Dr. Niamtu’s Weblog

….on cosmetic facial surgery

Simultaneous rejuvenation of the lower eyelids and the cheeks is a winning combination.

This image shows an actual surgery patient of Dr. Niamtu.  The aging midface (left) is rejuvenated by lower eyelid surgery and cheek implants (right).


Facial aging is an interesting multi factorial phenomenon.  Many things contribute to an aged midface including sun damage to skin, atrophic and gravitational changes to fat, muscle and bone.  Two of the biggest things that make us look old and tired occur in the lower eyelids and cheeks.

The lower eyelids can undergo aging changes as early as the third decade.  The skin becomes crinkly and sags, fat can protrude from around the eyeball and produce sausage shaped fat bags on the lower eyelids.  This protruding fat also causes a shadow from overhead light which contributes to the dreaded “dark circles” under the lower lids.  In addition, due to the aforementioned changes, the “tear trough” (technically the nasojugal groove) becomes accentuated.  This produces a deep grove under the eye from the side of the nose across the cheek.

Extremely related to midface aging is volume loss in the midface.  Young patients have full, plump and rounded cheeks.  This good fat in good places produces a smooth, continuous contour under the eyes and around the cheeks.  Gravitational and atrophic aging changes causes volume loss in the cheeks and gives us a drawn, gaunt and hollow appearance.  This is also very related to the lower eyelid aging as the lower lids are the upper cheeks.  The combination of aging produce an old and tired look and the only means to address this aging comprehensively is to address both the lower eyelids and cheeks at the same time.  I find it rare that patients with lower eyelid aging don’t need attention to the cheeks (midface).  I would say that 95% of my lower lid patients that are over 40 would benefit from simultaneous midface augmentation.  Fortunately, many of these patients understand this and combing procedures.

My approach to the healthy lower lid is pretty simple.  I remove conservative fat with a laser incision from the inside of the lid (transconjunctival blepharoplasty).  This means no external scar and no bleeding due to the laser.  No bleeding means faster surgery and recovery with less bruising and pain.  I am always very careful to only recontour the excess fat as not to produce further volume loss.  The second step of lower eyelid rejuvenation is addressing the aging skin of the lower lids.  Although some surgeons still cut off lower eyelid skin, I think that is a bad idea.  It only stretches the skin; it does nothing for rejuvenating the skin.  The skin will return to its normal wrinkling in a short time.  More of a problem is the fact removing skin from the lower eyelid can also contribute to lower eyelid malposition.  Due to the scarring that can occur inside the lower lid, the eyelid can be pulled down which looks unnatural and can cause problems.

To truly rejuvenate the lower eyelid skin, it needs to be resurfaced.  I prefer CO2 laser resurfacing or chemical peeling.  These modalities actually remove wrinkles and brown spots and makes new, younger skin. That is truly rejuvenation!

Since the aging does not stop at the lower lid, this is an excellent time to also address the midface.  The patient is already sedated and will be taking a week off of work, so why not be comprehensive with the rejuvenation?   My most common method of augmenting the aging midface is the use of silicone cheek implants. (Click here to view a video about cheek implants and facial aging)There are many reasons that I like cheek implants.  Among them is the fact that they are inserted from the inside of the mouth so there is not visible scar.  They are held to the cheekbone with a micro screw, so they are permanent, but they can be changed or removed in 30 minutes if the patient desires.  Not many things in cosmetic surgery are permanent but reversible!

By placing cheek implants, the youthful contour of the midface is reestablished and many times the tear troughs and even the nasolabial folds are also improved.  Alternatively, the cheeks and tear troughs can be volumized with injectable fillers.  This is non-surgical and is also reversible.  The downside of midface filler augmentation is that it is a temporary fix.

Simultaneous rejuvenation of the lower eyelids and the cheeks is a winning combination.  If a patient seeks lower eyelid rejuvenation and the surgeon does not discuss the midface aging, a second opinion may be in order.

To find out more about cosmetic facial surgery by Dr. Joe Niamtu, III in Richmond, Virginia visit www.lovethatface.com


Joe Niamtu, III DMD

December 6, 2011 Posted by | cheek implants, Cosmetic Eyelid Surgery, Eyelid Surgery, minimally invasive facelift | , , , , , , , | 4 Comments

Festoons: the baggage you don’t need!

Malar Festoons are the baggy pouches that form under the lower eyelids and on the upper cheek. I have been treating them with laser resurfacing for the last 15 years.

Festoons are a result of numerous causes including sun damage to the skin, fat loss of the cheek area, periorbital changes of skin, muscle and fat. They are also caused by a back up of the lymphatic drainage of this area which causes the tissue to become boggy. The net result is crinkly skin or pouches that make us look old and tired. Before the advent of laser technology, festoons were often treated by surgical excision, which of course left a scar. Other treatments that were supposed to improve festoons have been disappointing.

