21plastic surgery's Complete Guide to Under-Eye, Contour, and Lifting Plastic Surgery

Under-Eye Aging: Why Does It Look So Tired?

When under-eye fat protrusion and tear trough depression progress simultaneously, it can create an impression that appears 5-10 years older than one's actual age.

There are typically three structural causes that work together to make the area below the eyes look tired and aged.

First, there is protrusion of under-eye fat. As age increases, the orbital fat that surrounds the eyeball is pushed forward, making the area below the eye appear bulging, and the shadow beneath deepens, creating a dark circle-like appearance. This change can occur in people in their 20s depending on genetic factors.

Second, there is depression of the tear trough. As fat protrudes more prominently, a visual illusion occurs where the boundary area below appears relatively deeper. When this area deepens, dark circles appear more severe, and the entire eye area takes on a heavy and dark impression.

Third, there is an absence of aegyo-sal (the youthful under-eye pouch). When there is no slightly puffy aegyo-sal directly below the eye, the eye shape often appears flat or it is difficult to create a vibrant impression.

These three changes tend to progress together rather than occurring independently, making it important to analyze the structure by cause and then design a treatment direction.

While there is individual variation, on average, orbital fat typically begins to protrude noticeably from the mid-30s onward due to orbital septum weakening.

21plastic surgery analyzes the under-eye structure three-dimensionally by dividing it into the fat layer, muscle layer, and skin layer, and provides treatment plans tailored to each individual's condition.

What is Under-Eye Fat Repositioning?

Under-eye fat repositioning is a surgical method that removes protruding orbital fat or relocates it to depressed areas to naturally improve the under-eye contour.

Under-eye fat repositioning approaches the inner orbital area below the eye, appropriately organizes the unnecessarily protruding portion of fat tissue protecting the eyeball, and then moves and repositions the remaining fat into the depressed tear trough area.

Core Principles of Surgery

The important approach is not simply "moving" fat, but spreading the fat as thinly and widely as possible and evenly filling it into the depressed area. In this process, if autologous fat is additionally grafted, not only under-eye improvement but also aegyo-sal formation can be achieved, allowing simultaneous consideration of two goals: under-eye improvement and aegyo-sal formation.

Another important point is septum reinforcement. Through septum reinforcement, fat protrusion is prevented from recurring, maintaining good results long-term.

Cases Suitable for Under-Eye Fat Repositioning

When under-eye fat is protruding but skin elasticity is relatively maintained (mainly ages 20-40)
When dark circles result from shadows caused by fat protrusion
When the tear trough is deep and the under-eye appears hollow
When the eye shape appears flat without aegyo-sal or lacks vitality

The transconjunctival approach (through the inside of the conjunctiva) can be performed without incision marks on the skin surface, so recovery time is often expected to be relatively short.

Swelling and bruising after surgery vary by individual, and generally major swelling tends to subside within approximately 1-2 weeks. Final results often become naturally established over 6 months.

Under-Eye Fat Repositioning vs. Lower Blepharoplasty: What's the Difference?

When only under-eye fat protrusion is present versus when skin sagging and fat protrusion are both present, the recommended surgical method may differ.

Under-eye aging cannot be resolved by a single surgery in all cases. Depending on the patient's age, skin elasticity status, degree of fat protrusion, and changes in muscle and support tissues, the appropriate surgical method can vary. Please review the comparison table below to see the characteristics of the two treatment methods.

Comparison Item	Under-Eye Fat Repositioning	Lower Blepharoplasty
Primary Target Population	Fat protrusion focus, relatively good skin elasticity	Skin sagging + fat protrusion together, middle age and beyond
Approach Method	Transconjunctival (inside conjunctiva) or skin incision	Under-eye skin incision
Skin Sagging Correction	Limited	Direct excision of sagging skin possible
Fat Handling	Repositioning and grafting can be combined	Fat removal and repositioning can be combined
Recovery Period (Reference)	Approximately 1-2 weeks (individual variation)	Approximately 2-3 weeks (individual variation)
Aegyo-Sal Formation	Possible with autologous fat grafting	Partially possible to consider
Primary Suitable Age Group	20s-40s (when skin elasticity is good)	40s and older (when skin elasticity is decreased)
Incision Line Traces	No external traces with transconjunctival approach	Fine traces possible along under-eye boundary line

Lower blepharoplasty can be considered when both skin sagging and fat protrusion have progressed simultaneously, with the scope of application becoming wider in conditions where improvement effects cannot be expected from fat correction alone.

