The Netflix sensation Tiger King got a whopping 89% on the Rotten Tomatoes review website. One critic said it was “not what [he’d] call nutritious viewing” and “most of the people in it are horrible”. Others called it “a compelling tale”, “sensational”, and “compulsive viewing”. The story brings us into the odd world of Joe Exotic, a self-described “gay, gun-toting cowboy with a mullet” who owned over two hundred wild tigers, housed in his zoo in Oklahoma, USA. Like it or loathe it, Tiger King captivated public attention and most had an opinion either way. So what ingredient did Tiger King have that mesmerised audiences all over the world? Perhaps the stark contrast of the unaesthetic, unkempt zookeeper characters with the stunning beauty of the tigers that surrounded them. If Joe Exotic’s penchant had been to breed ostriches or llamas or horses, would the show have been watched by so many all over the world? Probably not. There’s just something beautiful about tigers. We seem to be able to appreciate their beauty, almost instinctively.
A closer look at the tiger’s face gives us clues to why we find these big cats so beautiful. It’s the eyes that stand out: large, tilted upwards, and without shadows or grooves. It’s as though the eyes are etched artistically into the forehead, perfectly framed. Cosmetic surgeons have described this “framing concept” and it’s usefulness when they consider treatments and procedures to beautify the eyes1. With a true understanding of what makes the face and eyes beautiful, management can be fine-tuned. The days of simply cutting away loose skin or removing a protruding eye bag in isolation are gone. In fact, we run the risk of making someone appear even older if we remove volume where it should be added, or neglect the anatomy around the eye during facial rejuvenation. It’s an art as much as it is a science.
CAT EYES
The “cat-eye” brow lift is considered a sexy look by many younger women who request treatments to hoist up the tail of the eyebrow and corner of the eyes. Some practitioners perform thread lifts to elevate the tail of the brow; others use fillers. The threads are usually dissolvable, like PDO threads, and the fillers too are non-permanent ones consisting of hyaluronic acid gels. Surgeons who have experience with oculoplastic surgery can lift the eye itself by inserting stitches into the lower eyelid and anchoring them to the bone around the eye. This is called a lateral canthopexy. The so-called “lateral canthal tilt” produced with this kind of surgical procedure is perceived to be an attractive female trait2. One study interestingly showed that a tilt of the axis of the eyes of five degrees was more beautiful—but only younger observers thought so. Older observers still preferred the standard eye shape that is horizontal, not lifted like a jaguar!3
Beauty is in the eye of the beholder, in this case anyway. Other tricks to lift the brow include keyhole surgery (endoscopic brow lift), tightening the skin above the brow using microfocused ultrasound or radiofrequency skin tightening, and direct brow lifting where skin is simply removed surgically. In direct brow lifts, the scars are hidden in the natural wrinkles that arise in the forehead just above the brow—not usually an option for smoother-faced younger women4.
HILLS AND VALLEYS
The real artistry in rejuvenation of the eye area is getting the volume right. Your experienced aesthetic provider will know all about volume replacement as a major part of rejuvenation. When skin sags above and below the eyes, sometimes the best option is to add volume. That might seem counterintuitive—adding volume when there is loose skin, but consider the balloon that deflates the longer you leave it sit there. Over time, air leaks out and the wrinkles and sagging on the balloon’s surface become more prominent. Thanks to some clever scientists and surgeons and some pretty interesting and intricate experiments in the lab and using special imaging, the aging process has largely been identified as an involutional process. A what? Well—basically the face is shrinking as we age, and the various delicate fat compartments of the face deflate5. So just like the balloon, if you want to look like you did ten or fifteen years ago, it’s much more natural to restore what’s been lost rather than simply chop away redundant skin. Adding lost volume around the eyes is a tricky and delicate process that requires considerable expertise.