I have used various types of lasers on this region (CO2, Erbium, Nd:YAG, KTP) and have personally had the best results with the CO2 laser. No other laser has been to shown to produce as much skin tightening or new collagen formation as the ultrapulsed CO2 laser. I believe it remains the gold standard in skin tightening. Although other lasers may claim to produce results with less downtime than the CO2, the result is often less or multiple treatments are required. In reality, the way the procedure is performed and the experience of the surgeon are the most important variables in terms of the best result. Experienced laser surgeons know how aggressive they can be with the skin resurfacing and yet not produce scarring. Good results can be obtained using CO2 and Erbium lasers.



The above patient was treated by Dr. Niamtu with upper and lower blepharoplsty and CO2 laser to the festoons.

Although festoons can be treated as a sole procedure, most patients that are having this area treated also benefit from upper and lower eyelid surgery as well. My most common combination of procedures to rejuvenate this region is transconjunctival blepharoplasty on the lower lids. This procedure does not involve a visible scar and is also safer in terms of not pulling down the lower lids. Instead of cutting skin off of the lower eyelids, the wrinkled skin is treated with the laser and the results are immediate. You can actually see the wrinkles disappearing as the laser contacts the skin. I prefer to treat the lower lids when I treat festoons as the aging process actually represents this entire area. More so, I encourage most patients to perform the laser treatment on their entire face if they desire more comprehensive rejuvenation. By treating the entire face, the patient does not have to worry about the festoon skin being a different color or texture if that is the only area treated.

As most patients that have festoons need their lower lids treated, the same can be said about their upper lids. It is very common to rejuvenate all four lids and the festoons at the same procedure.

In addition to improving malar festoons, the CO2 laser also revolutionized cosmetic blepharoplasty (eyelid tuck) as the surgery can be performed in much less time with no bleeding. That is not a misprint, there is literally no bleeding. During the procedure of operating of 4 eyelids, the total blood loss can be measured in a single Q Tip. Less bleeding means faster healing, less bruising and less pain. Those surgeons who have been using lasers for blepharoplasty can affirm these statements.

This patient was treated by Dr. Niamtu with upper and lower laser assisted blepharoplasty and laser to the lower lid and facial skin

Dr. Niamtu has performed over 5,000 eyelid surgeries with the CO2 laser since 1996 including festoon treatment and full face laser skin resurfacing. In addition, he has written numerous articles and text book chapters on laser treatment.









This patient was treated by Dr. Niamtu with lower transconjunctival blepharoplasty and lower periorbital laser resurfacing.









This patient was treated by Dr. Niamtu with lower transconjunctival blepharoplasty and lower periorbital laser resurfacing.


For more information about Dr. Joe Niamtu, III, cosmetic facial surgery in Richmond, Virginia visit www.lovethatface.com. Joe Niamtu, III DMD Cosmetic Facial Surgery Richmond, Virginia

July 20, 2011 Posted by | Cosmetic Eyelid Surgery, cosmetic facial surgery, Eyelid Surgery, Laser Resurfacing | , , , , | 8 Comments

Dr. Niamtu Recent Featured Cosmetic Facial Surgery Patient

Name: Brenda Michaels

Age: 61

See a video of Brenda Discussing her Surgery

Procedures Performed:

  • Facelift
  • Upper and lower eyelid surgery


I am a recent widow.  I have two sons and two beautiful daughter-in-laws, and three adorable grandchildren, ages three, five, and seven.


Self employed- buying and selling plastic raw materials.


I enjoy hiking, gardening, reading and playing my piano.

Why you wanted to have cosmetic surgery:

I had wanted a facelift for a number of years as time continued to take a toll on my neck and face.  For me, my neck was the deciding factor in my decision to have a facelift.

Why did you choose Dr. Niamtu:

When I found Dr. Niamtu’s website, I was most impressed with the amount of information that was given about cosmetic facial procedures and I just knew that he was the doctor that I wanted to perform my facelift.

What were you hoping to achieve with the surgery:

I wanted to achieve a more youthful looking face and neck and Dr. Niamtu gave me that.

How did you like the results:

I am most pleased with my facelift.

What advice would you give other women considering cosmetic facial surgery:

Several of my friends have told me that they wouldn’t want to spend the money for cosmetic surgery or put themselves through the surgery and recovery.  Certainly having cosmetic surgery is a very personal decision, but for me the results were worth it all.  I “love my face” and for any woman considering cosmetic facial surgery I would say “Go for It!”

Any special thoughts on your experience:

I feel that I was blessed to have found Dr. Niamtu and to have him perform my surgery.

Comments from Dr. Niamtu:

I think I have the greatest patients in the world and feel very lucky to do what I do for a living.  It just keeps getting better!









To find out more about cosmetic facial surgery by Dr. Joe Niamtu in Richmond, Virginia, visit


Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

November 25, 2010 Posted by | Cosmetic Eyelid Surgery, Cosmetic Facial Surgery Consultation, Eyelid Surgery, Facelift Surgery | , , , | Leave a comment

Cosmetic Eyelid Surgery/Blepharoplasty

If the eyes are the seat of the soul, they are the foundation of beauty.  The eyes are a beautiful, intricate and unique structures and are the first thing that humans notice about the face of other humans.  The youthful eyelid is tight, well defined, sculpted and is one of the basic clues about ones age.  As we get older, the upper face ages more rapidly than the lower face and it is not uncommon for me to perform eyelid surgery on patients in their late third decade and through their eight decade.  A healthy person is never too old to look younger!

