Lower blepharoplasty or malar lift
when each is needed

Eye bags and a sagging cheek are not the same problem. When lower blepharoplasty is enough and when a malar (midface) lift is needed.

“Bags under the eyes” and “hollow cheeks” are often treated as one problem, but their causes are different. When the wrong operation is done, the result is at best insufficient and at worst a changed, gaunt look. Here is how the two situations are told apart.

Lower blepharoplasty — for eye bags

Bags form when the fatty tissue behind the eye bulges forward because the septum that holds it back weakens. Sometimes there is also excess, loose skin on the eyelid.

• The fat is removed or — even more often — repositioned so that it fills the transition between the eyelid and the cheek.
• Access may be through the inner surface of the eyelid (with no visible incision) or just below the lash line when skin also has to be removed.
• It is most suitable for patients with bulging bags but a well-positioned cheek and good lower-lid tone.

Malar (midface) lift — when the cheek has dropped

Over the years the soft tissues of the cheek slide downward. The eyelid looks longer, and a groove forms from the corner of the eye down towards the cheek, and the bags look more pronounced. The cause is not the eyelid itself but the lack of support beneath it.

• The fat pad of the cheek and the tissues of the midface are lifted and fixed again.
• This shortens the distance between the eyelid and the cheek and smooths the transition.
• The approach is chosen according to the case and is discussed at the consultation.

How the decision is made

At the examination several things are assessed: how much fat there is in the bag, where the cheek sits in relation to the eye, how firm the lower eyelid is, and how much skin is in excess. If the cheek is in its place and the eyelid is firm, lower blepharoplasty is usually enough. If the cheek has dropped, blepharoplasty alone can leave the result incomplete, and in some cases make it worse. Often the best result is a combination of the two.

Risks of the wrong choice

• Removing too much fat when the cheek has dropped leads to a hollow, gaunt look.
• Pulling the skin of the lower eyelid too tight can draw it downwards — the white of the eye shows, and rarely the eyelid turns outwards (ectropion).
• That is why, with the lower eyelid, it is better to remove less rather than more.

Recovery

After lower blepharoplasty, swelling and bruising usually settle within 1–2 weeks. After a malar lift, swelling lasts longer, and the final result takes shape over several months.

What cannot be promised

• The disappearance of dark circles when they are due to pigment or to thin, translucent skin.
• Stopping ageing — surgery restores the position of the tissues, not time.
• An identical result to one in a photo from the internet or to other patients’ results — every face is different.