ESTHER LOH SPEAKS TO CONSULTANT PLASTIC AND RECONSTRUCTIVE SURGEONSABOUT WAYS TO REJUVENATE THE EYE AREA AND TAKE YEARS OFF THE FACE INSTANTLY.

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Our eyes are probably the first thingsthat people notice about us. Droopyeyelids make us look sleepy and

can actually impair eyesight, while wrin-kles and eyebags have an aging effect.Nowadays, we are lucky in that there is awhole tool box full of products to makethe eyes appear larger, more alert or mys-terious – from newfangled makeup tips tofalse eyelashes or lash extending mascarato tricks with eyeliner to coloured contactlenses. There is also a panoply of eyecreams and serums that can be massagedinto the periorbital area in the hope of get-ting rid of or keeping wrinkles at bay.However, there will come a time whenthese tricks no longer work to conceal ourfine lines, wrinkles and eyebags. What todo then?

As most Asians are born with singleeyelids, Asian blepharoplasty, or doubleeyelid surgery, is the procedure that ismost commonly performed in Asia. Butblepharoplasty isn’t just about adding afold to an otherwise foldless lid. It mayalso be about lifting the lid to make wayfor better vision, smoothing the skinaround the eyes, and removing excessbaggage. According to the American Soci-ety of Plastic Surgeons (ASPS), in 2011there were 196,000 eyelid surgeries donein the US, making it number four in themost asked for list of procedures. In Asia,while statistics are not available, mostplastic surgeons will tell you that eyelidand eye bag surgery rank at the top.

THE EYELID SURGERY TRANSITIONEyelid procedures can be traced back tothe first century when Aulus CorneliusCelus practiced a procedure to relax theupper eyelids, a procedure documented inhis book, De Medicine. In the tenth century,there are documented cases of Arabiandoctors removing fat from the upper eye-lids. More recently, in the 1800s, a doctorby the name of Karl Ferdinand VonGraefe, gave eyelid surgery the name ‘ble-pharoplasty’ when the technique was usedto repair deformities caused by cancer inthe eyelids.

In 1907, Dr. Charles Conrad Millerpublished Cosmetic Surgery – The Correctionof Facial Imperfections, writing extensivelyon blepharoplasty as a cosmetic proce-dure. Some of his text and detailed dia-grams on incisions are still in use asreference materials today. By the 1940s, fatremoval around the eyes had grown to bea popular procedure.

Developments in cosmetic surgerygrew in leaps and bounds during WorldWar I when doctors’ skills were honed by

better in a natural way. Previously, theytended to remove too much of their fat andskin, which created an unnatural result.Now, we give them a natural yet notice-able result.”

• Long lasting results with incisionaltechniqueDr. Lee mainly performs an incisional ble-pharoplasty technique as it is very versatileand appeals to almost anyone, he says, in-cluding young individuals with minimumfat and skin laxity and those with excessivefat and skin.

The height of the fold will be decidedafter a thorough consultation with the pa-tient. “I create a low fold which is abouttwo to three millimetres, medium fold ofthree to five millimetres and high fold thatcan be anything higher than that. How-ever, I do not encourage Chinese patientsto get a high fold as it can give a very un-natural appearance especially in young pa-tients,” says Dr. Lee.

“The eyelids are a very delicate areaand the margin oferror is very nar-row. A half mil-limetre differencecould affect theoverall result andcould lead to com-plications too.Hence, the proce-dure needs to bevery precise anddetailed,” revealsDr. Cheong, whosays it is very im-

Before and after incisional low fold upper eyelid surgery.

This patient underwent medium fold surgery of ap-proximately three to five millimetres to the uppereyelid with the incisional method.

Before and after stitch technique on the upper eyelidof the patient.

Upper blepharoplasty can be done for more distinc-tive eyelid folds.

Consultant plastic surgeonDr. Cheong You Wei saysthe mark-up is important.

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performing reconstructive procedures onsoldiers and other war injured. This laidthe foundation stones for modern cosmeticsurgery, allowing for trial and error in pro-cedures and leading to many of the ad-vancements that we know of today.

From invasive to minimally-invasivetechniques, blepharoplasty and other eye-enhancing procedures have helped manyto achieve their desired appearance of big-ger, brighter and younger-looking eyes.There are now basically two methods forproducing double eyelids and to removeeye bags – incisional and non-incisional.

EYELIDSCREATING DOUBLE EYELIDSAccording toMalaysian consult-ant plastic and re-constructivesurgeon, Dr. LeeKim Siea, the trendwith blepharoplastyis now to make thepatient look as nat-ural as possible –with smaller foldscompared to thehigher folds createdin the 1960s and1970s.

