Hello, I am Dr. Yoan Choi from Thank You Plastic Surgery

There are cases where people visit a plastic surgery clinic for under-eye fat repositioning, but the clinic recommends lower eyelid blepharoplasty and midface lifting together. Although they were interested in only 1 procedure, the clinic says they will need 3 procedures which surprises them. I would be bewildered as well if I was a patient. However, by understanding what lower eyelid blepharoplasty and midface lifting surgery are, you may get a better insight as to why plastic surgery clinics recommend not only under eye fat repositioning but all three procedures together.

What is lower eyelid blepharoplasty?

Lower eyelid blepharoplasty is the general term used for lower eyelid surgery. The surgical removal of sagging skin under the eyes is referred to as lower eyelid blepharoplasty. An incision is made under the lower lash line, the sagging skin gets lifted and the excess skin will be excised. Therefore, lower eyelid blepharoplasty can be seen as a necessary operation for those in their mid-to-late 40s when skin sagging occurs and fine wrinkles begin to appear under the eyes. Due to this reason, skin sagging can get worse if only under eye fat repositioning is done. If you are in your mid-to-late 40s and are concerned about your lower eyelid, lower eyelid blepharoplasty and under eye fat repositioning must be done together.

Most clinics usually recommend lower eyelid blepharoplasty and under eye fat repositioning together. In order to explain why, we first have to know the importance of orbital septum fixation. Through orbital septum fixation, the tissues under the eyes are strongly fixated to the bones so the under eyes can become sunken, which some clinics fail to explain the solution.  

That is why after lower eyelid blepharoplasty and under eye fat repositioning, the skin underneath the eyes can become flat, but the skin sagging and sunken look can remain which fails to achieve its goal in becoming a surgery that helps improve aging.

Why does mid-face lifting get mentioned during consultations for lower eyelid blepharoplasty?

Therefore, mid-face lifting gets brought up. Sunken and sagging skin remains after under eye fat repositioning as the tissues dividing the SOOF fat weaken due to aging, which cannot hold up the fat. If the sagging tissues are not lifted properly while only the outer skin tissues get lifted, the sagging will get worse and show no improvements. Similarly, you have probably heard about how face lifts pull up the SMAS and cuts the excess skin. You can think that the SMAS is similar to the SOOF tissues for the mid-face. By lifting the tissues, it improves the nasolabial folds, and gives volume to the front of the cheekbones. Therefore, it gives the effect of making it look like fat grafting was done while the results look more natural.

Will scarring occur if lower eyelid blepharoplasty & mid-face lift surgery are done together?

Lower eyelid blepharoplasty is a surgery that improves only the brown area, but through the incision, the light gray area can be peeled and lifted which makes getting mid-face lift surgery (SOOF lifting) possible at the same time. It will give a youthful appearance to the sunken under eyes without the need for under-eye fat repositioning.

If you have a lot of facial tissues and if the sagging is severe, then a mid-face lift is needed. This area does not improve through face lift surgery so it must be done together with lower eyelid blepharoplasty.

When is mid-face lifting needed together?

○When you are concerned about deep nasolabial folds

The SOOF fat makes nasolabial folds look deeper so if you are in your mid-to-late 40s and are experiencing bulging fat beneath the eyes and severe nasolabial folds, mid-face lifting surgery is needed together with lower eyelid blepharoplasty.

○Those who are considering facial fat graft due to rapid aging compared to their age

The purpose of facial fat graft surgery is to give volume to the face and to make it look more lively and youthful. It is similar to when we gain weight, the face looks fuller. However, if the sagging SOOF does not get lifted and fat grafting is done, the added fat will weigh down the mid-face. That is why the SOOF tissues have to be lifted and fixated first before facial fat grafting.

○When the skin under the eyes are severely sunken but the buccal fat bulges out

When an area bulges out, it means there is enough volume in that area. But when we decrecibe it as “severe,” it means the volume has sagged down. The sagging tissues will be pulled up and the sunken area will also be lifted which will give natural and remarkable results.  

What are the disadvantages and side effects of lower blepharoplasty and mid-face lift?

1. Lower eyelid ectropion (out-turning eyelid) may occur during lower eyelid blepharoplasty and mid-face lift surgeries. For this reason, lateral canthus fixation must be carried out to prevent outward-turned under eyes, and caution must be taken so that the skin will not be cut excessively. In addition, it is necessary to prevent swelling of the surgical area to prevent outward-turned under eyes.
2. Swelling and bruising may occur during mid-face lift. The SOOF tissue will be firmly fixated to the periosteum (bone membrane). Therefore, when the periosteum and tissue are separated, different kinds of swelling and pain can occur in various areas.
3. During mid-face lift, nerves under the eyes are affected, and temporary deterioration of sensations may occur in the side cheekbones, upper lip, and nostrils. It affects the nerve because it has to lift and move the tissue called SOOF that surrounds the nerve. However, it does not disconnect the nerves directly, so permanent sensation loss will not occur. However, temporarily weakened sensations may last about a month or two.

In conclusion, it is difficult to see noticeable results with only one type of anti-aging surgery. Think of it like remodeling a home. Changing the wallpapers in an old, worn-out house will not make it feel like a new house. If the goal of plastic surgery is to maintain a youthful face, depending on the patient's condition and desired surgical results, one or two more surgeries will be needed than the surgery that the patient initially thought they needed. Therefore, the plastic surgeon may recommend two or three surgeries during the consultation. If patients consider my surgical recommendations, I will try my best to deliver results they won’t regret. Thank you.