After middle age, it is common for skin elasticity to decrease along with changes in the fat layer, muscle layer, and support tissues. When such complex changes are involved, it is important to confirm through sufficient consultation which surgical method is appropriate.

Relationship Between Upper Eyelid Sagging and Forehead Tension

If the habit of unconsciously tensing the forehead continues, it may be necessary to check for the possibility of upper eyelid ptosis (blepharoptosis).

Have you ever felt yourself unconsciously tensing your forehead when looking in the mirror? When the eyelid becomes heavy, a compensatory action naturally occurs to lift the eyes using the forehead muscles. If this state continues, deep forehead wrinkles can develop and the eye shape can gradually appear narrower.

Connected Structure of Upper and Lower Eye Aging

The eye area has a structural connection between the upper (upper eyelid area) and lower (lower eyelid area).

Upper changes: Skin below the eyebrow sags, covering the double eyelid and making the eye shape appear narrower
Lower changes: Under-eye skin stretches and cheek-area fat layer sags, deepening the tear trough and making dark circles appear more severe

When upper and lower areas change together in this way, correcting only one area can result in overall harmony mismatch. This is why upper and lower areas must be designed together for the entire eye area to come alive naturally.

Role of Brow Lift (Browpexy)

Brow lift is a method that makes an incision along the eyebrow boundary line and lifts the sagging eyelid skin. Rather than directly lifting the eyebrow position, organizing the stretched skin below the eyebrow can create a naturally sharper eye appearance. Because the incision line is positioned at the eyebrow boundary, scars tend to be relatively inconspicuous.

The recovery period after brow lift varies depending on individual skin condition, but suture removal typically occurs within about 7 days after surgery.

Surgical Approach to Double Chin Improvement

The treatment direction differs depending on whether the cause of double chin is simply excess fat or a structural problem from a weak chin.

It is difficult to definitively say that double chin is caused by "having excess fat." In reality, double chin is often emphasized because the chin point is short or recessed structurally, narrowing the submental space. Without accurate identification of the cause, performing only simple fat removal procedures may make it difficult to achieve the expected results.

Main Methods of Double Chin Surgery

Double Chin Muscle Plication: This method organizes and sutures the submental muscle structure, including the digastric muscle and mylohyoid muscle that compose the double chin. When combined with liposuction, it can help enhance contour improvement effects.

Genioplasty (Chin Advancement): After analyzing the left-right asymmetry of the mandible and evaluating the chin point position based on Ricketts Line through CT analysis, this surgery moves the chin bone to an appropriate position to harmoniously improve facial proportions when viewed from the side.

Genioplasty differs from simple chin implant insertion in that it moves the bone itself, making it a method known to simultaneously address double chin resolution and lateral silhouette improvement.

Importance of Compression Management After Surgery

After double chin muscle plication and liposuction surgery, wearing a compression bandage (commonly called a "pulling band") can help in the recovery process. It is recommended to maintain maximum usage during the first day after surgery except during sleep, and then wear it intermittently according to circumstances for approximately one month thereafter.

Compression management is important because it helps minimize dead space created where fat has been removed, allowing tissues to adhere well. If compression management is not sufficiently performed, it can affect recovery results, so following medical staff's instructions is important.

21plastic surgery analyzes structural causes through CT analysis before double chin and genioplasty surgery, and provides customized surgical plans for each individual.

Philtrum Reduction and Philtrum Deepening: Designing Facial Proportion and Three-Dimensionality

The length and shape of the philtrum is one of the key factors affecting facial upper, middle, and lower proportions and overall impression.

When looking at the same face photo, sometimes it appears sharp and organized, while other times it appears elongated or the center seems shifted downward. This difference often stems not from prominent areas like the eyes or nose, but from the facial midline and proportions.

The philtrum is the distance between the nose and upper lip, serving as a reference point dividing the facial upper, middle, and lower. When the philtrum is long or flat in shape, the entire face can appear stretched or the mouth can appear protruding.