Malaysian con-sultant plastic surgeon, Dr. Cheong YouWei, also adds that patients do not want tobe asked if they have had cosmetic surgerydone. “They want to look younger and

Consultant plastic and reconstructive surgeon Dr. Lee Kim Siea sayssmaller folds are in at themoment.

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UNDER EYEELIMINATING EXCESS BAGGAGEPuffiness or the appearance of bags underthe eyes occur from weakening of the or-bital septum muscles, could cause the innerlayer of fat to bulge out. Hereditary factorsalso play a part in eyebag formation. Re-lated conditionssuch as dark circles,which are some-times shadows castby puffy eyelids orsunken areas underthe eyes, also ap-pear as age catchesup on us.

According toMalaysian consult-ant plastic and re-constructivesurgeon, Dr. HengKien Seng, the trendfor eliminating

portant to mark up the patient accuratelybefore surgery.

According to Dr. Cheong, the surgerystarts with an incision on the upper eyelidin the pre-determined location. A minimalamount of skin may be excised accordingto the degree of the patient’s skin laxity.Then, he will make an opening on the or-bital septum which exposes the orbital fat.The orbital fat is only removed if deemednecessary, otherwise the fat is preserved.He will then attach the aponeurosis (flatconnective tissue that serves as an exten-sion of the levator muscle that elevates theeyelid) to the muscle and skin with suturesto create the crease for a double eyelid.

“Patients will experience swelling, theworst being on the second day after sur-gery, but this will subside in time. Stitcheswill be removed five days after surgery.They will also notice that the double eye-lid folds created are higher, thicker andmore prominent during the first fewweeks after the procedure. This is commondue to swelling tissue. They need to waitabout two to three months for the eyelidsto return to normal and look naturalagain,” says Dr. Cheong.

After the procedure, antibiotics andpainkillers will be given. Dr. Cheong alsosuggests that patients apply ice packs anduse extra pillows to elevate the head whensleeping to minimise swelling.

Dr. Lee, who uses a carbon dioxidelaser to perform the incisions, finds thatthe laser is useful in reducing bleedingand swelling. “As for fat, I like to conserveit as far as possible because patients willlose fat volume as they grow older. I no-tice that removing too much fat during theoperation may potentially result in sunkeneyes as they grow older.”

Dr. Lee also warns of complications suchas haematoma, asymmetrical folds, scarring,sunken eyes, an unnatural look and ptosis(droopy eyelids). Blindness can also occurdue to removal of fat without stopping thebleeding which results in a large haematomacompressing the optic nerve. However, inproper, well-qualified hands this should nothappen or would be rare.

• Scarless Stitch TechniqueThe stitch technique is also known as thescarless double eyelid procedure and, as thename states, does not involve any incisions.“There have been many variations and re-finements to this stitch technique, and it hasbecome known by many different fancynames but the principles of the procedureremain unchanged,” says Dr. Lee.

The stitch technique gives good re-sults to young patients with thin skinwho do not have excessive skin and fat,says Dr. Lee. However, it carries a higherchance of asymmetry and there is also thepossibility of losing the fold – up to about50 percent after a year – although somesurgeons have better results than others.

“This procedure involves applyingstitches through the skin to create a foldon the upper eyelid. I usually apply threestitches to get a nice fold. This method of-fers the advantage of quick recovery un-less blood vessels are accidentlypunctured which may result in moreswelling and bruising,” explains Dr. Lee.

Dr. Cheong adds that this techniquedoes not leave any scarring as no inci-sions are involved and a closed method isused. “Surgeons do not have a direct viewof the internal anatomy but instead, stitchthe eyelid skin to the aponeurosis basedon experience. When the stitching is done,the aponeurosis will attach to the overly-ing skin to create a double eyelid foldwhen the eye opens. Also, a small incisionof two to three millimetres to the lateralside of the eyes can be done to removeany excess fat if necessary.”

Similar to the incisional technique, theeyelids will be higher and thicker afterthe procedure but patients can see naturaland final results within one or twomonths. “Minimal swelling and bruisingwill occur but they are much less than theincisional technique,” assures Dr. Cheong.

Post operatively, cold compresses canbe used to reduce any swelling and bruis-ing – which could last for about twoweeks. Patients must keep the area cleanand apply antibiotic ointment to thewound, advises Dr. Cheong.

Patients can experience lasting results with incisional double eyelid surgery.

Consultant plastic and reconstructive surgeon Dr. Heng Kien Seng sayspatients are opting forless invasive eye bag re-ducing techniques.

