From an aesthetic perspective that part of the face is a bit complex, and not always easy to understand. A lot of basic facial aesthetics, especially in young people is primarily based on bone structure even though it often seems like soft tissues are the problem. In reality what happens is the skeletal foundation allows the soft tissue coverage to drape certain ways that some people may find appealing or less appealing. In an ideal, youthful face, the lower eyelid and the area below should be snug and tight with lots of immediate fullness just below that in the upper part of the cheek or midface. with premature facial aging we get a reverse of those contours. The lower eyelid shows bulging from fat pads around the eye that begin to protrude with loss of volume immediately below. When making an assessment, it’s important to differentiate if the problem is bulging fat pads in the lower eyelids or a loss of volume just below this in the midface, the tear trough deformity. Often it’s a combination of both. If the primary problem is bulging a fat pads in the lower eyelids, then plastic surgeons, sometimes remove some of that fat to improve the contour. If there’s a volume deficit in the upper midface then we sometimes restore volume in that area to improve facial aesthetics. Because the two areas are immediately adjacent upon each other it’s important to differentiate what the problem is and recognize that treatments need to be quite precise, in order not to worsen the problem immediately adjacent.
