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

Eyelid Surgery Vs Browlift: What’s it all about?

One of the most common points of confusion in cosmetic facial surgery is  understanding the diagnosis and treatment options between eyelid surgery and brow and forehead lift surgery.

Put plain and simple, the brow and forehead are intimately related to the eyelids in youth and aging.  If you look at your picture in your 40’s or 50’s and compare them to your high school picture, the chances are that your brow has drooped, your forehead has wrinkled and your eyelids have excessive skin, muscle and fat.

Although cosmetic eyelid surgery is one of the most popular procedures worldwide, many times people have skin removed from their upper eyelids when in fact they should have a brow and forehead lift.  The problem with misdiagnosing the need for browlift surgery is that if a patient has excessive skin removed from his or her eyelids then it may be impossible in the future to have a brow lift as there will not be enough skin left  to close the eye.  Likewise, even if conservative skin removal is performed and then repeated later a brow lift may be impossible.  Finally, if a patient already has low brows and more skin is removed, the brow can be lowered even more. So, what do you do?

Basically, when you seek a consult for upper eyelid rejuvenation, if the doctor does not mention the word “brow” in the first several sentences, you should seek another opinion.  This is because many surgeons do not understand the extreme importance of upper facial aesthetics.  In female patients, the brow normally sits above the upper bony rim of the eye socket (superior orbital rim).  If you ( as a female) reach up and feel your brow and it sits at or below the rim, you may be a candidate for a brow lift.  In males, the brow usually sits at the orbital rim.

Not every patient is a candidate for brow and forehead lifting, but many patients are.  If you look in a mirror and relax your brow and forehead and they gently elevate your brow on the middle and lateral portions regions you can see a preview of what a brow and forehead lift may do.  In the average patient a brow lift of 5-8 millimeters (less than ½ inch) will produce a more youthful, alert, awake and open eyed look.  When I manually elevate a patient’s brow they either love it and say “that is how I used to look years ago” or they feel that it is excessive or unnatural.  Obviously, browlift is not an option unless one likes the look.  In my experience about 60% of patients like the look and the other 40% don’t like the look.  There is no doubt that an excessively elevated brow looks very fake, so conservative surgery is imperative for a natural look.

For those that do like the elevate brow appearance, they will notice that it elevates the most lateral (side) region of the brow.  As this area gets saggy, it causes a “sad puppy” appearance which doctors call lateral hooding.  Elevating this hooding makes most patients look younger.  You will also notice when you elevate the brow that the excess eyelid skin significantly improves.  This is because elevating the brow lifts the saggy tissues and fat and repositions them to a more youthful position.  Many times, patients present to the office asking for blepharoplasty (cosmetic eyelid surgery) and after education them, they opt for brow and forehead lift which corrects the upper eyelid aging as well as the sagging brow and forehead.  Patients with significant excess skin or fat may need eyelid surgery and browlift at the same time.  Another benefit of brow and forehead lift surgery is the ability to improve forehead wrinkles by tightening the forehead skin.

Obviously, not all patients need brow and forehead lift as many patients do not want or need their brows elevated.  In these patients, removal of skin, muscle and fat on the upper eyelids is all that is necessary.  A brow lift is a more comprehensive procedure and is a bigger surgery with a longer recovery when compared to blepharoplasty.  When I perform blepharoplasty I don’t use scissors or scalpels, but rather high tech devices such as CO2 laser and radiowave surgery.  These modalities prohibit bleeding and blood loss is several drops.  Less bleeding means, less bruising, less swelling, less pain and faster healing.  Normally surgery on all four eyelids take about an hour and is usually performed with light sedation.  The recovery is generally one week, although most patients are up and around in less time.

Most old fashioned brow lifts were performed by a very aggressive incision at the top of the head to reflect the entire front scalp during the procedure (coronal brow lift).  Contemporary brow and forehead lift is frequently performed with endoscopic surgery through small, button hole incisions hidden in the hairline.  Another very popular contemporary method of brow and forehead lift is the mini open brow technique.  In this technique, a small incision is made just behind the hairline in a very specialized manner to allow the hair to regrow through the scar, making it extremely cosmetic.  One big advantage of the mini open procedure is that it does not raise the hairline.  All other brow lift procedures will raise the hairline to some extent.  This is not a problem for patients with low hairlines, but many females already have elevated hairlines and would not look good with an even higher hairline.   There are pluses and minuses of both of these procedures and each patient is different.  A competent surgeon will offer multiple means of performing brow and forehead lift to tailor a custom procedure for that specific patient. 

The take home message here is that if you think you need your upper eyelids improved, success may lie in eyelid tuck, brow and forehead lift or both.  If your surgeon does not offer both options or discuss the importance of either, a second opinion may be in order.


Joe Niamtu, III DMD

Cosmetic Facial Surger

Richmond, Virginia


March 6, 2008 Posted by | Brow Lift Surgery, Eyelid Surgery | , , , , | Leave a comment