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Beautiful eyes

Esther Loh speaks to consultant plastic and reconstructive surgeons ABOUT ways to rejuvenate the eye area and take years off the face instantly.

Our eyes are probably the first things that people notice about us. Droopy eyelids make us look sleepy and can actually impair eyesight, while wrinkles and eyebags have an aging effect. Nowadays, we are lucky in that there is a whole tool box full of products to make the eyes appear larger, more alert or mysterious – from newfangled makeup tips to false eyelashes or lash extending mascara to tricks with eyeliner to coloured contact lenses. There is also a panoply of eye creams and serums that can be massaged into the periorbital area in the hope of getting rid of or keeping wrinkles at bay. However, there will come a time when these tricks no longer work to conceal our fine lines, wrinkles and eyebags. What to do then?

As most Asians are born with single eyelids, Asian blepharoplasty, or double eyelid surgery, is the procedure that is most commonly performed in Asia. But blepharoplasty isn’t just about adding a fold to an otherwise foldless lid. It may also be about lifting the lid to make way for better vision, smoothing the skin around the eyes, and removing excess baggage. According to the American Society of Plastic Surgeons (ASPS), in 2011 there were 196,000 eyelid surgeries done in the US, making it number four in the most asked for list of procedures. In Asia, while statistics are not available, most plastic surgeons will tell you that eyelid and eye bag surgery rank at the top.

The Eyelid Surgery Transition

Eyelid procedures can be traced back to the first century when Aulus Cornelius Celus practiced a procedure to relax the upper eyelids, a procedure documented in his book, De Medicine. In the tenth century, there are documented cases of Arabian doctors removing fat from the upper eyelids. More recently, in the 1800s, a doctor by the name of Karl Ferdinand Von Graefe, gave eyelid surgery the name ‘blepharoplasty’ when the technique was used to repair deformities caused by cancer in the eyelids.

In 1907, Dr. Charles Conrad Miller published Cosmetic Surgery – The Correction of Facial Imperfections, writing extensively on blepharoplasty as a cosmetic procedure. Some of his text and detailed diagrams on incisions are still in use as reference materials today. By the 1940s, fat removal around the eyes had grown to be a popular procedure.

Developments in cosmetic surgery grew in leaps and bounds during World War I when doctors’ skills were honed by performing reconstructive procedures on soldiers and other war injured. This laid the foundation stones for modern cosmetic surgery, allowing for trial and error in procedures and leading to many of the advancements that we know of today.

From invasive to minimally-invasive techniques, blepharoplasty and other eye-enhancing procedures have helped many to achieve their desired appearance of bigger, brighter and younger-looking eyes. There are now basically two methods for producing double eyelids and to remove eye bags – incisional and non-incisional.


Creating Double Eyelids

Dr. Lee Kim Siea
Consultant plastic and reconstructive surgeon Dr. Lee Kim Siea says smaller folds are in at the moment.

According to Malaysian consultant plastic and reconstructive surgeon, Dr. Lee Kim Siea, the trend with blepharoplasty is now to make the patient look as natural as possible – with smaller folds compared to the higher folds created in the 1960s and 1970s.

Malaysian consultant plastic surgeon, Dr. Cheong You Wei, also adds that patients do not want to be asked if they have had cosmetic surgery done. “They want to look younger and better in a natural way. Previously, they tended to remove too much of their fat and skin, which created an unnatural result. Now, we give them a natural yet noticeable result.”

Pictures courtesy of Dr. Lee Kim Siea

Before and after incisional low fold upper eyelid surgery.

Before and after stitch technique on the upper eyelid of the patient.

Before and after incisional low fold upper eyelid surgery.

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

Before and after stitch technique on the upper eyelid of the patient.

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

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

Patients can experience lasting results with incisional double eyelid surgery.

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

• Long lasting results with incisional technique

Dr. Lee mainly performs an incisional blepharoplasty technique as it is very versatile and appeals to almost anyone, he says, including young individuals with minimum fat and skin laxity and those with excessive fat and skin.

