As the global pandemic drags into a full year of mask wearing, we have been getting more and more inquiries from clients about under-eye bags and what to do about them. It seems that as our eyes have become the focal point of the face with masks on, many people started noticing that their eye bags are more prominent and visible. With that in mind, we sat down with Dr. Shens of Shens Clinic to ask him about the Korean style of Scarless Under-Eye Bag removal as well as whether there are non-surgical options available on the market. Let’s begin:
Thank you again for talking to us today, Dr. Shens. Now, when we say “Scarless Eyebag Removal,” can you tell us exactly what it is?
Dr. Shens: When we say “scarless,” essentially, patients do not want an incision visible to the naked eye on their face. So to do that we approach the eye bag via a trans-conjunctival route, which is on the inside of the lower eyelid. So we actually gently flip the eyelid down and make a cut to access the three pockets of eye bag fat. Depending on where the eyebag excess are located, we can be selective as to how much we remove to create the desired look.
And what about the technique that you use makes it “Korean?”
Dr. Shens: There are many variations we can add to the removal of the eyebag. Essentially, for people whose tear trough region is very sunken, in the past, while we removed the eye bag we would sometimes perform a transposition of the fats to fill in the hollow. But the preferred technique we use now is not a transposition method, because a lot of patients I’ve seen where other doctors have performed a transposition, they actually remove a part of the fats and then place them on the rim and stitch them down. But this tends to result in lumps that are palpable or visible on the face.
So the Korean method is that we will remove these eye bags and do fat grafting, which is actually liquid fat harvested from a different area of the patient, and the fat is re-injected around the tear trough region. That gives a smooth appearance that blends very well, and has an added advantage in reducing the appearance of dark eye circles. This greatly improves the results and patient satisfaction with the procedure.
Can you tell us what causes eye bags?
Dr. Shens: Eye bags are, essentially, genetic. There are some patients I've seen who have eye bags as early as in their teens and others who develop them in their late 30s/40s and onwards but the genetic component is the main component. Aging does play a part in terms of skin laxity and loosening skin as the fats start to herniate and grow and push on the skin and looks worse. But, if you have the genetic predisposition to these fats, they will grow faster and the aging makes it look more exaggerated.
So, based on what you are saying, it is possible that even if you get the fat pads removed they may return?
Dr. Shens: Yes. If you are one of the people who has a genetic propensity for this, we will warn the patient that the fats do grow back, and the surgery might be good for about 8-10 years, perhaps longer. But we do not promise them that this is a one-off treatment, because it's not. But it does offer you the opportunity to live for close to a decade without this issue.
If a patient is re-doing the surgery 10 years later, will it be an issue to do scarless method again?
Dr. Shens: Not at all. You can still do a scarless method even with follow-up surgeries. It won’t be an issue.
Can you tell us if there are different degrees of severity of eye bags?
Dr. Shens: Yes, so what we’ve noticed is that patients will come in at different ages and points in their lives where the eye bags bother them.
Grade 1 Eye Bags
In the first case it is usually minor, or Grade 1 eye bags - when you look up, you'll see the bulge, but when you look straight it is not so apparent and looking down, the fats actually recede so it's not so noticeable.
Grade 2 Eye Bags
Grade 2 is when the eye bags have grown a bit bigger and even when you look straight up the bulge looks worse when you look up and when you close your eyes. THe skin tightens and the eye muscles tighten and the excess fats push out. Grade 1 and 2 eye bags are the best candidates for scarless eye bag removal.
Grade 3 Eye Bags
Grade 3 is when someone has the fat pads coupled with laxity of the overlying skin, so we will need to tighten the skin and in those cases we cannot do a scarless method because we have to cut on the skin to remove the excess skin and tighten the muscle at the same time.
How long does the surgery usually take?
Dr. Shens: It takes me about 15-20 minutes to finish, sometimes up to 10 minutes per eye. Of course if it is a Grade 3 eyebag and we have to do skin tightening it will take me about 30 minutes per eye.
