Singaporean cosmetic surgeon Dr. Woffles Wu talks to Dan Childs about a minimally invasive option for eliminating under-eye bags
Sure, it may be true that beauty is in the eye of the beholder. However, when it comes to the difference between a vivacious look of youth and an age-worn, tired visage, you’ll likely find that the eye of the beholden is often a major factor.
Think about it – no other feature of the face speaks more to youth and vivacity than the eye. Sparkling, wide, young-looking eyes endow even older faces with a youthful glow. Conversely, an aged appearance around the eyes lends a haggard appearance to even the faces of teenagers and young adults.
In particular, the under-eye area has a tremendous impact on the appearance of the eyes and the rest of the face. Here, a smooth contour and firm, supple tissues create a healthy, alert appearance. Alternatively, the presence of prominent bags and drooping skin in this crucial zone can leave one looking weary, tired – and even years older than he or she actually is.
Singaporean cosmetic surgeon Dr. Woffles Wu says that while the equation of age in the under-eye region involves a veritable symphony of different factors – from the slope of the midface contour to the prominence of a crucial channel in the face known as the nasojugal groove – most of the patients who come to his practice simply say that they feel that their faces look tired, weary and old.
“Actually there are two things that contribute to an aged look in the eye,” Dr. Wu says. “First, the fat in the lower eyelid can accumulate and become puffy. Secondly, the fat in the lower eyelid can appear relatively puffy if the midface has begun to droop, which is what happens as our faces age.”
The solution, Dr. Wu says, is to decrease the puffiness of under-eye bags. The procedure that has arisen specifically to accomplish this task is known as blepharoplasty.
Consider for a moment that old couch you just can’t seem to bring yourself to throw out. Sure, it’s comfy. But years of sitting and lounging have caused the cushions to lose their original shape. Perhaps there are lumps of foam that have even pushed free of the wooden frame, creating bulges under the cloth of previously smooth surfaces.
With age, the soft tissues under your eyes act a bit like the soft stuffing inside your couch – they tend to bulge outward from beneath the skin, creating a drooping, puffy look. Most of this bulge can be attributed to the fat that is naturally present in what is called the orbit of the eye – the hollow area in which our eyeballs reside. When our faces are young, this fat is contained within the orbit by a structure in our lower eyelids known as the septum; the name is easy to remember, since this structure separates the fat from everything else. However, as this barrier weakens, the pads of fat beneath our eyes tend to slip out and protrude. Loosening of skin and the appearance of wrinkles further contributes to the sagging effect below the eyes, and before you know it, your eyes look significantly older and wearier. With this in mind, Dr. Wu notes, the solution to a younger looking eye is simple.
“What causes the big puffy eyelid is fat,” he says. “So by removing or repositioning some of this fat you’re fixing this.”
In essence, a blepharoplasty operation is to your eyes what a good reupholstering job would be to your old couch – the padding within is stitched back into place, the offending bits are removed, and the cloth is pulled nice and tight for a smooth result.
Though under-eye bags are most often associated with an aging face, the root cause of these bags is not always simply aging. In fact, heredity can play a role – so if your mother or father lamented at the mirror about their under-eye bags, the chances are higher that you will too. Additionally, certain diseases and health conditions, including allergies, heart or kidney disease, cirrhosis of the liver, and hyperthyroidism, may also contribute to puffiness around the lower eyelid.
Of course, any analogy can only be stretched so far, and it turns out that there are quite a few more ways to go about getting rid of under-eye bags than there are to refurbish your old sofa. Traditionally, most under-eye blepharoplasties are performed using something called the open technique – that is, the surgeon makes an incision in the lower eyelid and works from there to either tuck the fat back in where it came from or remove it.
The technique has its advantages – namely, that it offers surgeons a clear and direct path to the offending fat bags. Add to this the fact that in ideal situations, the scarring from the procedure is minimal. Unfortunately, Dr. Wu notes, the approach is associated with many complications.
“For one, you are distorting the architecture beneath the lower eyelid, which is a unique area of the face in terms of skin and muscle structure,” Dr. Wu says. “When you do this, the area takes on in many cases a very fake plastic look, and it becomes very flat.”
He adds that the new direction of tension from the altered tissues can also result in unwanted effects in the skin around the eyes. “In patients who have had an open lower eyelid blepharoplasty, if they look in the mirror and are really honest with themselves, these patients will notice that every time they smile they will see more crows feet wrinkles than they had before,” Dr. Wu notes.
Improperly performed open blepharoplasty can also lead to other unwanted cosmetic consequences. One of these is ectropion – a condition in which part of the inside of the lower eyelid folds outward and becomes visible. With scleral show, another possible side effect of a poorly performed procedure, the patient will find that a small part of their sclera – the “white” of the eye – will show even when they close their eyes.
Despite these drawbacks, Dr. Wu says that open blepharoplasty is the best indication in some cases. However, he says that it is also possible to treat under-eye bags using a minimal-incision, scar-free technique – and in so doing, avoid some of the more common complication associated with the traditional open technique.
