I Am Considering a Cheek Lift/lower Eyelids Lift to Correct the Hollowness and Dark Shadows Under my Eyes? (photo)

I had a consult with an excellent eye surgeon who recommended a cheek lift procedure. An incision would be made right under the lashes on the outside of the eye. My concern is whether or not this procedure can result in pulling the lower lid down since the incision is made under the lashes? I already have eyes that show some white naturally on the lower lid and I am scared that I will only make it worse. I've heard about restylane for hollowing under eyes but I've heard that it could cause bulge

Update 4/26/12:
I've posted a picture and would like your opinion. I went for a consultation to a great Occular Plas. Surgeon who recommended a Cheek Lift to correct the hollowness under my eyes.I was concerned about ectropion and whether this is the ideal surgery for my eyes. I want to know if injections would be a better solution or should I get the cheek lift? I was told that I I don't have much fat near the orbital bone based on the exam.I am very unhappy and need to do something to improve my tired look.

Doctor Answers 18

I personally think that most mid face surgery is a disaster.

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I generally cannot advise primary mid face surgery for the type of issue you appear to have in the photo.  Perhaps your surgeon will produce an amazing result.  However, there are many unhappy mid face surgery patients.  Fillers are a much safer way to accomplish improvement in this area.  The challenge is the thin skin.  Treatment here is fussy and often requires an adjustment.  However there is no question that it is possible to accomplish results with the fillers that can never be accomplished with surgery.

Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

Many options are available...

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Without photos, you'll get many differing opinions on different possibilities. Having the photos will certainly help taper down some suggestions.

Whenever a lower eyelid skin incision is made, there is a possibility of lower lid retraction. However, in the hands of a skilled surgeon, with a good cheek lift, tightening of the eyelid attachments, these risks are minimized.

Having said that, in my practice, I haven't done a  cheek lift in years. One reason is that even in the best of hands, the longevity of a cheek lift is questionable.  Secondly,  fat transfer  has allowed me to add volume to the cheek, as well as the cheek-lid junction in a much safer fashion that, in my opinion, rejuvenates the face more naturally than a cheek lift can.

So, having not seen your photos, I would say that my preferred techniques these days is transconjunctival fat excision [sometimes re-positioning, with a small pinch skin excision, if needed] with fat transfer to the cheeks.

Remember, there are a lot of different techniques, and different surgeons will have different comfort levels and expertise in these techniques. You have to find one that you feel comfortable with.

Good luck

A.J. Amadi, MD
Seattle Oculoplastic Surgeon
5.0 out of 5 stars 42 reviews

Fat Grafting for under eye hollows and deflated cheeks

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The primary aging change in the cheek area consists of a combination of deflation and descent of the cheek fat pads, creating a hollowed appearance below the lower lids and deepened nasolabial folds (oblique lines which extend from each side of the nose to the area beside the corners of the mouth). Descent of the midface/cheek fat pad can also contribute to the exaggeration of marionette lines and downturning of the corner of the mouth.

This aging change is significant, but is often not fully appreciated as a feature which can age the face considerably. When I see a person who is in their sixties or older but doesn't 'look their age' (but hasn't had plastic surgery), quite often they will have cheeks which are full and prominent, a feature that the brain immediately associates with youth. Look at an infant!

Cheek area rejuvenation by mean of a mid face lift can be performed as part of a facelift procedure, but is also sometimes performed alone to specifically address deflation and descent of the cheek fat pad. The procedure is performed through two hidden incisions. One is made inside the mouth, at the apex of the space between the gums and the lower cheek. The second incision is hidden behind the hairline of the temple area. Through the intra-oral incision, the cheek fat pad is freed from the cheekbone. A suspension suture is used to grasp the cheek fat pad, and the suture is then passed below the skin to the temple-area incision. Upward traction on the suture elevates the cheek fat pad, and with it the corner of the mouth is elevated slightly. The nasolabial folds soften and in some cases can be almost completely eliminated. The suspension suture is then anchored to the deep soft tissues below the scalp, producing a permanent elevation of the midface.