And is this done under local or general anesthesia?
Dr. Shens: 80% of patients get this done under local anesthesia, it's very well tolerated. For those who are quite anxious, then they’ll request to be under light sedation. Your upper eyelids are actually closed during the procedure so it isn’t like you’re sitting there watching me work on you.
Do keep in mind that one of the effects of having the local anesthesia is that it can cause a bit of double vision for the first couple of hours. So we have patients stay in the office to let it wear off, and in some cases will give them an eye patch to help balance their vision because otherwise they don't have stereo vision and they cannot judge distance properly. This wears off within 4 hours of the procedure.
What is the pain level?
Dr. Shens: I would say it is about 2/10 - you will feel a sensation of pressure on the eyeball but it isn’t pain, I would say that's mild discomfort.
And the downtime?
Dr. Shens: Downtime is variable, but the majority of patients who have the transconjunctival eye bag removal will be back to work within 3-4 days. In terms of bruising, the bruising is worse the second day but by day 3-4 the bruise will turn a light yellowish color and it is easily covered up by cosmetics.
Are there stitches inside your eyelid? How does that work?
Dr. Shens: Actually, for the scarless method we don’t stitch the inner wound. When the fats are removed, the conjunctiva basically pulls itself closed, so you do not have to put in stitches. About 15 years ago we used to place stitches but we found that by doing a watertight closure with stitches, it would result in more swelling and bruising. So we haven't been using stitches for a long time - we find the wounds close well and the healing time is lessened.
What are the risks with this type of procedure?
Dr. Shens: Well, there can be swelling and usually bruising. Some patients who take lots of vitamins and supplements tend to actually have more bruising. Those patients who are on blood thinners, we ask them to stop taking that medication for at least 5 days in the week prior to the surgery. We also tell patients not to exercise in the first couple of days or force a cough and control their sneezes. Each of these actions increases pressure on blood vessels and that can increase the bruise. Once we review them a week post surgery and they are healing well they can go back to mild exercise, but heavy exercise like gym activities can resume only at two weeks.
What is the average age of your eye bag removal patients?
Dr. Shens: To be honest, I’ve had patients in their late teens all the way to around 40s and early 50s, as some people still have excellent skin laxity and we don’t have to tighten the skin at 50! But a majority of patients who have the laxity will be over 50.
What about for people who are not ready to have surgery. Are there any non-surgical methods to reduce eye bags?
Dr. Shens: There is a method using radiofrequency (RF) to melt the fats. Having said that, we did look into bringing this machine in and we actually called a representative to explore this option for Shens Clinic. However, when the vendor came in and and we asked him about specifics, like, for example, how long it takes the swelling to go down, he said it takes about a week. And he had a look at our “After” results and he was impressed at our surgical results. He also mentioned that some patients will require two or three sessions in a year to melt the fat. For me, if you’re doing something non-invasive, it doesn't make sense to have to deal with swelling for a week, two to three times a year.
We have had patients who did try the non-invasive method and then ended up coming for surgery anyway because the results weren’t optimal. Because when you melt the fats with RF, they (fats) will necrose (die) and sometimes they form cysts and that results in a lump. So we still have to go in surgically and remove it! It's an unfortunate double whammy for the patient.
Earlier you mentioned that you might do a fat graft for people with hollow set eyes. For those patients who don’t do a fat graft, would those patients do under-eye fillers?
Dr. Shens: So, fat grafting is a volumizing procedure, and so are fillers. The difference is, of course, the fillers have to be repeated every 9 months to a year because they dissolve. One of the advantages to fat grafting is that it can actually relieve the dark eye discoloration for some patients, whereas fillers can sometimes cause something called the Tyndall effect, which causes a light bluish tinge in that lower eye region. Of course, the fat grafting will also last longer than fillers which have to be repeated every 9-12 months. The choice is always up to the patient.
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