Have you ever wondered why tear grooves form and what sets them apart from dark circles? In this article, we'll unravel the mysteries behind under-eye issues, exploring the difference between tear trough deformity and dark circles. Discover how under-eye fat repositioning surgery can significantly enhance the under-eye area, diminishing wrinkles and rejuvenating your appearance.

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Under eye fat repositioning surgery can improve not only sagging under the eyes but also dark circles. But do you know why tear grooves form and what makes them different from dark circles? We will tell you about the difference between the two and introduce how much better you can improve under-eye fat relocation, which improves wrinkles under the eyes, with a review of under-eye fat relocation.

1. What is the naso-jugal groove or tear trough deformity?

Tear troughs, those semicircular depressions under the eyes and on the nose, can be a common concern as we age. While some individuals naturally have a slight depression in this area, aging often accentuates the sunken appearance due to the deformation of the surrounding fat under the eyes.

2. Why do tear grooves form?

Facial bones play a crucial role in supporting the tissues around the eyes.

The orbital retaining ligaments, resembling a ring around the eye, become more pronounced as we age. Initially, when these ligaments hold the skin and muscle tightly, the tear trough may be less noticeable. However, as aging progresses, surrounding tissues sag, fat diminishes, and bones recede, making the tear troughs more prominent.

3. How are Dark Circles and Tear Troughs Different?

Dark circles can result from various factors, encompassing the following categories:

• Pigmentation of the Skin Itself:
  If you've noticed dark circles since a young age, they may stem from inherent pigmentation issues. Toning lasers and similar treatments can enhance pigmentation.
• Thin, See-Through Skin:
  Thin skin can make underlying structures visible. Nano fat transplantation is an effective method to reduce the visibility of dark circles by providing coverage.
• Shadow Phenomenon:
  Shadows beneath the eyes contribute to the appearance of dark circles. Fat relocation or lower eyelid surgery may be necessary, especially if a shadow is caused by darkening. Often, a combination of procedures is required due to the multifaceted nature of dark circle causes.

4. Does the Lower Lid Get Elongated with Age?

As we age, the once inconspicuous boundary between the lower lid and cheeks may become more pronounced, accompanied by sagging and tear grooves. This can give the illusion that the lower eyelids have stretched.

The area beneath the eyes, commonly referred to as the sky blue area, is often the initial indicator of facial aging. To address this, lower eyelid surgery or under-eye fat repositioning can be effective.

5. Lower Blepharoplasty and Fat Repositioning Under the Eyes

The core principle of eye surgery involves manipulating fat to create a softer boundary between the lower eyelid and cheek, thereby blending the lid-cheek junction. This is achieved by cutting the extraocular ligament.

To maintain the softened border and prevent the recurrence of the severed retaining ligament, fat is transferred (fat relocation). If insufficient, fat transplantation is considered. For more comprehensive information on the treatment of under-eye bags, click here.

6. Conclusion

Dark circles are considered one of the signs of aging, often exacerbated by under-eye hollows and tear troughs. Treating these dark circles depends on the underlying causes, categorized into cases where pigmentation is the sole issue (addressed with laser treatments) and more complex situations requiring a combination of treatments (laser + surgery). The challenge lies in identifying the exact cause of dark circles before initiating treatment. Another difficulty in treatment is the multifaceted nature of its origins, necessitating a combination of various procedures. Some patients may hesitate to start treatment due to the uncertainty of pinpointing the exact cause. However, surgeries and treatment processes are not overly complex or challenging, and with a hospital adept at addressing the various causes of dark circles, effective treatment can be achieved easily. The recovery period is also short, making it a feasible option for those facing multiple causes of dark circles.

Unfortunately, unwanted things happen after upper or lower blepharoplasty. If you had eyelid surgery for the first time, you might have no idea whether this is the usual process or early signs of the side effects. This article will classify the cases that can happen after surgery into three categories; spontaneous improvement as time passes, short-term follow-up required, and the surgical intervention needed. We will introduce some solutions to the listed problems also.