A technique which does not require incisions or sutures and which I find applicable to more and more patients is structural fat grafting, which involves carefully and painstakingly grafting (by micro-injection) a patient's own fat into areas which benefit from volume restoration. This is an excellent alternative for facelift patients who have flattening of the midface without significant aging changes in the nasolabial folds or oral commissures (corners of the mouth). In selected patients, I have found this to be a powerful but less invasive means of restoring cheek volume and projection.

Structural fat grafting can also be utilized in patients undergoing a midface lift, if additional enhancement of the lateral aspect of the cheekbones is desired. The midface lift and structural fat grafting, alone or in combination, allow me to restore or create youthful cheek and lower lid contours, without the need for cheek implants. Aside from the associated risks of migration, infection, and bone resorption, I feel that cheek implants tend to produce results that are not natural-appearing, and for that reason I do not use them in any facial rejuvenation procedures.Structural fat grafting is a powerful tool for correcting one of the primary processes of facial aging: the gradual loss of facial soft tissue volume, which primarily represents the atrophy of facial fatty tissue. The importance of restoring facial fullness cannot be emphasized enough, for without it, very few facial cosmetic surgical procedures are truly rejuvenating. As we age the skeletal features of the face become more obvious, and create subtle visual clues that tell the observer 'this is an older person'. Fat atrophy is often very obvious when it appears as hollowness in the temple area and as flattening of formerly full cheeks, but can also exist as more subtle changes that still convey an appearance of advancing age, such as the development of a hollow in the space between the upper lid and eyebrow, or as indentations in a formerly smooth and gently curving jawline.

Lifting skin and trimming the excess has been the standard approach to the treatment of facial aging for centuries, but when performed without some means of restoring the youthful fullness of facial soft tissues, the result is an older-looking person with tighter skin. The word 'rejuvenation' means literally 'to restore youthfulness' or 'to make young again', so if the goal of surgery is to rejuvenate the face then it cannot be accomplished solely by means of redraping the skin and removing the excess.

In my practice fat grafting is not an afterthought that is thrown into the surgical plan for the occasional patient. It is a key component of almost every major facial rejuvenation surgery that I perform. It is in fact that very first part of the surgical procedure for my patients undergoing a full facial rejuvenation surgery.

Fat grafting also gives the surgeon the ability to provide a minimally invasive, quick recovery solution for some of the earliest signs of facial aging, in many patients long before they could or should consider a more involved (and much longer recovery) procedure like a facelift. Most people show evidence of facial soft tissue atrophy in their thirties, long before they develop the degree of skin laxity that warrants skin redraping and removal. So younger patients now have a means for 'turning the clock back' by maintaining or restoring facial fullness through structural fat grafting. These enhancements look beautiful and natural, not like surgery, and over and over I hear fat grafting patients tell me that "none of my friends or co-workers can figure out why I look so great".

As with any cosmetic surgical procedure, there can certainly be 'too much of a good thing'. Over-grafting of fatty tissue will distort facial features and produce unnatural proportions that look like surgery rather than appearing to turn back the clock. An important part of my preoperative evaluation is reviewing photographs with patients from their twenties and thirties (and from their forties for patients in their sixties and seventies). Such photographs are invaluable in confirming the manner in which a face has aged, and in planning a surgery that is designed to help a patient look more like their youthful self.

Michael Law, MD
Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 123 reviews

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I Am Considering a Cheek Lift/lower Eyelids Lift to Correct the Hollowness and Dark Shadows Under my Eyes? (photo)

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In our practice we offer lower eyelid surgery (blepharoplasty) for removal of fat pads under the eyes which can cause dark shadows.  By removing the fat pads the skin lays down flat against the skin and the light is reflected and absorbed differently so the appearance of dark shadows is less visable.  You can also use Sculptra to rebuild collagen in your cheek bones if you are not ready for a cheek lift. 

Stuart B. Kincaid, MD, FACS (in memoriam)
Beverly Hills Plastic Surgeon

Cheek lift

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In the picture presented it appears that there are herniated fat pads in the medial and middle compartments in the lower lids.  The fat pads can be removed by transconjunctival blepharoplasty, which will give a nice new contour to the lower lids. 
The aging process reduces the overall fat volume of the face and is best restored with small cheek implants, not a cheek lift.

