Numerous patients with lower eyelid laxity or bulging have different degrees of midface sagging, typically characterized by hollow tear-through grooves that extend to the middle area of the cheek below the eye bag and result in a transverse furrow at the midface submalar triangle (commonly called “Indian’s wrinkles”) as well as deeper nasolabial folds. Such problems are mainly ascribed to early sagging and pulling of the cheek, which makes the original tear-through groove deeper and longer, and are different from the occurrence of an eye bag or tear-through groove caused by simple lower eyelid laxity. Therefore, both lower eyelid and midface sagging should be addressed so that the surgical effects are not compromised.

This surgery is conducted in a similar way to a lower blepharoplasty with eye bag removal. Dr. Chuang first makes an incision at the margin of the lower eyelid close to the eyelash line that ends at the eye tail (sub-ciliary incision), dissects the pouch skin, and removes excess fat via the incision before performing subperiosteal dissection at the cheekbone below the tear-through groove to above the nasolabial folds. This will release majority of the midface skin from bone. Then, Dr. Chuang will apply several lift threads or an Endotine midface implant under the skin to suspend the submalar triangle upward to the periosteum near the orbital bone where it is fixed. The level of fixation and number of sutures vary depending on the degree of skin laxity, and the surgical purpose is to re-elevate and restore the sagging or hollowing submalar triangle to its original position and effectively sculpt a 45° S-shaped curve. After the midface lift is done, pouch fat grafting to the tear-through groove may be conducted, and the loose lower eyelid skin is properly suspended and excised before wound closure.

Due to its proximity to the sagging skin and the execution of the deep periosteal dissection, this combined lower blepharoplasty and midface suspension surgery will closely adhere the skin and suture to the bones, which is therefore particularly effective to correct the tear-through groove and submalar triangle. It is appropriate for patients who want to improve eye bags and midface skin laxity at one time but are unwilling to accept endoscopic facelift.