1. Spontaneously Improving Side Effects

1) Swelling and Bruising

Swelling and bruising are normal after eyelid surgery and vary among individuals. They typically improve with rest and compresses.
Cold (for the first three days) or warm (after three days) compresses are sufficient for faster recovery and we will share some tips to shorten the recovery periods.

2) Asymmetry

Asymmetry is a common concern for patients, but it often improves over time as swelling subsides. Even a slight swelling can affect the lid shape as the eyelid skin is very thin. This susceptibility is why most early post-operative asymmetries are not a big concern, as it improves over time.

3) Scleral Show

The scleral show, excessive exposure of the white part of the eye, can occur after lower eyelid surgery. This symptom is a temporary issue that usually improves within a month. Sometimes, the initial results of this symptom can be proportional to the desired outcome in lateral lower enlargement or lateral canthoplasty: And the patient should accept some trade-offs in the early recovery period.

2. Short-term Follow-Up Required

1) Dry Eye Syndrome

Some patients may experience dry eyes after blepharoplasty, but this usually resolves on its own or with artificial tears. If symptoms persist for over two months, IPL treatment may be considered. This symptom relates to a decrease in Meibomian gland function with age. (Randomised double-masked placebo-controlled trial of the cumulative treatment efficacy profile of intense pulsed light therapy for meibomian gland dysfunction).

2) Hematoma

Hematoma, bleeding inside the surgical site, can cause a mass-like lesion. If small, it will usually resolve on its own, but hyaluronidase injection may be done if large. Surgical drainage may be necessary if the size seems to get bigger.

3) Conjunctival Edema

Conjunctival edema, also known as chemosis, can occur after lower blepharoplasty and usually resolves with time. Antibiotics or steroid eye drops may be helpful if it lasts more than two weeks.

3. Side Effects That May Require Surgical Intervention

Unfortunately, some side effects from eyelid surgery may require surgical correction. We will discuss some case examples of when revisional surgery may help alleviate symptoms.

1) Upper Eyelid Complications

             a) Lagophthalmos

Lagophthalmos is a condition where the eyes do not close fully. In most cases, it improves spontaneously within 2 to 4 weeks. However, it can be more challenging to treat if it's caused by excessive skin removal or over-correction during ptosis surgery. The timing and method of re-operation will depend on the individual case.
Risk factors for lagophthalmos include protruding eyes, hyperthyroidism, and the habit of opening your eyes while sleeping. Patients should discuss these conditions with their doctor before surgery.

             b) Retraction

Retraction is a sign that the upper white part of the eyes is visible during a normal gaze. It can happen by over-correction of the levator muscle during blepharoptosis surgery. If this occurs in the early recovery phase, a surgeon can easily treat it. The best time for resolution is usually within 3 to 4 weeks of the first operation.

             c) Triple eyelid fold

A triple eyelid fold can occur when adhesions form in places other than the intended line and is often caused by excessive fat removal. Unlike retraction, it's better to wait 6 months for surgical intervention.

             d) High lid crease

A high lid crease can cause "sausage-look eyes," when the skin below the crease looks puffy. This appearance can be corrected with dual-plane dissection if the crease is designed too high.

2) Complications on the lower eyelids

             a) Lagophthalmos

Lagophthalmos can also occur after lower eyelid surgery and is caused by injury to the facial motor nerve during incision on the medial side of the eye muscle. If this happens after lower eyelid surgery, it often has short-term sequelae.

             b) ectropion

Ectropion is a rare but frustrating side effect after lower blepharoplasty, where the eyelids turn outward. It can be divided into two categories: those that require surgery and those that improve spontaneously. If there is a small gap between the lower lid and the orbit, spontaneous healing may occur and the small amount of sclera that shows may disappear. However, surgical correction is necessary if the red conjunctiva inside the orbit is noticeable.