The height of the fold will be decided after a thorough consultation with the patient. “I create a low fold which is about two to three millimetres, medium fold of three to five millimetres and high fold that can be anything higher than that. However, I do not encourage Chinese patients to get a high fold as it can give a very unnatural appearance especially in young patients,” says Dr. Lee.

“The eyelids are a very delicate area and the margin of error is very narrow. A half millimetre difference could affect the overall result and could lead to complications too. Hence, the procedure needs to be very precise and detailed,” reveals Dr. Cheong, who says it is very important to mark up the patient accurately before surgery.

Dr. Cheong You Wei
Consultant plastic surgeon Dr. Cheong You Wei says the mark-up is important.

According to Dr. Cheong, the surgery starts with an incision on the upper eyelid in the pre-determined location. A minimal amount of skin may be excised according to the degree of the patient’s skin laxity. Then, he will make an opening on the orbital septum which exposes the orbital fat. The orbital fat is only removed if deemed necessary, otherwise the fat is preserved. He will then attach the aponeurosis (flat connective tissue that serves as an extension of the levator muscle that elevates the eyelid) to the muscle and skin with sutures to create the crease for a double eyelid.

Pictures Courtesy Of Dr. Cheong You Wei.

Patients can experience lasting results with incisional double eyelid surgery.

Patients can experience lasting results with incisional double eyelid surgery.

“Patients will experience swelling, the worst being on the second day after surgery, but this will subside in time. Stitches will be removed five days after surgery. They will also notice that the double eyelid folds created are higher, thicker and more prominent during the first few weeks after the procedure. This is common due to swelling tissue. They need to wait about two to three months for the eyelids to return to normal and look natural again,” says Dr. Cheong.

After the procedure, antibiotics and painkillers will be given. Dr. Cheong also suggests that patients apply ice packs and use extra pillows to elevate the head when sleeping to minimise swelling.

Dr. Lee, who uses a carbon dioxide laser to perform the incisions, finds that the laser is useful in reducing bleeding and swelling. “As for fat, I like to conserve it as far as possible because patients will lose fat volume as they grow older. I notice that removing too much fat during the operation may potentially result in sunken eyes as they grow older.”

Dr. Lee also warns of complications such as haematoma, asymmetrical folds, scarring, sunken eyes, an unnatural look and ptosis (droopy eyelids). Blindness can also occur due to removal of fat without stopping the bleeding which results in a large haematoma compressing the optic nerve. However, in proper, well-qualified hands this should not happen or would be rare.

• Scarless Stitch Technique

The stitch technique is also known as the scarless double eyelid procedure and, as the name states, does not involve any incisions. “There have been many variations and refinements to this stitch technique, and it has become known by many different fancy names but the principles of the procedure remain unchanged,” says Dr. Lee.

The stitch technique gives good results to young patients with thin skin who do not have excessive skin and fat, says Dr. Lee. However, it carries a higher chance of asymmetry and there is also the possibility of losing the fold – up to about 50 percent after a year – although some surgeons have better results than others.

“This procedure involves applying stitches through the skin to create a fold on the upper eyelid. I usually apply three stitches to get a nice fold. This method offers the advantage of quick recovery unless blood vessels are accidently punctured which may result in more swelling and bruising,” explains Dr. Lee.

Dr. Cheong adds that this technique does not leave any scarring as no incisions are involved and a closed method is used. “Surgeons do not have a direct view of the internal anatomy but instead, stitch the eyelid skin to the aponeurosis based on experience. When the stitching is done, the aponeurosis will attach to the overlying skin to create a double eyelid fold when the eye opens. Also, a small incision of two to three millimetres to the lateral side of the eyes can be done to remove any excess fat if necessary.”

Similar to the incisional technique, the eyelids will be higher and thicker after the procedure but patients can see natural and final results within one or two months. “Minimal swelling and bruising will occur but they are much less than the incisional technique,” assures Dr. Cheong.

Post operatively, cold compresses can be used to reduce any swelling and bruising – which could last for about two weeks. Patients must keep the area clean and apply antibiotic ointment to the wound, advises Dr. Cheong.

Under Eye

Eliminating Excess Baggage

Dr. Heng Kien Seng
Consultant plastic and reconstructive surgeon Dr. Heng Kien Seng says patients are opting for less invasive eye bag re- ducing techniques.