Philtrum Reduction Surgery vs. Philtrum Deepening Comparison

Category	Philtrum Reduction Surgery	Philtrum Deepening Surgery
Primary Purpose	Shorten philtrum vertical length	Form philtrum depression line, provide three-dimensionality
Incision Location	Below nose boundary line	Central philtrum area
Scar Location	Below nose (relatively inconspicuous)	Inside philtrum groove
Single Procedure Feasibility	Possible	Possible (more effective when combined with reduction)
Primary Improvement Effect	Length adjustment, enhanced upper lip volume	Philtrum shape and depth adjustment, enhanced three-dimensionality
Suitable Cases	When philtrum is long	When philtrum is flat and lacks three-dimensionality

Philtrum reduction is similar to "length adjustment," while philtrum deepening is closer to "shape and depth adjustment." These two surgeries have a complementary relationship, so considering both the length and shape of the philtrum together can often provide more natural results.

When combining philtrum reduction and philtrum deepening surgery, it allows designing in a direction that enhances three-dimensionality of the facial center rather than simply reducing length, enabling consideration of overall harmony.

Neck Wrinkles: Causes and Treatment Approaches

Neck wrinkles often result from the combined action of two factors: decreased skin elasticity itself and repetitive postural habits.

While people put effort into facial care, the neck area is easily neglected. In reality, neck wrinkles often result from the combined action of not just simple skin aging, but physical changes that accumulate from repeated posture of bowing the head during smartphone use.

Two Main Causes of Neck Wrinkles

① Decreased Skin Regeneration Capacity When fibroblast activity decreases, collagen and elastin synthesis reduces, and combined with cumulative sun exposure, skin gradually becomes thinner and fine wrinkles become established. While people carefully apply sunscreen to the face, many fail to include the neck area, which can cause the neck skin's collagen damage rate to be relatively faster.

② Skin Crease Imprinting from Repetitive Posture When the posture of bowing the head is repeated hundreds of times a day, from seconds to several hours at a time, horizontal creases continuously form on neck skin. When this creasing accumulates over years, it becomes physically established as wrinkles on the skin.

The effectiveness of neck wrinkle procedures depends on the type of wrinkles (fine wrinkle type vs. deep crease type) and skin elasticity status, requiring different treatment approaches to enhance satisfaction.

For neck wrinkle improvement, there is a Lieto + filler combination method that promotes skin regeneration and provides direct volume supplementation. The appropriate method can vary depending on individual wrinkle condition, skin thickness, and elasticity level.

Facial Contouring Surgery: Harmonious Design of Cheekbones, Square Jaw, and Chin

Facial contouring surgery requires three-dimensional design considering overall facial proportions rather than single-area correction, which significantly impacts the naturalness of results.

When seeking facial contour improvement, the three areas of cheekbones, square jaw, and chin do not exist independently but form a continuous facial silhouette. Therefore, correcting only one area can actually create imbalance, and design considering overall proportions is important.

Role of Three Contour Procedures

Cheekbone Reduction Surgery: Can be expected to narrow facial width by reducing protruding cheekbones. After surgery, facial contour tends to change gradually over 4 months to 1 year.
Square Jaw Long-Curve Excision: Rather than simply shaving the angular mandibular angle area, the excision range is designed in a direction to create soft and natural curved lines.
Genioplasty (Chin Advancement): After confirming the relationship between maxilla and mandible, and adjacent structure positions through CT analysis, this method advances the chin forward to improve both lateral silhouette and frontal proportions.

Cheekbone reduction surgery typically shows intermediate progress around 4 months post-operatively, and final results tend to stabilize within approximately 1 year after surgery.

Facial contouring surgery may have prolonged swelling during the recovery period, with return to daily activities often recommended at approximately 1-2 weeks after surgery, depending on individual condition. However, vigorous activity is recommended to be started gradually from 4-6 weeks onward.

Lifting Procedures and Facelift: Differences in Handling Sagging

If lifting procedures repeated multiple times show no effect, it may be necessary to consider the possibility that sagging of the skin and muscle structure itself has exceeded the scope of procedures.

It is not uncommon to hear concerns that despite receiving multiple lifting procedures, significant changes are not felt. Non-surgical lifting (thread lifting, radiofrequency, ultrasound lifting, etc.) can stimulate skin regeneration or provide temporary tightening effects, but when the SMAS (superficial musculoaponeurotic system) layer that supports the skin itself is sagging, it may be difficult to achieve satisfactory effects with procedural approaches alone.

