, it may sag down out of the ideal position often resulting in an irritated, tearing eye.  The risk of this is increased when someone has had surgery or a procedure on the skin of the lower eyelid.

If a patient with horizontally loose eyelids is planning to have a procedure on his or her lower eyelid skin, a canthoplasty and prophylactic tightening of the eyelid at the outer corner is advisable.  This surgery is necessary if the eyelid sags so much that it is unsightly or results in tearing and/or irritate of the eye.  A canthoplasty is performed using a small incision at the outer corner of the eye extending less than one centimeter in to a smile line.  The lateral canthus is reattached to its previous attachment place at the lateral orbital rim and the lower eyelid may be shortened as well.  This usually heals with minimal evidence of a previous incision.

Bilateral lateral canthoplasties improved her dry eye symptoms. She also had bilateral posterior ptosis repair, more on the right, to make her upper eyelid levels even.

Lower Eyelid Blepharoplasty With Skin Incision

If a patient has excess skin in the lower eyelids, some skin may need to be removed.  This skin can be removed using an incision that is hidden in the normal crease just below the eyelashes.  Although this procedure used to be the common way lower eyelid surgery was performed, it is more rarely performed in current times.  It is needed if there are folds of excess skin, not just wrinkles, in the lower eyelids.  Because this procedure has the risk of pulling the eyelid down and out of position, most patients will also need to have a lateral canthoplasty performed to tighten and hold the eyelid margin in proper position during healing.