As a general rule of thumb, any incision has the potential to leave a scar, no matter how small. Consequently, the only way to ensure a scar-free result is to place any cuts that need to be made where they will not be seen.
In the case of lower eyelid blepharoplasty, this involves actually pulling the lower eyelid open and making the necessary incision within this natural pocket. This technique is called the transconjunctival technique.
“I’ve tried out a variety of techniques for lower eyelid blepharoplasty, and over the years I have evolved a preference for this particular style, which I’ve modified myself,” Dr. Wu notes. “Basically what’s involved is pulling the eyelid open and making an incision inside, direct into the conjunctiva. This gives direct access to the fat pads, so we can either remove or reposition those. By doing it this way, you’re not making any extraneous incisions, and it heals very quickly.”
The transconjunctival technique takes less time to perform as well, Dr. Wu notes. “It’s a 20- to 25-minute procedure, as opposed to the one-hour procedure that you get with the traditional open procedure,” he says.
Dr. Wu says that he currently uses the transconjunctival technique in about 90 per cent of his blepharoplasty patients. As for the remaining 10 per cent, the transconjunctival approach may not be the best option for a variety of reasons. If, for example, the unwanted bulge is a result of an overdeveloped eyelid muscle rather than a bulging pad of fat, a different technique would be the best solution for the problem. Additionally, because this technique only addresses the fat beneath the eye, it will not reduce the excess of loose skin under the eye that often accompanies fat bags. In order to deal with this, Dr. Wu says, it is sometimes necessary to trim the excess in addition to removing or repositioning the under-eye fat pad.
“Now, if you still have excessive skin afterwards, as some of these patients do, you may need to cut a bit of skin, since when you do the transconjuctival approach you don’t cut anything off,” he says. “But then again, if there’s a little excess skin, so what? This ends up looking much more natural than the alternative.”
“There may come the time where you need to snip a little skin. But the key here is not to destroy the muscle, because when you destroy the muscle, you run the risk of destroying the nerve as well,” he adds. “When you make a cut through the muscle, you actually cut off some of the nerves. This is what contributes to the lower eyelid becoming slack.”
Suffice to say, a blepharoplasty can often work wonders when it comes to taking a few years off an aged face. However, additional procedures are sometimes necessary in order to elicit a comprehensively rejuvenated appearance. Dr. Wu says that transconjunctival blepharoplasty can be combined with a host of other minimally invasive procedures.
“Usually, these patients will come to me and say that they look tired,” he says. “That’s when I tell them that I can take out the puffiness under their eyes, but this alone may not correct the tired look. For this, I may need to use fillers, fat injections, or threads to elevate the midface, such as in the Woffles Lift. Any of these I can do in conjunction with transconjunctival blepharoplasty in order to restore a younger look.”
While drooping, sagging tissues are often associated with older patients, Dr. Wu says that under-eye bags don’t always discriminate according to age. For this reason, he notes, there is no typical age for the potential patients who visit his clinic hoping to get rid of under-eye bags.
“There really is no one patient age group,” Dr. Wu remarks. “I get people coming in who are 17 and 18, people who are in their 20s and 30s, people forty and above, and all of them have the same complaint of puffy eyes and an old and tired look. My oldest patient is 85.”
Younger patients may reap greater benefits from blepharoplasty alone than their older counterparts, since it is likely that the younger skin is, the more elastic it will be. However, even patients with lax, loose skin beneath their eyes can get a smooth result if another procedure is combined with a fat-removing blepharoplasty operation.
Although the transconjunctival approach to lower eyelid surgery is a scar-free procedure, it is important to note that it is still surgery – and each surgery has its own set of considerations and possible complications.
Since the transconjunctival approach involves creating an incision beneath the eyelid, there is the possibility of the formation of a hematoma – in other words, a collection of blood beneath the skin. This condition is fairly easily treated, but another trip to the surgeon will be needed. Also, as with any other surgery, wound infection is a possibility.
Other problems associated with this procedure are primarily cosmetic. “The most common error of judgement is to take out too much fat, so the area appears too hollow,” Dr. Wu says. “This, however, is easily corrected by putting in a filler.”
Side effects can include a minor amount of bruising and swelling under the eyes, which can last for a few days or more. However, Dr. Wu notes that the side effects associated with the transconjunctival approach are generally less severe than those that accompany the traditional open approach.
“The reason why there are fewer side effects is because in the course of the procedure you are disturbing fewer structures,” Dr. Wu notes.
The cost of lower eyelid blepharoplasty ranges widely according to a number of factors – the country in which the surgery is performed, whether the open or the transconjunctival technique is used, and whether other techniques are added in, to name a few.
Dr. Wu says he generally charges S$3,900 to S$4,500 for a procedure using the transconjunctival technique and S$4,950 to S$5600 for a procedure employing the open technique.
“The open technique is usually combined with a fat redistribution, as well as a midface lift,” Dr. Wu adds. “Not all people need this though.”
For many, it is a small price to pay when it comes to unpacking those under-eye bags. The most important thing to remember, however, is to seek a properly trained and certified cosmetic or plastic surgeon when it comes to any kind of surgical procedure.