A 76-year-old man came to me with a complaint of eyelid eversion (ectropion) after lower eyelid surgery performed by an unknown surgeon. He mentioned that the previous surgeon had tried to correct the issue with a skin graft, but it did not improve the problem. I performed a lateral canthoplasty to correct the ectropion and am pleased with the results which have been well maintained.
When the eyes are closed, the ectropion causes a "fish mouth" appearance (as seen in the left middle image), and in a bird's-eye view, the eyelid conjunctiva is not in contact with the eyeball (bottom left image).

4. Conclusion

This article discussed side effects that may occur after eyelid surgery and whether they can be resolved spontaneously or require medical or surgical treatment. Most patients' concerns about their early results are often resolved over time. I hope this article provides relief for those worried about potential problems.

Facial aging rarely occurs in one region of the face alone. It occurs throughout the whole face and affects all layers; including bones, muscles, and skin. Atrophy of the deep layer accelerates the sagging of unsupported fat above the muscles and the loss of skin elasticity, creating jowls, marionette lines, nasolabial folds, and neck changes, including the platysmal band. This article will explore these aging changes and introduce facial rejuvenation surgery such as facelifts, neck lifts, and brow lifts.

1. In What Facial Part Does Aging Occur?

This wonderful lady above is of her age 20 and 70. Analysis of the aging change is as on the right.
In the past, doctors used to think that aging was just due to skin sagging or fat herniation. However, several anatomical studies have shown that aging affects all layers of the face.

1. Bone is absorbed.
2. The retaining ligaments and muscles become lax.
3. Fat underneath the muscles is atrophied.
4. As a result, the fat above the muscles is not supported and begins to sag downwards.
5. The skin lost elasticity and became lax.

A plastic surgeon evaluates the face into three parts: upper, middle, and lower thirds, and establishes a plan accordingly. This article will discuss the aging face similarly and introduce surgical solutions.

2. Upper Third of the Face

1) Forehead wrinkles: Solution ▸▸▸ Botox or Brow lift

As one age, the skin on the upper eyelid sags and often disturbs vision. This drooping leads to raising eyebrows unconsciously to improve eyesight, result forehead wrinkles. As botox blocks muscle movement, it helps to fade creases a little. Forehead or brow lift is a surgery that can improve moderate wrinkles. However, these may have some limitations in improving deep wrinkles.

Three months after the endoscopic forehead lift. Though wrinkles may dramatically improve, deep wrinkles may remain to some degree.

2) Glabellar wrinkles: Solution ▸▸▸ Botox or Endoscopic forehead lift

When expressing anger, the medial eyebrows descend downwards, the same direction as contracting glabellar muscles. Usually, the wrinkles between the eyebrows begin at the 40s and make 11 lines.

3) Temporal hollowing: Solution ▸▸▸ Fat grafting

As we age, the soft tissue on the temple shrinks and bony appearance becomes more prominent. In this case, it is helpful to fill in the depressed area. If the contours of the facial bones are jutting, the fat graft will soften the border.

4) Hooded eyelids surgery ▸▸▸ Upper blepharoplasty or Sub-brow lift or Endoscopic forehead lift

The #1 reason that middle-aged visit plastic surgery clinic is to improve the sagging upper lid. There are usually three operative options depending on the characteristics of the eyes, and each has its pros and cons. The upper lid lift is the single most performed plastic surgery in Korea and it is beneficial when the patients want a double eyelid crease. However, it may result in an operated look if inappropriately performed. Subbrow lifts are an excellent choice for skin excess with natural results. Still, they can aggravate wrinkles in the glabellar area. Although endoscopic forehead lift benefits the forehead and glabellar lines, the outcome may limit the effect on sagging skin compared to sub-brow lift. Middle-aged eyelid rejuvenation: upper blepharoplasty vs. sub-brow lift vs. endoscopic forehead lift article will give you more information.