Principle of Facelift (Face & Neck Lift)

Facelift involves making an incision along the front and back of the ear, then directly lifting and securing the SMAS (superficial musculoaponeurotic system) layer below the skin. Rather than just tightening the skin, because the facial support structure itself is repositioned, a more lasting effect can be expected.

Facelift: Primarily aims to improve cheeks, mid-face, and nasolabial folds, and can be considered when sagging has progressed overall in the face.
Neck Lift Combination: Simultaneously correcting sagging of neck skin and platysma muscle can provide lateral silhouette improvement.

When designing facelift and double chin muscle plication simultaneously, it is possible to approach facial and submental boundary line improvement together, which can be advantageous in considering overall contour harmony.

Thread lifting (thread lift) is a non-surgical method that inserts dissolving threads beneath the skin to expect temporary tightening and skin regeneration effects. It can be considered as a primary option when sagging is in early stages or surgical approaches are difficult. Generally, effect duration is known to be approximately 1-2 years, after which re-treatment may be necessary.

Frequently Asked Questions (FAQ)

What is the difference between under-eye fat repositioning and simple fat removal?

Under-eye fat repositioning is not simply removing protruding orbital fat, but rather organizing as needed and then moving and repositioning remaining fat to the depressed tear trough area. If only simple fat removal is performed, while the previously bulging area may improve, the hollow area below can actually become more prominent. The repositioning method aims to use fat as a resource to balance volume throughout the under-eye area, so more natural results can often be expected. However, the appropriate method can vary depending on individual under-eye structure and skin condition, so it is important to establish a treatment plan after accurate diagnosis.

I had double chin liposuction but feel there's no effect. Why is that?

When double chin liposuction does not produce expected changes, there can be several causes. One of the most common causes is when the cause of double chin is not simply excess fat but a structural problem from chin recession (weak chin). When the chin point is short or recessed, even with fat removal, the submental space structure appears visually narrow, which can make double chin persist. In this case, approaches combining genioplasty or double chin muscle plication can be considered to address structural causes. If compression management (pulling band wear) was not sufficiently performed after surgery, it can also affect recovery results.

I've had multiple lifting procedures but feel no effect. What should I do?

Non-surgical lifting (thread lifting, radiofrequency, ultrasound, etc.) can provide skin regeneration stimulation and temporary tightening effects, but when the SMAS (superficial musculoaponeurotic system) layer supporting the skin itself is sagging, it can be difficult to achieve sufficient effects with procedural approaches alone. If the degree of sagging is determined to exceed procedure scope, facelift surgery that directly lifts the facial support structure can be considered. The appropriate method should be confirmed through consultation based on multiple factors including skin thickness, elasticity, degree of sagging, and bone structure.

Is philtrum reduction alone sufficient if my philtrum appears long?

When the philtrum appears long, philtrum reduction surgery alone can provide certain improvement effects, but if the philtrum area is flat and lacks three-dimensionality, reducing length alone may leave a still-flat impression. Combining philtrum deepening can help design the philtrum groove depth and shape together, which can help enhance three-dimensionality between the nose and upper lip. These two surgeries have a complementary relationship, and it is important to decide whether to perform them alone or in combination based on individual facial proportions and philtrum shape.

Swelling persists for a long time after under-eye surgery. Is there a way to reduce it?

Swelling after under-eye surgery (fat repositioning, lower blepharoplasty, etc.) varies by individual constitution, recovery speed, and surgical scope. Generally, major swelling tends to noticeably subside within approximately 1-2 weeks, but fine edema often resolves gradually over 3-6 months. In early recovery, cold therapy (first 1-2 days after surgery) and warm therapy (thereafter) can be applied in stages, and avoiding lowered head positions or excessive bending postures can help. Hyperbaric oxygen therapy (HBOT) and other recovery support methods can be combined in some cases, but these are not applied in all situations, so please consult with your medical staff.

This content was created for the purpose of providing general information about plastic surgery and procedures. Treatment results can vary depending on individual health status and body structure, so it is essential to receive sufficient consultation with a specialist before deciding on surgery or procedures.