The goal of adding volume around the eyes is to recreate the youthful convex surfaces of youth and remove unwanted or irregular shadows. Under the eyebrows there’s a fatty area called the infrabrow fat. The smooth, full infrabrow fat reflects light in youth and should blend seamlessly with the area above the brow and the eyelid. With aging, it either sags and creates hooding, or shrinks and creates hollows. The hooding, called dermatochalasis, either requires tightening of the tissue or surgery. If the area shrinks instead, then hollows and shadows become evident. This is particularly true under the brow closer to the nose, where we see what’s called the A-frame deformity. Deformity is hardly a flattering description for a normal aging process. In any case, to restore fullness when it’s shrivelled away, experts use either your own fat or fillers. Tiny droplets or threads of fillers or fat are injected using microcannulas—very fine blunt-tipped sterile tubes. This kind of filling can frame the eye and make you look years younger. However, if the skin is too loose or the eyelids are heavy and sagging, tightening or tucking might be the preferred option rather than filling.
EYELID LIFT
An upper blepharoplasty or eyelid lift is one of the most common cosmetic surgical procedures performed. Less complicated than lower eyelid surgery, upper blepharoplasty can be performed under local anaesthesia using numbing injections alone. Basically, excess skin, muscle and fat are trimmed away after the area is carefully marked.
Like a tailor, your surgeon will carefully measure and mark what needs to be removed and what needs to be left behind. Fine stitches are used to close the incision, leaving a scar that should almost be invisible, hidden in the crease of the eyelid. With so many modern gadgets and devices available, though, sometimes surgery might not even be required. You can tighten skin these days with various lasers and with controlled heating using ultrasound or radiofrequency (RF) or plasma energy6. Different procedures deliver different degrees of controlled injury to the skin, requiring different lengths of downtime afterwards. When skin is heated, whether that’s with lasers, RF energy or ultrasound, collagen tightens and remodels. The result is fewer fine lines and more youthful looking skin. Generally, laser resurfacing means you’re red or pink for a week. Radiofrequency needling causes some redness and swelling for a couple of days. Non-invasive radiofrequency or ultrasound has practically no downtime. All of these energy-based devices are tunable though, so like most machines, you can turn them up or down. As a rule of thumb, the higher the energy, the longer the downtime. Your provider should know the sweet spot—just enough to get the best results but not too much so as to avoid excessive downtime and complications.
BANISHING BULGING BAGS
Aging is normal. And it’s fine. And even accepted—until it stares you in the eyes! One of the bugbears of so many women and men is aging under the eyes: the changes are insidious. Fine lines morph into deeper grooves and shadows.
The skin and muscle that was once a tight drum keeping everything nicely in place starts to bulge and betray, revealing the underlying fat pads that push out like little balloons, until one day you wake up and look in the mirror and realise you have eyebags. And now what?
Your journey to turning back the clock with infraorbital or under-the-eye treatments depends on your age and what’s going on. Your provider will usually be able to give you options after reviewing photos in different angles. For fine lines below the eyes, there are many options. These include laser resurfacing, radiofrequency skin tightening, needling, and plasma skin rejuvenation. If the skin is looser and there are fatty bulges too, you may be advised surgery that fixes the skin and the bulges, or even a combination of surgery and non-surgical skin tightening. The surgery under the eyes is called blepharoplasty. This kind of surgery can be quite complex, so be sure to discuss options with an expert before proceeding.
There are two approaches to lower lid blepharoplasty: removing or repositioning the fat pads from an incision under the eyelid (transconjunctival) or making an incision below the lash line so the skin and fat can be removed or repositioned (transcutaneous blepharoplasty)7.
The goal is to smooth the unwanted shadow between the eyelid and cheek so that the eye can be framed beautifully as described earlier. To do this, the fat that’s bulging needs to be either trimmed to reduce it, or repositioned so the fat is pushed downwards over the rim of the eye socket and anchored in place, effectively acting as a padding. One key element of lower eyelid blepharoplasty is to make sure the lower eyelid doesn’t drop down. That’s called lid retraction—not a good look, and not an easy complication to correct8. Some surgeons will place a stitch in the lower eyelid at the outer part and anchor the eyelid to the bony rim to stabilise it and prevent it from dropping9. This delicate manuevre can even enhance the axis of the eye and create a subtle “canthal tilt”. A jaguar eye is better than a basset hound eye! Scars from surgery around and close to the eyes generally heal very quickly with little evidence or tell-tale signs.