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 158 reviews

Cheek/midfacelift with Lower eyelid blending

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The many good responces to this common problem are difficult to follow due to the descriptive terminology used. Over time the cheek and midface lift have come to mean the same thing. Lifting the cheek via a lower blepharoplasty incision is rarely done anymore due to the problems with the subsequent lower lid position, shape and the problem with lid paralysis due to the dfficulty suspending the cheek. There seem to schools of thought on this problem. There are the camouflagers (fillers, implants) and the lifters who recognize the problem as one of descent of the cheek tissues. The cheek can be tightened and lifted via parts of the minifacelift incision and the tear trough / hollowness attacked through  the lower blegh incision by blending the lower lid / cheek area

Paul S. Howard, MD, FACS
Hoover Plastic Surgeon

I Am Considering a Cheek Lift/lower Eyelids Lift to Correct the Hollowness and Dark Shadows Under my Eyes?

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 From the photos, aesthetically speaking, the anterior portions of the cheeks are quite flat.  There are some minor issues, with the lower eyes but this IMHO is secondary to the proper shaping of the cheek area if you want a naturally, more attractive face.  Fillers or cheek implants would soften the entire face without a any type of Face Lift.  Pulling the heavier cheek tissue upwards to fill in the tear troughs, IMO, is more likely to pull the much lighter lower eyelid tissues downward and will not soften or feminize the face.  

  Face Lifts are done to remove excess skin and tighten the lower face which doesn't seem to be required in this particular case.  Before you do anything you might want some Perlane injected into the cheeks to create the desired aesthetic effect.  There's no inherent magic in any filler or procedure but rather resides in the plastic and cosmetic surgeon's ability to understand and follow the proper aesthetics of facial beauty for the creation of a naturally, more attractive face.  

Francis R. Palmer, III, MD
Beverly Hills Facial Plastic Surgeon
4.7 out of 5 stars 28 reviews

Options for dark lower eyelids and hollowness

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You are experiencing one of the first and earliest signs of facial aging which is an ovalization of the orbital area causing a skeletonization of the lateral orbital rim along with a tear trough and a distinct line where the lower eyelid stops and the cheek starts.  You appear to be young and I would suspect this condition runs in your family.  There are several options for improvement of this zone.  If it is your desire to avoid surgery then a trial of a filler is not unreasonable.  The use of a hyaluronic gel filler such as Juvederm can nicely fill in the tear trough zone and Radiesse can be used to build up the upper malar and cheek region.  This would give you and improved appearance in this zone.  Without a lateral photograph  or an examination it is difficult to recommend surgery.   Lower eyelid surgery may be your best option and this could include repositioning of your orbital fat and a tightening of the orbicularis muscle as well as excision of some skin of the lower lid.  If your lower eyelid is lax then this may need to be tightented with a cantholysis and canthopexy type procedure.  Also a mini type cheek lift is possible where a small amount of the malar fat is elevated to fill in the lateral orbital zone.  

Jeffrey Zwiren, MD
Atlanta Plastic Surgeon
4.5 out of 5 stars 20 reviews

Cheek lift for hollowness

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The most important photo to assess your situation is a lateral view. I suspect that you have insufficient support under your eyelid (i.e. negative vector). A cheek lift is, in my opinion, not the answer and is potentially problematic, if done from above. It depends on how the lift is anchored. I suspect that the bags are relative because of the lack of support. Injections are temporary and camouflage the problem and can be tricky. Depending on what your specific aesthetic goals are, I suspect that some sort of a malar or extended tear trough implant with or without a mid-facelift performed from below, not above, would be helpful.


Robin T.W. Yuan, M.D.

Robin T.W. Yuan, MD
Beverly Hills Plastic Surgeon

Options for lower eyelid hollows

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Incision below the lashes, called infraciliary incision, has a definite risk of pulling the lower eyelids down.  If possible, the transconjuctival approach is safer.  Fillers are another option which are safe if used conservatively.  Consider seeing an oculoplastic surgeon.

Mehryar (Ray) Taban, MD, FACS
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 91 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.