5) hollowed eyes: Solution ▸▸▸ Fat grafting or Upper eyelid surgery with Ptosis correction

Caucasians lose upper lid volume more than East Asians when they age. Fat infection can be helpful if you have a nursing home appearance. Occasionally, ptosis surgery together with blepharoplasty can improve moderate depression. In addition, there are cases of sunken upper lids due to compensatory forehead muscle action, and it is essential to diagnose the cause for each feature.

3. Middle Third of the Face

1) Lower lid and mid-cheek depression: Solution ▸▸▸ Lower blepharoplasty W/wo Fat injection

Lower lid fat bag bulges as we age. These bags under the eyes are often misunderstood as fat that has been enlarged with aging. Actually, the loosening of the muscles and other soft tissues surrounding the fat bag is the cause. Though someone with large fat should be trimmed cautiously, fat repositioning during lower blepharoplasty can fill most of the depressed tear trough. But people with extensive mid-cheek hollows should consider the fat graft together as fat repositioning alone may not be sufficient. Fat infection is advantageous when the mid-face beyond the lower lids is aged.

2) Wrinkles on lower lids: Solution ▸▸▸ Lower blepharoplasty 

This 64-year-old female is three months after lower blepharoplasty and subbrow lift. Wrinkles caused by sagging and excess skin almost always require an excision. If the wrinkles are not deep, dermabrasion with CO₂ or Er:YAG laser might benefit Caucasians. However, it seems less effective in Asians.

3) Tear trough: Solution ▸▸▸ Lower lid surgery, either transconjunctival or skin approach

Above is five months post-op of subbrow lift and lower lid surgery in a 56-year-old female. The tear trough is a depression that sits near the sides of the nose in an oblique shape. This location is where the retaining ligament is attached. As the adjacent soft tissue change with aging, the retaining ligament pull becomes more noticeable. If it is not severe, it will improve through fat repositioning, which moves the fat to other areas.

4) Nasolabial fold: Solution ▸▸▸ Midface lift or Facelift W/wo Fat injection

The nasolabial fold is the most addressed reason for those seeking face rejuvenation. And it is also the most challenging area to improve. People with severe smile lines usually have redundant tissue over the fold and insufficient skeletal support beneath it. So the doctor should fill the volume of the deep layer with a fat graft and lift the sagging tissue with a facelift. 

4. Lower Third of the Face

1) Elongated philtrum: Solution ▸▸▸ Upper lip lift

The area between the nose's base and the upper lip's border is called the philtrum. Because the philtrum gets elongated as one age, an upper lip lift can make one look younger. Please refer to the before and after photos of the upper lip lift.

2) Marionette line and Jowls: Solution ▸▸▸ Thread lifting or Face lift W/wo Fat grafting

A) Marionette line

The wrinkles that run vertically between the corners of the mouth and chin are called the marionette line. Retaining ligaments are located near this wrinkle and add to the aged appearance. The various kinds of facelift procedures can improve this crease by severing the retaining ligament to move lax soft tissue freely. And for long-lasting results, the doctor should fill the depression with a fat injection.

B) Jowls

The jowls are bulging skin and fat just lateral to the marionette line. As there is no retaining ligament in this structure, soft tissue laxity appears more prominent than the marionette line. It can be improved by face lifting, thread lifting, or micro-liposuction. It is an important area to make a smooth jawline.

5. Neck lift

1) aging neck Solution ▸▸▸ Neck lift with fat removal

As in the photo above, the neck may look droopy on the lateral view. Patients call this "turkey neck." For ideal shape and rejuvenation for the neck, we will discuss more in other articles. 

6. Conclusion

Facial aging affects multiple areas of the face; therefore, a comprehensive treatment plan is necessary to achieve optimal results. For this reason, a multi-disciplinary approach is crucial to restore balance and harmony to the entire face.

Lower blepharoplasty, also known as a lower eyelid lift, is a surgical procedure that aims to rejuvenate aging features such as wrinkles, tear troughs, bags under the eyes, and dark circles. This article will provide an overview of the surgical process and history of lower eyelid surgery. You'll also see before and after photos to understand what can be improved through surgery and why fat grafting may be necessary in some cases.

