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Dr. Barry Eppley

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Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Posts Tagged ‘cheek lifts’

The Tear Trough Deformity – Its Anatomy and Surgical Correction

Friday, June 8th, 2012

One facial area that has caught a lot of attention over the past few years is that of the tear trough deformity. Technically known as the nasojugal grove, it is a skin indentation that begins at the inside of the lower eyelid and extends obliquely downward to the lower rim of the eye socket. While some people have it naturally, most do not and it is usually appears with aging. As the fat of the lower eyelid herniates or becomes protrusive, the depth of the tear trough becomes more apparent and deeper. This leads to the dreaded ‘dark circles’, which often drives patients to some form of treatment.

While the tear trough has been around for a long time and is a well acknowledged  deformity, why does it exist and what causes it? On this surface this question may seem somewhat irrelevant, but effective treatments relay on correcting the underlying anatomic problem.

In the June 2012 issue of Plastic and Reconstructive Surgery, a study evaluated the anatomic basis for the tear trough deformity. Through cadaveric facial dissections, an osteocutaneous ligament was found on the upper part of the maxilla which extends up into and through the orbicularis muscle on the inner aspect of the lower eyelid. This is why tear troughs exist and is know going forward as the tear trough ligament. How much of a tethering effect that this ligament has is one major determinant on how prominent the tear trough deformity appears. Other factors creating or exaggerating its appearance is bulging orbital fat above the ligament and infraorbital/maxillary bony retrusion below it.

The most common treatment of the tear trough deformity are injectable fillers, usually hyaluronic-based materials. (e.g., Restylane, Juvederm) By adding volume beneath the tear trough, the soft tissues containing the ligament are pushed outward, softening its appearance. This volumetric approach works best when the tear trough is mild and is very technique-sensitive. Injecting into the ligament and above it just under the skin will actually worsen its appearance.

A similar effect is seen with medial orbital rim or tear trough implants. Placed beneath the ligament and on the bony rim, they add a permanent volumetric outward push. The placement of implants is also assisted by the subperiosteal dissection used to place them. This inadvertently releases the maxillary origin of the ligament thus eliminating the tethering effect.

In cheek lift procedures, dissection should be carried across to the medial orbit rim to release this ligament. This will help soften the tear trough through the pull of the tissues lateral to the orbit over the cheek. Transposing orbital fat into the released tear trough space will help create a more permanent effect.

The tear trough deformity is more than just a simple skin indentation in the lower medial eyelid area. It is there due to the tethering effect of an actual ligament, which is why it changes in appearance with smiling and squinting. Injectable fillers temporarily efface it by adding volume. This is usually a good place to start for more mild tear troughs. Lower blepharoplasties with fat transposition is useful when substantial lower fat herniation (bags) exists. Tear trough implants can be used when one is younger with deep tear troughs and a flatter midface profile. Cheek lifts and ligament release are used as part of a more extensive facial rejuvenation approach in more advanced stages of aging.

Dr. Barry Eppley

Indianapolis, Indiana

Midface Rejuvenation – Cheek Lifts vs Cheek Implants

Saturday, October 17th, 2009

As one ages, the entire face changes. Some parts of facial aging are more obvious than others as the face does differentially age. The forehead, brows, eyes, mouth, jawline and neck are all areas whose aging is well recognized. The aging of the midface and cheek areas, however, has only become more recently recognized.

With the aging process, the fatty tissue that normally drapes over the cheekbones can begin to sag. The result is less prominent cheekbones, and a droopy fold of skin and fat between the nose and the cheek (the nasolabial fold). The sagging cheek fat can also alter the appearance of the lower cheek. For example, bagginess of the lower eyelids often becomes more apparent after the fat of the upper cheek begins to sag. This in essence ‘unveils’ the bagginess of the lower lids, which have always been there. In addition to sagging of the skin and fat of the midface, there is also volume loss in the cheek due to loss of fat and muscle.

A number of cheek lift or midface lift procedures exist to address this aging area. The goal of all of them is to lift up droopy cheek tissue over the cheekbone restoring the more prominent youthful contour, improving the tear trough and bagginess of the lower lids, and softening the undesirable cheek fold. Fundamentally, they may be divided into lifting approaches vs volumetric addition. In some cases, they may even be done together.

Lifting approaches aim to reposition the sagging fat of the cheek over the cheekbone to restore the youthful fullness of the cheeks. Such midface lifts use differing access including the lower eyelid, scalp, and temporal incisions using open incisional or endoscopic instrumentation. Implants have also been devised to provide less invasive options including suspension sutures and bone-anchored lift devices. The plethora of differing lifting approaches suggests that no one of them is universally successful.

Contrarily, cheek implants have also been used to help create a degree of cheek lifting. By placing an implant through the mouth onto the cheek bone, some fullness is added to the volume-depleted cheek and the cheek tissue on top of the implant is pushed upward. While not creating as dramatic effect as a lifting procedure, it is far simpler and with fewer complications. This cheek lift approach, using a specially designed submalar implant which fits on the underside of the cheek bone, has been around for nearly two decades. When used in the right patient and properly sized, it can have a good cheek enhancement effect. But it is also easily overused and overdone (too large a size) as older celebrity faces are rife with examples of odd-looking and peculiar cheek prominences due to oversized implants.

Given the choices between cheek lifts and cheek implants, which is the most helpful for cheek rejuvenation? The answer is no one of them is best for all patients. Over the years, I have used almost of all of them in my Indianapolis plastic surgery practice….and have also seen and learned the downsides to each of them. Midface or cheek rejuvenation is as much an art form as almost any area of anti-aging facial surgery. Given the potential complications that can occur with lifting procedures, most specifically lower eyelid ectropion, their use should be reserved for the most severe sagging cheek problems. More moderate cases with less prominent cheekbones may benefit with a small to moderate-sized implant. In all cases, moderation is the key…not too much lift or too big of an implant. The midface is one area that does not look good overdone and is easy to do.

Barry L. Eppley, M.D., D.M.D.

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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