Puffiness or the appearance of bags under the eyes occur from weakening of the orbital septum muscles, could cause the inner layer of fat to bulge out. Hereditary factors also play a part in eyebag formation. Related conditions such as dark circles, which are sometimes shadows cast by puffy eyelids or sunken areas under the eyes, also appear as age catches up on us.

According to Malaysian consultant plastic and reconstructive surgeon, Dr. Heng Kien Seng, the trend for eliminating under eye issues used to be invasive. But now, patients opt for less invasive methods. “They just want filler injections to camouflage the problems and they’re happy with their imperfections.” He further explains, “For example, a woman in her 60s who doesn’t have any wrinkles and eye bags would be too perfect for someone in her 60s. They prefer to look like they have aged naturally or are several years younger and have some improvement to their areas of concern. However, non-surgical methods can only help to a limited extent and surgery will still play an important role in eye rejuvenation especially in eye bag removal.”

Pictures Courtesy Of Dr. Heng Kien Seng

Visible results can be seen after transcutaneous lower blepharoplasty.

Visible results can be seen after transcutaneous lower blepharoplasty.

Pictures Courtesy Of Dr. Heng Kien Seng

No visible scarring after transcutaneous lower blepharoplasty.

No visible scarring after transcutaneous lower blepharoplasty.

Pictures Courtesy Of Dr. Heng Kien Seng

Patients who are not ready for surgery can opt for lower eyebag removal with botulinum toxin type A and fillers injections.

Patients who are not ready for surgery can opt for lower eyebag removal with botulinum toxin type A and fillers injections.

Dr. Tan Geok Puan
Consultant plastic and reconstructive surgeon Dr. Tan Geok Puan says dark circles can be hard to treat.

Malaysian consultant plastic and reconstructive surgeon, Dr. Tan Geok Puan, adds that dark circles are difficult to treat at times. “If it was caused by eye bag protrusion, then treating it by removing the fat should suffice. If it is due to increased vascularity or pigmentation of the skin, then the patient may need additional treatments on top of surgery. Furthermore, some patients have syringomas (sweat gland tumours presenting as tiny bumps) and scars on the lower eyelids which may be partially corrected after the eyebag surgery. These conditions may require other additional treatments such as laser ablation.”

Pictures Courtesy Of Dr. Tan Geok Puan

Younger looking eyes can be achieved with transcutaneous blepharoplasty.

Younger looking eyes can be achieved with transcutaneous blepharoplasty.

Younger looking eyes can be achieved with transcutaneous blepharoplasty.

• Targeting loose skin and fat with the transcutaneous technique

Also known as the open technique, the transcutaneous method involves making an incision on the outside of the lower eyelid. This provides more opening for surgeons to address excessive loose skin as well as fat.

Dr. Heng says that this method is often accompanied by a minor canthopexy, a procedure done to strengthen the support of the lateral canthal tendon at the outer corner of the eyelids to prevent ectropion, a condition where the lower eyelid turns outwards.

He explains of the transcutaneous method, “I will cut through the muscles and raise the flap. Then, I will dissect the skin and muscle of the fat layer and remove them or reposition the fat as needed. Then, I will proceed with a canthopexy. Thereafter, excess skin will be trimmed away and lastly, the incision will be closed.”

Healing of the wound takes about two to three weeks and scarring will fade over about three months. In the mean time, patients can camouflage it by putting on make-up. Dr. Heng advises patients not to exert themselves and says not to bring their heads lower than the heart. “Good fibre intake is also important to prevent straining and constipation. Remember not to rub the eyes or strain them in front of the television or computer. Cold compresses can be applied for 20 – 30 minutes to reduce swelling. This is recommended for the first 24 hours after the procedure. Stitches can be removed after five to seven days.”

Risks include depression or sunken eyes if too much fat is taken out. Double vision may occur if the muscle is injured. If the lateral canthus is not stitched up properly, it may cause an unnatural look to the corner of the eye. And as with all blepharoplasties, ectropion, scleral show, dry eyes and chemosis are all possibilities. But results can last for many years if the patient ages well and leads a healthy lifestyle. “Ageing is accelerated if the patient consumes alcohol, smokes and has lots of late nights out,” says Dr. Heng.