FAQ

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1. What is Lower Eyelid Surgery? : Understanding the Goals and Techniques

Lower blepharoplasty addresses under eyelid wrinkles and eye bags to restore a youthful appearance to the lower eyelid. The surgery can be divided into two categories based on the incision placement: transconjunctival (incision on the inner aspect of the eyelid skin) and transcutaneous (incision on the outside of the skin).

The main goal is typically to achieve three results:

• Reduce the size of the fat bags under the eyes (yellow),
• Improve the appearance of depressed tear troughs (green),
• Remove any lax skin and improve lower lid wrinkles.

The transcutaneous approach addresses all three goals, while the transconjunctival approach focuses on the first two. Later technique is typically recommended for patients in their mid-40s who have tight skin without noticeable wrinkles.

2. Incision Scar Visibility After Eyelid Bag Removal

To mask the scar, the incision for lower eyelid surgery is typically placed at the borderline between the eyelid and cheek. As a result, the scar is usually not noticeable. Please follow the before and after photos below to better understand what the scar will look like.

3. Evolution of Lower Eyelid Lift

1) Skin incision and Fat Excision (the 1950s to 1970s):

In the past, doctors primarily focused on removing fat bulges in the lower eyelid. (Blepharoplasty for herniated intraorbital fat. Anatomical basis for a new approach). This approach was widely used until the 1970s. Further surgical modifications had blossomed to tighten the muscle. (The orbicularis oculi muscle: Management in blepharoplasty).

2) Skin incision and Fat Repositioning (the 1980s to Present):

Dr. Loeb revolutionized lower eyelid surgery by advocating for the repositioning of fat rather than its removal. He believed that transferring the fat was more effective in improving aging features around the lid-cheek junction. (Fat pad sliding and fat grafting for leveling lid depressions).
This idea was further developed by Dr. Hamra, who proposed the "septal reset" method of moving the fat downward beyond the arcus marginalis. ." (The role of orbital fat preservation in facial aesthetic surgery: A new concept).

His idea spread worldwide, and today fat repositioning is the most common technique among Korean plastic surgeons. Recent studies have shown that fat decreases with age, so doctors believe that relocating fat instead of removing it is a more effective rejuvenation method.

3) Subconjunctival Fat Repositioning and Non-Invasive Techniques (the 2000s to Present):

In recent years, there has been a trend toward minimizing the post-operative recovery period. Therefore, fat repositioning though conjunctiva (the innermost layer of the eyelid) approach or using hyaluronic acid fillers became popular in addressing volume loss. Non-invasive techniques, like dermabrasion to treat lax skin have also been introduced.

Treating eye bags through the conjunctiva and removing skin laxity from the outside can help preserve the orbital muscle, reducing the risk of ectropion. This minimal invasive approach has gained popularity due to its safety, quick recovery, and ease of use for less experienced surgeons.

4. Ideal Facial Rejuvenation: What to Look For

When it comes to cosmetic surgery, it's not just about medical importance but about meeting the needs and desires of consumers. For that reason, there is little room for error regarding side effects and complications. One of the most common causes of disappointment after a lower eyelid lift is an evaluation error during the consultation, leading to an incorrectly selected procedure.

To achieve an ideal result, the following criteria should be met:

1) No Side Effects

A flawless cosmetic surgery with no complications is a must.

2) Short Recovery

No matter how good the results are, no one wants a long and tedious recovery.

3) Natural Appearance

A harmonious and youthful appearance should be comprehensive and include all parts of the face.

4) Long-lasting Results

Surgical results should be long-lasting and not require frequent repetition.

5) Technical Ease

The ideal procedure should be easy for any doctor to achieve the best results.

While it can be challenging to satisfy all these criteria, many surgeons might be surprised that fat grafting is the secret key to achieve these ideal goals.