Visible results can be seen after transcutaneous lowerblepharoplasty.

No visible scarring after transcutaneous lower blepharoplasty.

Patients who are not ready for surgery can opt forlower eyebag removal with botulinum toxin type Aand fillers injections.

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under eye issues used to be invasive. Butnow, patients opt for less invasive meth-ods. “They just want filler injections tocamouflage the problems and they’rehappy with their imperfections.” He fur-ther explains, “For example, a woman inher 60s who doesn’t have any wrinklesand eye bags would be too perfect forsomeone in her 60s. They prefer to looklike they have aged naturally or are sev-eral years younger and have some im-provement to their areas of concern.However, non-surgical methods can onlyhelp to a limited extent and surgery willstill play an important role in eye rejuve-nation especially in eye bag removal.”

Malaysian con-sultant plastic andreconstructive sur-geon, Dr. Tan GeokPuan, adds thatdark circles are dif-ficult to treat attimes. “If it wascaused by eye bagprotrusion, thentreating it by re-moving the fatshould suffice. If itis due to increasedvascularity or pig-mentation of theskin, then the patient may need additionaltreatments on top of surgery. Furthermore,some patients have syringomas (sweatgland tumours presenting as tiny bumps)and scars on the lower eyelids which may bepartially corrected after the eyebag surgery.These conditions may require other addi-tional treatments such as laser ablation.”

• Targeting loose skin and fat withthe transcutaneous techniqueAlso known as the open technique, thetranscutaneous method involves makingan incision on the outside of the lower eye-lid. This provides more opening for sur-geons to address excessive loose skin aswell as fat.

Dr. Heng says that this method is oftenaccompanied by a minor canthopexy, aprocedure done to strengthen the supportof the lateral canthal tendon at the outercorner of the eyelids to prevent ectropion,a condition where the lower eyelid turnsoutwards.

He explains of the transcutaneousmethod, “I will cut through the musclesand raise the flap. Then, I will dissect theskin and muscle of the fat layer and removethem or reposition the fat as needed. Then,I will proceed with a canthopexy. There-after, excess skin will be trimmed away andlastly, the incision will be closed.”

Healing of the wound takes about twoto three weeks and scarring will fade overabout three months. In the mean time, pa-tients can camouflage it by putting onmake-up. Dr. Heng advises patients not toexert themselves and says not to bringtheir heads lower than the heart. “Goodfibre intake is also important to preventstraining and constipation. Remember notto rub the eyes or strain them in front ofthe television or computer. Cold com-presses can be applied for 20 – 30 minutesto reduce swelling. This is recommendedfor the first 24 hours after the procedure.Stitches can be removed after five to sevendays.”

Risks include depression or sunkeneyes if too much fat is taken out. Doublevision may occur if the muscle is injured.If the lateral canthus is not stitched upproperly, it may cause an unnatural lookto the corner of the eye. And as with allblepharoplasties, ectropion, scleral show,dry eyes and chemosis are all possibilities.But results can last for many years if thepatient ages well and leads a healthylifestyle. “Ageing is accelerated if the pa-tient consumes alcohol, smokes and haslots of late nights out,” says Dr. Heng.

• Scarless transconjunctival techniqueThe scarless transconjunctival approachinvolves no incisions, hence there will beno scarring. It is most suitable for youngpatients with only eye bags or dark circles.It does not address excessive skin.

Dr. Tan says, “The incision is made in-side the lower eyelid, just under the tarsalplate, a plate of dense connective tissuealong the border of an eyelid. Excess fat isremoved through this incision. This tech-nique provides blind access – where we donot have a clear view into the eyelid areaas it is done from the inside. Hence, agood outcome depends on the skills andexpertise of the surgeon.”

He adds that the amount of fat to beremoved and left behind needs to be bal-anced. The patient will be left withsunken eyes if too much fat is removed. “Iprefer to do it more conservatively rather

than too aggressively to prevent furthercomplications.”

With this scarless approach, patientscan expect less downtime in terms ofbruising and swelling compared to theopen technique. The eyes should look nat-ural within two to three weeks.

DARK CIRCLESTREATING DARK CIRCLES WITHFAT GRAFTSFor correcting darkcircles around theeye, Korean plasticsurgeon Dr. Koh IkSoo uses fat injec-tions. According toDr. Koh, under eyedark circle and eyebag removal arehighly populartreatments inKorea.

This treatment,which was developed and enhanced byDr. Koh, combines fat injections with eyebag removal via surgery. These two proce-dures appeal to his patients from bothgenders and across all ages as they are ef-fective in facial rejuvenation to improvedark circles and reduce hollowness andeye bags.