• Scarless transconjunctival technique

The scarless transconjunctival approach involves no incisions, hence there will be no scarring. It is most suitable for young patients with only eye bags or dark circles. It does not address excessive skin.

Dr. Tan says, “The incision is made inside the lower eyelid, just under the tarsal plate, a plate of dense connective tissue along the border of an eyelid. Excess fat is removed through this incision. This technique provides blind access – where we do not have a clear view into the eyelid area as it is done from the inside. Hence, a good outcome depends on the skills and expertise of the surgeon.”

He adds that the amount of fat to be removed and left behind needs to be balanced. The patient will be left with sunken eyes if too much fat is removed. “I prefer to do it more conservatively rather than too aggressively to prevent further complications.”
With this scarless approach, patients can expect less downtime in terms of bruising and swelling compared to the open technique. The eyes should look natural within two to three weeks.

Dark Circles

Treating Dark Circles With Fat Grafts

Dr. Koh Ik Soo
Korean plastic and surgeon Dr. Koh Ik Soo.

For correcting dark circles around the eye, Korean plastic surgeon Dr. Koh Ik Soo uses fat injections. According to Dr. Koh, under eye dark circle and eye bag removal are highly popular treatments in Korea.

This treatment, which was developed and enhanced by Dr. Koh, combines fat injections with eye bag removal via surgery. These two procedures appeal to his patients from both genders and across all ages as they are effective in facial rejuvenation to improve dark circles and reduce hollowness and eye bags.

Although fat injection is not a new technique, it requires substantial expertise to inject the fat cells into the right layer so that they survive better and to avoid uneven results on the surface of the skin. Furthermore, the surgeon needs to know the best place from which to harvest the right quality of fat, and to remove it gently to minimise damage to the cells.

“I will inject the fat into the muscle layer where fat cells can build a network of blood supply and prevent absorption by the patient’s own body. This leads to higher chances of survival and the surviving fat cells will remain where they are. Fat injection into the subcutaneous layer will cause the cells to be resorbed by the body or to disappear with ageing.

“Another advantage of fat injections into the muscle is that it will not cause an uneven surface after the procedure. The fat is injected little by little to make sure the fat cells are distributed evenly into the muscle layer for a smooth surface and to guarantee a good survival rate,” Dr. Koh explains.

Since fat cells need at least three months to settle and survive in the new area, patients should not touch or apply pressure to the treated area. Such actions can cause fat displacement and affect the survival rate of the cells. If the fat does not survive successfully or is displaced, a repeat procedure will be needed.

Pictures Courtesy Of Dr. Koh Ik Soo.

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

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

Correcting An Epicanthic Fold

Apart from the common condition of single eyelids, Asians, especially those in Mongolia, China, Japan, Korea and Taiwan, are more likely to have an epicanthic fold. It is a veil of skin draping in the inner segment of the eye which leads to the appearance of a wider distance between the eyes. This condition can be corrected with a medial epicanthoplasty.

“If the patient chooses to undergo double eyelid surgery without removing the epicanthic folds, it will end up widening the distance of the eyes and fail to give the eyes a fresh look. Therefore, patients with epicanthic folds should have them removed first and undergo double eyelid surgery by making the crease from the epicanthus. For those who already have double eyelids, undergoing medial epicanthoplasty can make their eyes look more alert and engaging,” Dr. Koh says.

Pre-surgery discussion is very important to achieve a satisfying result for the patient. During consultation, Dr. Koh will create a false line to simulate the final result the patient can achieve. “I will also explain thoroughly how much veil will be removed and where the resection area is. Upon mutual understanding, we will go ahead with the procedure. Patients have to realise what practical, achievable results can be seen through this procedure,” Dr. Koh adds.

He begins the procedure by pulling out the veil towards the nose and reveals the area covered by the epicanthic fold. Then, he makes an incision according to the markings over the area that will be removed during the operation. By moving the medial canthus closer towards the nose, it will lengthen the eyes and give it a fresh look. Lastly, the incision is closed and it will fade into the eye layer after swelling subsides. There is no scarring involved with this method.