5. A Blueprint for Lower Eyelid Rejuvenation

The history of lower eyelid surgery can be seen as a logical evolution in managing orbital fat. Once thought of as something to be removed, now it is considered to be preserved. Due to each individual's varying aging process and facial structure, it's difficult to provide satisfaction with just one surgical method. This challenge is where fat grafting comes in, helping to overcome these limitations in contemporary orbital rejuvenation.

6. Bags Under Eyes Surgery Before and After: Lessons Learned from Case

In this case study, we will look at the differences in results between patients who underwent eye bag removal with or without fat grafting.

1) Satisfied results without fat graft

Satisfaction without fat grafting is more common when there are fewer aging stigmas. These cases are where the herniated fat pad is sufficient to fill the small depression of the lower lid. In such cases, only repositioning the fat can produce satisfactory results.

2) Less favorable results without fat graft

In some cases, patients may achieve better results if fat grafting is done together with lower lid surgery. This longing is often due to insufficient skeletal support or limited orbital fat to reposition and fill the depression.

The above photo shows the results of lower blepharoplasty. Even though her tear troughs have been softened, it is still visible. You might be noticed that her pre-op fat pad is not big enough to fill the whole depressed lower lid. This is why she shows remnant tear troughs.

A 55-year-old patient who had bags under eyes treatment showed improvement after one week, two months, and four months post-op. However, her medial cheek bones were too weak to support the soft tissue, leading to remnant depression. She might have achieved a better outcome if the fat graft had been done in conjunction with the procedure.

A 51-year-old patient who underwent lower blepharoplasty three months prior showed a lack of skeletal support on the left side of the face. The results would have been improved if fat grafting had been performed along with the procedure.

In the left photo, a 68-year-old patient has noticeable eye bags. Right photo shows seven weeks after lower eyelid lift. While the patient is satisfied, the hollow appearance under the eye was too pronounced to be fully corrected by the eyelid lift alone. The result could have been improved by adding a fat transfer to fill the hollow area.

3) Satisfied results with fat graft

A 60-year-old patient who underwent lower blepharoplasty ten years prior agreed to have simultaneous fat grafting and lower lid surgery due to severe depression and lack of soft tissue support. The results were well-maintained with the fat graft allowing large depressed areas to be filled.

Another patient in her early 40s with typical aging lower lid features had her mid-cheek area filled with fat harvested from her abdomen. In the pre-op photo, she had little orbital fat with a distinct tear trough, the elongated appearance of lower lid with mid-cheek volume loss. The fat graft along the lower lid and mid-cheek area, trimmed with a subconjunctival incision, resulted in a well-blended lid-cheek junction. The patient was pleased with the outcome.

A man in his mid-30s concerned about hyperpigmented lower lid had a successful transconjunctival fat repositioning and nano fat graft applied to soften the dark circles. The nano fat graft is an effective solution for patients with dark circles caused by a thin skin.

A 43-year-old patient with a largely pseudo-herniated fat bag caused by a tear trough underwent fat grafting. The excess lower lid skin was incised and trimmed, but not the muscle, resulting in improved results. It is somewhat careful to judge the surgical result due to short-term follow-up and heavy makeup. Still, from personal experience, the fat graft is beneficial for better results.

In conclusion, the above cases demonstrate that fat grafting can provide better results than blepharoplasty alone with less downtime.

7. Is Simultaneous Fat Graft Necessary in Every Lower Lid Rejuvenation?

This article aims not to assert that fat grafting is always necessary but to stress that in many cases, it is crucial in achieving satisfactory and long-lasting results, especially in cases where disappointment might occur without it. The choice of the most suitable method among the various procedures depends on the experience and expertise of the surgeon.

8. Conclusion

The field of medicine evolves in a series of the thesis, antithesis, and synthesis. What was once considered right may become wrong as medical science advances. By revisiting history, we can gain valuable insight into the development of surgical techniques. In this article, I have shared my perspective on rejuvenating the lower lids and provided a brief overview of the surgical evolution in a lower blepharoplasty. Aesthetics in surgery are subjective, and there is no one-size-fits-all solution. I hope these thoughts are helpful to readers.