Although fat injection is not a newtechnique, it requires substantial expertiseto inject the fat cells into the right layer sothat they survive better and to avoid un-even results on the surface of the skin. Fur-thermore, the surgeon needs to know thebest place from which to harvest the rightquality of fat, and to remove it gently tominimise damage to the cells.

“I will inject the fat into the musclelayer where fat cells can build a networkof blood supply and prevent absorption bythe patient’s own body. This leads tohigher chances of survival and the surviv-ing fat cells will remain where they are.Fat injection into the subcutaneous layerwill cause the cells to be resorbed by thebody or to disappear with ageing.

Consultant plastic and reconstructive surgeon Dr. Tan Geok Puan saysdark circles can be hardto treat.

Younger looking eyes can be achieved with transcutaneous blepharoplasty.

Korean plastic and surgeon Dr. Koh Ik Soo.

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“Another advantage of fat injectionsinto the muscle is that it will not cause anuneven surface after the procedure. Thefat is injected little by little to make surethe fat cells are distributed evenly into themuscle layer for a smooth surface and toguarantee a good survival rate,” Dr. Kohexplains.

Since fat cells need at least threemonths to settle and survive in the newarea, patients should not touch or applypressure to the treated area. Such actionscan cause fat displacement and affect thesurvival rate of the cells. If the fat does notsurvive successfully or is displaced, a re-peat procedure will be needed.

CORRECTING AN EPICANTHICFOLDApart from the common condition of sin-gle eyelids, Asians, especially those inMongolia, China, Japan, Korea and Tai-wan, are more likely to have an epicanthicfold. It is a veil of skin draping in the innersegment of the eye which leads to the ap-pearance of a wider distance between theeyes. This condition can be corrected witha medial epicanthoplasty.

“If the patient chooses to undergodouble eyelid surgery without removingthe epicanthic folds, it will end up widen-ing the distance of the eyes and fail to givethe eyes a fresh look. Therefore, patientswith epicanthic folds should have them re-moved first and undergo double eyelidsurgery by making the crease from the epi-canthus. For those who already have dou-ble eyelids, undergoing medialepicanthoplasty can make their eyes lookmore alert and engaging,” Dr. Koh says.

Pre-surgery discussion is very impor-tant to achieve a satisfying result for thepatient. During consultation, Dr. Koh willcreate a false line to simulate the final re-sult the patient can achieve. “I will also ex-plain thoroughly how much veil will beremoved and where the resection area is.Upon mutual understanding, we will goahead with the procedure. Patients have torealise what practical, achievable resultscan be seen through this procedure,” Dr.Koh adds.

He begins the procedure by pullingout the veil towards the nose and revealsthe area covered by the epicanthic fold.Then, he makes an incision according tothe markings over the area that will be re-moved during the operation. By movingthe medial canthus closer towards thenose, it will lengthen the eyes and give it afresh look. Lastly, the incision is closedand it will fade into the eye layer afterswelling subsides. There is no scarring in-volved with this method.

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Dr. Koh uses fat to correct under eye dark circles. He combines it withsurgical eyebag removal for better results.

REPOSITIONING THE FAT Rather than throwing it away, fat is now moved and put to different usesPreviously in cosmetic surgery, fat was deemed as useless tissue to be discarded. Morerecently, however, it has been put to use as an autologous volumising agent, particularlyfor the breasts and buttocks. With eye surgery, rather than discarding fat, it is nowadaysusually repositioned to fill up hollow under eye areas (minus the centrifugation and in-jection that would be required with autologous fat treatments).

Dr. Heng shares, “Instead of taking the mountain and throwing it away, now we fillup the valleys with it. We can reposition or lift the fat to achieve the results of a midface lift. It acts as natural filler and gives a good outcome for holistic eye rejuvenation.”

According to Dr. Tan, the fat is not cut at all but is left attached and repositioned tothe mid cheek. The fat is then stitched to the bone area to give a smooth transitionfrom the eyelid to the mid cheek area. Any excessive fat will be trimmed accordingly.

“Besides that, fat grafting can be done for those who have lost fat volume due toprevious surgeries, where too much fat might have been removed. It can be done ei-ther on the upper eyelid or lower eyelid area,” Dr. Tan continues.

Dr. Lee says that a procedure called microfat grafting – where surgeons harvest thefat, centrifuge it, treat it and then inject it with small cannulas, dispersing the graft ontop, within and beneath the muscle layers – is used to correct sunken eye areas.

