The mid-face is the rectangular area located below the eyes and beside the nose. The lower eyelid is intricately connected to the mid-face in terms of aesthetics and functionality. Changes in the mid-face region have a visible impact under the eyes.
During the aging process, especially in individuals with susceptible bone structures, the soft tissues of the mid-face both shrink and sag downwards. These tissues typically provide a barrier that supports the front of the lower eyelid's fat pads and prevents them from protruding forward. When the mid-face descends, only a micro-thin membrane remains in front of the lower eyelid fat pads. This membrane stretches rapidly, leading to the formation of under-eye bags.
Therefore, one of the fundamental reasons for the hollowing and puffiness we observe under the eyes is the gravitational descent of the mid-face.
In the early stages of plastic surgery, under-eye problems were perceived merely as issues related to the lower eyelid. The primary approach for treating under-eye problems was lower eyelid cosmetic surgery (lower blepharoplasty). In this procedure, bags were removed or repositioned, and the skin and muscles were tightened. However, a standalone lower eyelid surgery, even if successful within itself, wouldn't yield the ideal outcome we consider today. This is because reducing bags through lower blepharoplasty can further emphasize the appearance of hollowness under the eyes. Based on these observations, modern lower eyelid surgeries have evolved to increase mid-face volume. There are currently two main approaches:
The first approach involves performing mid-face volume augmentation through fat tissue transfer concurrently with or following lower eyelid surgery. This approach is suitable for patients with clear mid-face volume deficiency. The desired volume can usually be achieved in 2-3 sessions of fat injection, ultimately increasing the overall facial volume.
The second approach involves performing a mid-face lift simultaneously with lower eyelid surgery. In this procedure, the tissues under the eye are lifted as a whole over the bone, repositioning them higher and more ideally. No additional external tissue is added; instead, the patient's own cheek tissue is redistributed. The advantage is that we can maintain a more elegant and refined facial structure. Mid-face lifting is particularly suitable for patients with a negatively inclined bone structure. This group often begins to complain about under-eye issues in their twenties. The soft tissue mass of the cheek is positioned lower on the bone structure than it should be. There is often a familial/genetic predisposition. Sometimes we operate on patients in this group as early as their twenties, as under-eye anatomy doesn't improve with age.
On the other hand, if a patient has well-developed mid-face and under-eye bone structures, significant under-eye puffiness might not develop even beyond sixty. However, the option of mid-face lifting, although more durable and long-healing, can sometimes be unattainable due to a lack of timing, resources, or courage. Nonetheless, these circumstances don't change the reasons for under-eye deformities or alter the outcomes of treatment.
When treating under-eye problems, it's crucial to consider the holistic approach. If, during the preoperative consultation, a significant lack of volume under the eyes is apparent, and I've suggested mid-face lifting, yet you've declined this option, then you implicitly accept that under-eye hollowing will persist after surgery. Without addressing the under-eye hollowing, we cannot achieve a more rejuvenated and healthier appearance. Bags might disappear, but the patient may still appear fatigued.
Mid-face lifting is a more long-lasting, slow-healing, and costly option. Some individuals might lack the time, resources, or courage for such a procedure. However, this doesn't alter the causes of under-eye deformities or the results of treatment.
When excluding the mid-face from the equation in the treatment of under-eye problems, you inadvertently reduce the support for the lower eyelid. Raising the cheek mass to support the lower eyelid from below significantly decreases complications like scleral show and ectropion. Additionally, asymmetries caused by the mid-face cannot be rectified without addressing the mid-face itself. If there's a mid-face-related asymmetry and you exclude the mid-face from the treatment plan, performing only a lower eyelid surgery will inevitably result in an asymmetrical outcome.
In summary, the aesthetics and functionality of the mid-face and lower eyelid are interconnected, and they should ideally be treated together. Treatment plans should be personalized; there's no universally applicable template. However, treating under-eye issues isn't as straightforward as saying, "Doctor, just remove these bags, and I don't want anything else."
For more detailed information about the contributions and potential treatment options for under-eye problems involving the mid-face and lower eyelid, feel free to get in touch with us.
Stay with love,
Stay beautiful,
O.B.