The Evolution of Lower Eyelid Rejuvenation

BEFORE AND AFTER:
a surgical procedure to transpose the patient’s eyelid fat pads beneath
the dark circle/depression of the lower eyelid.

When I first started performing eyelid surgery some 20 years ago, I realized that it was quite rare that a patient has an excess of skin in the lower eyelids. This is why attempts to rejuvenate the lower lids by removing skin did not generally produce a good cosmetic or functional result. In fact, removal of skin from the lower lids when there is no excess of skin results in retracted lower eyelids, dry eyes, and an unnatural appearance. While working in Los Angeles, more than a third of my practice was devoted to correcting the complications caused by others who remove too much skin from the lower lids during cosmetic surgery.

Twenty years ago my attention was directed at the eyelid fat pads, which were felt to be in excess in nearly all patients with bags or dark circles in the lower lids. With further research we discovered that only a few patients whom typically have a history of bags in the lower eyelids from a very young age actually have an excess of fat in the lower lids. In this small group of patients removing fat from the lower eyelids rejuvenates the lids. However, this only works well for the minority of patients while in the majority of patients removing fat from the lower lid results in a hollow aged appearance.

The majority of patients who develop bags in the lower eyelids in their forties and fifties do not
actually have an excess of fat in the lower lids. What they do have is a separation of cheek fat and eyelid fat caused by downward migration of the cheek. This separation of fat leaves a depression or dark circle at the intersection of the cheek and lower lids. With this new understanding I currently focus my attention on two primary treatments for lower eyelid bags,
one that is a minimally invasive injection and the other a surgical procedure.

The minimally invasive procedure involves injecting filler such as Restylane in the lower lids to
elevate the depression or dark circle at the intersection of the lower lid and cheek (below).
This procedure works best on those with thicker skin and with some pigmentation as this helps conceal the filler beneath the skin. This is a minimally invasive procedure resulting in only minor bruising, but the procedure needs to be repeated about every 18 months to maintain the result. For properly selected patients the result can be as good as surgery.

Many patients either are not a good candidate for the injections or opt for a more permanent
surgical result. The surgical procedure involves making an incision on the back of the lid to
create a pocket beneath the dark circle. The eyelid fat is then transposed into the pocket and
secured with sutures. By moving the fat of the eyelid beneath the depression or dark circle, the dark circle is elevated while the bulge in the lower eyelid is flattened. The depression, which causes the dark circle, is filled with the patient’s own fat. The fat remains attached to its natural blood supply so that the result is long lasting (top left).

It is great to be able to offer my patients a minimally invasive and a surgical procedure for rejuvenation of the lower eyelids.

BEFORE AND AFTER:
injection of Restylane filler beneath the dark circle or depression at the
intersection of the lower eyelid and cheek fat pads.
By John McCann, MD, PhD

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Center for Facial Appearances