Most us that are over 35 can testify to the subtle changes that begin in the mid 30’s.  Usually we fires notice the “crow’s feet” wrinkles that develop on the side of the eyes and are accentuated when we squint and smile.  The next change that becomes apparent is the excess skin that forms on the upper and lower eyelids.  The upper lids get droopy and the excess skin can lie on the eyelashes or lower.  This can actually obstruct a patient’s vision and if this is the case is often covered by health insurance.  For a cosmetic procedure to be covered, the patient must first visit their eye doctor and undergo a test to see if the skin excess qualifies for insurance.

Women will notice that they can no longer wear eye shadow because the eyelid shelf (the area above the lashes) is covered with skin.  Men will usually notice that their eyes look smaller.

The other big change is the development of fat bags around the upper and lower lids.  The eye is surrounded by a protective cushion of fat and as we age, the tissues that keep the fat in place weaken and the fat pockets protrude under the skin.  This (along with skin changes) gives patients a puffy and tired appearance.  It is not usual for patients to present to the office and say “Dr. Joe, I work out, watch my diet and take care of my self but I always look tired. My friends ask me if I am stressed or not sleeping!”  What these patients are actually saying is that they have aging changes in the eyelids.


The above picture illustrates aging changes in the eyelids.

Many patients that think they need eyelid surgery actually need brow and forehead lift surgery.  See this topic on my previous blog topics.  Brow and forehead lift is sometimes performed alone or with the combination of brow and eyelid surgery.  The photo below shows a patient with a tired appearance that was refreshed with brow lift and eyelid surgery.

The above patient complained of looking tired and was treated with brow and forehead lift and blepharoplasty (cosmetic eyelid surgery).

Upper eyelid cosmetic surgery is a relatively standard procedure in that an incision is made on the upper lid and excess skin, muscle and fat are removed or recoutoured.  The procedure takes about 20 minutes per upper lid and stitches are placed the dissolve or are removed at about 5 days.  The recover for upper eyelid blepharoplasty is usually about a week although most patients could don sunglasses and go about their business (excluding heavy lifting) in several days.  Many surgeons use scalpel or scissors for eyelid surgery.  Dr. Niamtu performs all his cosmetic eyelid surgery with high technology modalities such as lasers and radiowave surgery.  By using these advance devices, there is virtually no bleeding.  This means less pain, swelling and bruising and a faster recovery.

Lower eyelid surgery is more diverse in the number of surgical approaches the doctor uses.  Basically there are external approaches which leave a scar on the lower lid and internal approaches which are performed from the inside of the lower eyelid (transconjunctival approach) that leave no scar.  Dr. Niamtu generally uses the internal approach due to the fact that there will be no scar and also there are less complications with lower eyelid position with this approach.  Using the external approach can cause a pulled down lower eyelid which is not a problem with the internal approach.  When using either approach, the excess fat is reduced or repositioned to improve the bags under the lower eyelids.  This represents the first part of the operation and the second part is tightening the excess lower eyelid skin.  This thin, crinkly skin is addressed by numerous methods including cutting, lasering and chemical peeling.  Dr. Niamtu prefers treating the skin with the laser as there are no incisions.  The upside of the laser is that it makes new skin.  The aged skin is removed as well as pigment that contributes to dark circles under the eyes.  The downside is that the recovery is longer as the patient cannot wear makeup for about 10 days and will have some residual pinkness that can be covered with make up which can last up to several months.  The best results are available with the laser if the patient can tolerate the recovery.  Dr. Niamtu prefers chemical peel as the second option for lower eyelid skin tightening.  Although not quite as effective as the laser, the chemical peel also tightens the skin and removes unwanted skin damage and has a much shorter recovery which is usually a week and the patient is back in makeup.  A third method of tightening lower eyelid skin is to remove a small amount of skin.  Dr. Niamtu usually reserves skin removal for selected patients that are not candidates for laser or chemical peel.

The patient plays an important part in the success of any operation and especially eyelid surgery.  Serious complications are rare with eyelid surgery.  Bleeding behind the eye can be catastrophic and although very rare can be caused by bending, lifting, over activity, high blood pressure and medications as simple as aspirin that can affect the clotting system.  It is vitally important to adhere to the pre and post operative instructions provided by our office.

The following pictures show before and after cases of cosmetic eyelid surgery. 



Dr. Niamtu and his staff invite you to visit our office for a free consult for eyelid rejuvenation as well as visit our website www.lovethatface.com for more information about Dr. Niamtu and cosmetic eyelid surgery in Richmond, Virginia.

June 9, 2008 Posted by | Cosmetic Eyelid Surgery | , , , | Leave a comment