Done under local anaesthesia, post-procedure swelling will subside in two weeks and the final results can be seen after three months.

Repositioning The Fat

Rather than throwing it away, fat is now moved and put to different uses
Previously in cosmetic surgery, fat was deemed as useless tissue to be discarded. More recently, however, it has been put to use as an autologous volumising agent, particularly for the breasts and buttocks. With eye surgery, rather than discarding fat, it is nowadays usually repositioned to fill up hollow under eye areas (minus the centrifugation and injection that would be required with autologous fat treatments).

Dr. Heng shares, “Instead of taking the mountain and throwing it away, now we fill up the valleys with it. We can reposition or lift the fat to achieve the results of a mid face 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 to the mid cheek. The fat is then stitched to the bone area to give a smooth transition from 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 to previous surgeries, where too much fat might have been removed. It can be done either on the upper eyelid or lower eyelid area,” Dr. Tan continues.

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

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

The Brow

Brow Lifting Procedures

In upper face and periorbital rejuvenation, a brow lift can lift the brow as well as lift the upper eyelid skin and minimise wrinkles around the eyes. In some cases of droopy upper eyelid due to ageing, a brow lift can be done rather than upper blepharoplasty alone. Proper assessment is required to decide on the best option for the patient.

• Endoscopic

Dr. Cheong performs the endoscopic brow lift, which involves making small incisions behind the hairline. A special dissector is used to free the forehead skin from the bone. Then, the skin is pulled up, repositioned and anchored to the bone.

“There will be swelling for about a week and some patients may need a drain for a day. Recovery is faster than with eyelid surgery. The patient should keep the wound dry and apply ice packs to reduce swelling.”

• In Eyebrow

Apart from that, the patient could opt for a direct brow lift. This is a simple and fast procedure that involves excision of excess skin just above the brow. “However, it is not as versatile as the endoscopic brow lift. You’ll have a scar along the upper eyebrow but it heals very well. The patient can have eyebrow embroidery or an eyebrow tattoo to conceal the scarring,” Dr. Cheong adds.

Bottom Line

Indeed, surgery to the eye area has come a long way since it was first introduced in the first century! Many procedures have evolved and gone through countless modifications and improvements and they are constantly refined to provide better results with minimal risks and complications.

Dr. Heng comments, “By learning from senior surgeons and from our own experience, we know what causes possible complications. Now that we know how to prevent and correct them, we can produce good results with fewer complications and at the same time, prevent them from occurring. We are moving towards a time of fewer complications with less re-do surgeries in eye procedures.”

Dr. Lee adds that recovery time has also shortened due to good techniques. “There are many aids available such as better sutures and the use of lasers to help surgeons perform 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-specialists or worse, non-medical personnel!”

Alternative And Complementary Procedures

Limited blepharoplasty, pinch blepharoplasty and other treatments

Depending on a patient’s condition and preferences, the issues faced by them could be addressed through various modifications and refinements by surgeons.

“Some patients prefer minor surgery to improve their condition without having long downtime. To accommodate their preferences, we can customise the procedures for them 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 lifting at the sides of the eyes. The excess skin is lifted and excised to give some degree of improvement to the overall appearance without removing the fat. On the other hand, the pinch blepharoplasty is minor surgery where the surgeon will remove excessive skin over the eyelid.

Although the downtime for these two procedures is much shorter, they do not thoroughly 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 not want full surgery. He was not looking for big changes but minor improvements with minimal swelling, bruising and downtime. So, I made a couple of small incisions of half a centimetre over the fat area and removed some of the fat while leaving the skin intact. He was happy because he did not feel the excess baggage under the eyes anymore,” Dr. Tan adds.

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

• Complementary non-invasive treatments

To complement the results of surgery, different treatments, ranging from botulinum toxin type A to fillers and lasers can be added.

Dr. Tan Geok Puan says, “For patients from an older age group, we would recommend additional treatments for a complete rejuvenation around the eye area or whole face. It is because aged skin has more dramatic changes such as fine lines, wrinkles, pigmentation 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 appearance to the area below the eyes,” Dr. Heng says.

Guide to Malaysian Doctors of Aesthetics

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