GETTING IN THE GROOVE
From A-Frame deformities above and bulges below, the giveaway signs of aging around the eyes are seemingly everywhere. But some changes occur even in young people, in their twenties and thirties. The tear trough hollow describes the shadow that runs from the inner corner of the eye near the nose downwards and outwards toward the cheek. It’s the shadow that gives a tired look, and certain lights make it appear worse, despite concealer. In younger people where the skin is pretty good and there are no bulging fat pads, fillers can work miracles. The filler of choice in this area is nearly always hyaluronic acid—a filler that can be dissolved if unwanted bumps or unevenness occur, using an enzyme called hyaluronidase.
In expert hands, tear trough filler treatments are an excellent way to smooth away shadows and bring the attention back to the beauty of the eye itself rather than shadows around the eyes10. Fat can also be used to soften the tear trough shadow.
Shakespeare said the eyes are the window to your soul. They’re also central to facial beauty, and framing them by ensuring there is adequate volume, no shadows, and smooth skin is the hallmark of “periorbital rejuvenation”. Both non-surgical and surgical cosmetic procedures play an important role in this rejuvenation.
These include upper and lower blepharoplasty, brow lifting, and a range of skin tightening procedures such as lasers, needling, radiofrequency and other modern devices.
References
- The Benslimane's Artistic Model for Females' Gaze Beauty: An Original Assessment Tool. Benslimane F, van Harpen L, Myers SR, Ingallina F, Ghanem AM. Aesthetic Plast Surg. 2017 Feb;41(1):81-89
- Female eye attractiveness - Where beauty meets science. Prantl L, Heidekrueger PI, Broer PN, Knoll S, Thiha A, Gründl M. J Craniomaxillofac Surg. 2019 Jan;47(1):73-79.
- The "jaguar's eye" as a new beauty trend? Age-related effects in judging the attractiveness of the oblique eye axis. Gründl M, Klein S, Horczakiwskyj R, Feser D, Jung M, Eisenmann-Klein M, Prantl L. Aesthetic Plast Surg. 2008 Nov;32(6):915-9
- Direct brow lifting: Specific indications for a simplified approach to eyebrow ptosis. Pascali M, Bocchini I, Avantaggiato A, Carinci F, Cervelli V, Orlandi F, Quarato D.Indian J Plast Surg. 2016 Jan-Apr;49(1):66-71
- Newer Understanding of Specific Anatomic Targets in the Aging Face as Applied to Injectables: Superficial and Deep Facial Fat Compartments--An Evolving Target for Site-Specific Facial Augmentation. Ramanadham SR, Rohrich R J.Plast Reconstr Surg. 2015 Nov;136(5 Suppl):49S-55S
- Energy-Based Facial Rejuvenation: Advances in Diagnosis and Treatment. Britt CJ, Marcus B. JAMA Facial Plast Surg. 2017 Jan 1;19(1):64-71
- Current Trends in Upper and Lower Eyelid Blepharoplasty Among American Society of Ophthalmic Plastic and Reconstructive Surgery Members. Kossler AL, Peng GL, Yoo DB, Azizzadeh B, Massry GG. Ophthalmic Plast Reconstr Surg. 2018 Jan/Feb;34(1):37-42
- Treatment of post-blepharoplasty lower lid retraction by free tarsoconjunctival grafting. Ferri M, Oestreicher JH.Orbit. 2002 Dec;21(4):281-8
- Preventing Lateral Canthal Malposition in Modern Blepharoplasty. Rohrich RJ, Mohan R. Plast Reconstr Surg. 2020 Feb;145(2):324e-328e
- Tear Trough Deformity: Study of Filling Procedures for Its Correction.
Pascali M, Quarato D, Pagnoni M, Carinci F.J Craniofac Surg. 2017 Nov;28(8):2012-2015