“The success rate has been good, without any lumpy appearance. However, theprocedure is more complicated and it produces more swelling and bruising, hencethere is longer downtime,” he says.

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Done under local anaesthesia, post-procedure swelling will subside in twoweeks and the final results can be seenafter three months.

THE BROWBROW LIFTING PROCEDURESIn upper face and periorbital rejuvenation,a brow lift can lift the brow as well as liftthe upper eyelid skin and minimise wrin-kles around the eyes. In some cases ofdroopy upper eyelid due to ageing, a browlift can be done rather than upper ble-pharoplasty alone. Proper assessment isrequired to decide on the best option forthe patient.

• EndoscopicDr. Cheong performs the endoscopic browlift, which involves making small incisionsbehind the hairline. A special dissector isused to free the forehead skin from thebone. Then, the skin is pulled up, reposi-tioned and anchored to the bone.

“There will be swelling for about aweek and some patients may need a drainfor a day. Recovery is faster than with eye-lid surgery. The patient should keep thewound dry and apply ice packs to reduceswelling.”

• In EyebrowApart from that, the patient could opt for adirect brow lift. This is a simple and fastprocedure that involves excision of excessskin just above the brow. “However, it isnot as versatile as the endoscopic brow lift.You’ll have a scar along the upper eye-brow but it heals very well. The patientcan have eyebrow embroidery or an eye-brow tattoo to conceal the scarring,” Dr.Cheong adds.

BOTTOM LINEIndeed, surgery to the eye area has come along way since it was first introduced inthe first century! Many procedures haveevolved and gone through countless mod-ifications and improvements and they areconstantly refined to provide better resultswith minimal risks and complications.

Dr. Heng comments, “By learningfrom senior surgeons and from our ownexperience, we know what causes possiblecomplications. Now that we know how toprevent and correct them, we can producegood results with fewer complications andat the same time, prevent them from oc-curring. We are moving towards a time offewer complications with less re-do sur-geries in eye procedures.”

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ALTERNATIVE AND COMPLEMENTARY PROCEDURESLimited blepharoplasty, pinch blepharoplasty and other treatmentsDepending on a patient’s condition and preferences, the issues faced by them could beaddressed through various modifications and refinements by surgeons.

“Some patients prefer minor surgery to improve their condition without having longdowntime. To accommodate their preferences, we can customise the procedures forthem or suggest other methods such as limited blepharoplasty and pinch blepharoplasty,”Dr. Tan Geok Puan says.

A limited blepharoplasty involves removing excess skin laterally and gives some liftingat the sides of the eyes. The excess skin is lifted and excised to give some degree of im-provement to the overall appearance without removing the fat. On the other hand, thepinch blepharoplasty is minor surgery where the surgeon will remove excessive skin overthe eyelid.

Although the downtime for these two procedures is much shorter, they do not thor-oughly correct the underlying source of the problem.

“I had one patient who is in his 60s. He was unhappy with his eye bags but did notwant full surgery. He was not looking for big changes but minor improvements with mini-mal swelling, bruising and downtime. So, I made a couple of small incisions of half a cen-timetre over the fat area and removed some of the fat while leaving the skin intact. Hewas happy because he did not feel the excess baggage under the eyes anymore,” Dr. Tanadds.

Dr. Tan also spoke about a hypertrophic orbicularis muscle – a condition where themuscle beneath the lower eyelid hardens and is often mistaken as an eye bag. Treatmentfor this condition includes botulinum toxin type A for young patients to shrink the muscleto remove the eyebag appearance. That would also result in bigger eyes when he or shesmiles.

• Complementary non-invasive treatmentsTo complement the results of surgery, different treatments, ranging from botulinum toxintype A to fillers and lasers can be added.

Dr. Tan Geok Puan says, “For patients from an older age group, we would recom-mend additional treatments for a complete rejuvenation around the eye area or wholeface. It is because aged skin has more dramatic changes such as fine lines, wrinkles, pig-mentation and a drop in quality of skin texture. Apart from a proper skincare regimen,these treatments are recommended to enhance the results of surgery.”

“For example, the transconjunctival technique does not address skin laxity issues,hence a laser treatment could come in handy to tighten the skin and give a smooth ap-pearance to the area below the eyes,” Dr. Heng says.

Go to this URLhttp://csb.my/node/495for discussion

Dr. Lee adds that recovery time has also shortened due to good techniques. “Thereare many aids available such as better sutures and the use of lasers to help surgeons per-form better surgeries. Qualified surgeons offering these services are also widely available,which enables patients to obtain their services more easily – avoiding the use of non-spe-cialists or worse, non-medical personnel!”

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