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. “What causes the big puffy eyelid is fat,” says Dr Wu, “So by removing or repositioning some of this fat, you’re fixing this.”
Though under-eye bags are most often associated with an ageing face, the root cause of these bags is not always ageing. 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 may also contribute to puffiness around the lower eyelid.
Traditionally, most under-eye blepharoplasties are performed using 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; it offers surgeons a clear and direct path to the offending fat bags and in ideal situations, the scarring from the procedure is minimal. But Dr. Wu notes that the approach is associated with certain 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.”
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. Despite these drawbacks however, Dr. Wu says that open blepharoplasty is the best indication in certain cases, such as when a significant amount of skin must be removed from the lower eye area. However, he says that it is also possible to treat many cases of 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.
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.
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.”
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, 40 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, 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 haematoma – 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 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.
“Certain diseases and health conditions, including allergies, heart or kidney disease may also contribute to puffiness around the lower eyelid”
“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.”
