Dr Terino - Eye Area

Nothing detracts more from facial beauty than tired, hollow looking eyes. Remember, when people first meet you and you them, you are looking at their face but actually directing your view to their eyes, cheeks, and nose. Hollow, tired looking eyes occur from many causes.

Sometimes they are hereditary in nature and are visible in a child or a young person’s face. Because these types of faces are young and smooth, the eyes are forgiven by the observer in most cases.

Some hollownesses under the eyes are hereditary because cheek bones and the underneath part of the eye socket are shallow and not strong. This allows the natural fat inside the eye socket to bulge out and produce “eye bags.” Most of the time tired hollow looking eyes are greatly accentuated with aging, emotional stress, and many illnesses.

The original operation performed by plastic surgeons in the 1970s and 1980s are unfortunately still being performed by most cosmetic surgeons today, which is to remove fat from the eye socket and try to pull the lower eyelid skin tight to make the hollowness look more shallow and the skin wrinkles taken away.

Unfortunately, this treatment does not work in the majority of patients. Instead, the eyes look much, much worse afterwards. By taking the fat out, the eye socket looks more hollow and by trimming skin out, the lower eyelid which is a “curtain rod” type of structure, pulls downward leaving a very sad, bloodhound look to the eyes, rather than a natural beautiful almond-shaped uplifted appearance to the corners of the eyes.

Today, people are trying to inject fat from the patient’s body into the hollowness under the eyes and the “tear trough” which extends downward from the inner corner of the eye as a deep groove where tears flow down when the patient is crying.

Though there are surgeons who claim that they can make fat injections successful, in most cases. However, nearly all plastic surgeons who have tried this technique over the last 15 years have given it up and agree that most of the fat seems to go away, or at the very least fat injections need to be done several times over again. Also, unattractive lumpiness from the fat transplants are clearly seen through the thin eyelid skin. These look highly unattractive, and are most of the time impossible to remove to the patient’s satisfaction.

HA (hyaluronic acid fillers) do a reasonable job for an eye socket which is not too deep and hollow. 1 or 2 syringes may very well last for 6 months to a year and then require only a minor touch up. The nice feature of hyaluronic acid fillers is that the enzyme hyaluronidase, commercially known as Wydase, can be injected into the area where the fillers were placed and will dissolve the injected filler within 24-48 hours.

The main permanent correction, however, for tired hollow eyes, is a suborbital (underneath the eye socket) implant, which extends to the outside corner of the eye, or in many instances is combined with a cheek implant into one complete implant, that builds up the flatness underneath the eye and of the cheek all at the same time.

This new implant created by Dr. Edward O. Terino, pioneer of facial implant designs, has excellent results that are making many people extremely happy.

However, it is a more detailed and complicated, precise operation than a simple brief cheek implant insertion, because a certain amount of surgery has to be performed in the lower eyelid under the eyelashes, as well as inside the mouth. This is necessary to clearly identify the main nerve (called infraorbital nerve), which comes out under the inner part of the eye socket from the bone and provides feeling in the skin of the side of the nose, the lower eyelids, and the cheeks all the way down, including the upper lip. Minor damage to the infraorbital nerve may produce changes in feeling which will be only temporary and annoying. This occurs only rarely, even with an experienced surgeon. An experienced surgeon, however, will make certain that the implant has been placed properly around the nerve.

Therefore, a combined implant is placed on the lower bone of the eye socket on the outside of the orbital rim as it is called and onto the cheek as well. This requires about 2½ hours of surgery, compared to the 30-minute cheek implant or chin implant procedure.

The Hospital Group Plastic Surgeon doctors use computer photographs which enable them to make changes of the patient’s facial image in the major significant contours imitate surgical changes of the cheekbones, nose, chin, jaw, lips, eyes, eyebrows, forehead, and neck. The computer imaging consultations are designed according to the patients descriptions of the changes they feel will benefit them.

Alloplastic facial contouring has evolved from being an “ancillary procedure” to a standard valuable tool in the armamentarium of cosmetic facial surgeons over the last 25 years. Dr. Terino has pioneered most of the implants and techniques now used by surgeons worldwide (1). The results have proven over time to contour corrections of permanence and with minimum (less than 1%) morbidity. The many myths about alloplastic augmentation have been dispelled by the author from his 30 years of experience with these techniques and they can now be used safely and effectively by any well-trained plastic surgeon who has an interest in 3 dimensional aspect of aesthetic facial surgery.

According to Dr. Terino’s original anatomic zonal concepts of facial skeleton(2), the suborbital zygomatic region is comprised of: 1.) Zone 1, the major body of the malar bone defined medially from the infraorbital nerve and laterally by the beginning of the middle third of the zygomatic arch and 2) Zone 3, the paranasal suborbital zone which extends from the nasal bone – maxillary tissue to the infraorbital nerve. It contains the well-described “tear trough” sulcus.

The suborbital region has commanded significant attention over the past 10 years due to the advent of upper mid face suspension techniques designed to improve tired, hollow appearance and the depression of the lid-cheek junction(3), which occur mostly with the aging process but also as a hereditary variant. More over, it has now been validly established by prominent investigators (A)that the aging process of the upper mid face results largely from atrophy or shrinkage of the volume of fat contained in the periorbital and the malar regions which is present in the youthful phases of life, age 1 to 30 on the average.

This paper will discuss the significant advances made in aesthetic improvements of the suborbital, zygomatic, malar region which can be accomplished with alloplastic augmentation and also through the useful adjuncts of upper mid face suspension, Lateral Brow-temple contouring, and lateral canthopexy techniques. Alloplastic implants designed specifically for the sub orbital tear trough malar region can eliminate the need for techniques using fat rearrangement in the inferior orbital and suborbital region that may produce undesired sequelae such as lower lid retraction (ectropion) and visible unattractive irregular “lumpiness”.

Definition of the Suborbital Maxillary Tear Trough Malar Deficiency

A hollow suborbital groove, commonly occurs at the junction of the eyelid and the cheek.

Deficiencies of the facial skeleton in the suborbital malar zygomatic region can be hereditary or posttraumatic. This author’s original experience that stimulated the origin of his investigations into corrections of these deficiencies began with maxillo-facial deformities from poorly reduced suborbital or tri-malar fractures. In the late 1960s utilization of alloplastic materials such as hand carved Silastic sponge could produce a very successful improvement towards normal. This experience prompted the author to develop alloplastic anatomically contour silastic implants for the malar-zygomatic midface region.

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