The facial expression
In any assessment of the appearance of a face, the eye region is vitally important. Bags under the eyes and excess skin in the eyelids are just two of the causes of the characteristic tired look often seen in older people.
Many features can spoil the appearance of the eye region. The shape and the position of the eyebrows are very important: drooping eyebrows can make us look sad, the space between the eyebrows with two deep vertical frown lines can make us look bad-tempered, excess skin in the upper eyelid makes us look tired because the eyes do not open completely. Excess fat in the lower eyelids suggest that we aren't sleeping enough or go out too much at night, although in fact it is nearly always congenital. A half-closed eye with wrinkles distributed radially around the external canthus (known as crow's feet) contribute to creating this sad, aging appearance.
The novelty of the integral treatment performed at our Institute is that, via a single incision placed in the upper eyelid and carefully hidden within the eyelid fold, and a second incision placed in the conjunctiva of the lower eyelids, we can successfully treat all these features.
The excess skin is removed in an elliptical fashion, placing the scar to coincide with the upper border of the tarsal plate of the upper eyelid. In this way, the scar coincides with the eyelid fold and is inconspicuous. As for the bags under the eyes, both the internal and medial fat pads must be removed if necessary. A very conservative approach is used for medial fat pad removal, since overresection may lead to the sunken socket syndrome.
We perform inferior blepharoplasty via a transconjunctival approach: that is, through the mucosa lining the lower eyelid, and avoiding a skin incision. First a contact lens is placed to protect the eye and the cornea, and we reach the fat pads through the mucosa, always below the lower border of the tarsal plate so as not to injure it. After identifying the three fat pads, they are removed.
Resection of lower eyelid and its orbicularis muscle is avoided so as not to expose the sclera and to prevent an excessively round shape for the eye. When there is a large amount of excess skin in the lower eyelid, we resect it via a small incision below the eyelashes, preserving the orbicularis muscle. Thus, the fat pads are removed through a transconjunctival approach. In some highly selected cases the excess skin is removed externally, again in a very conservative fashion.
The tear through
To treat the tear trough (the depression or groove that goes downwards from the medial angle of the eye) we use our personal fat grafting technique. We fill the depression with a liquid fat emulsion and stem cells placed in the subcutaneous plane and the dermis to fill the depression and improve the dark color of the skin. This same technique is used to fill in circles, because merely removing pockets of fat is insufficient.
Height of the lower eyelid
The lower eyelid goes from the lashes as far as the orbital rim. Due to sagging, and the descent of the cheek, the lower eyelid is often excessively high and the dark circles greatly exaggerated. We perform a small fat graft in the cheek with microfat at the height of the orbital rim, not to increase the volume of the cheeks, but to ensure that the lower eyelid is the correct height.
Space between the eyebrows: corrugator and procerus muscles
We approach these muscles via the incision in the upper eyelid we made to perform the upper blepharoplasty. The dissection must be very delicate so as not to damage the supraorbital and supratrochlear nerves. Once located, we partially excise the muscles and thus obtain a smooth surface, with a relaxation of the wrinkles and a more youthful look.
Raising the tail of the eyebrow
When the tail of the eyebrow is depressed, we can raise it from the incision in the upper eyelid. To do this we detach the bands of the tendon around the tail of the eyebrow and suture the parenchyma of the tail to the periosteum of the lateral orbital rim in its upper portion. The suture is performed in depth so that it should not be visible and we measure the height very carefully so that the tail is symmetrical with the contralateral eyebrow.