Laser, Needle, Knife or Nothing: The Lower Eyelid Dilemma, Part 2

17 Jul 2013 at 9:00am

by Becca Smith, Narcissista.me

Narcissista is New York ad exec, RealSelf community member, mom, wife, and self-described “beauty veteran” Becca Smith, whose blog, Narcissista.me, deliciously and incisively examines the intersection of beauty, anti-aging, and loving (and navigating) life.


A few weeks ago, I learned that making my eyes look younger wasn’t going to be as easy an injection of pixie dust at lunch time.

My upper lids are holding up just fine, and Botox softened my crow’s feet. But my lower lids with their crepey skin and nascent bags that ebb and flow with the rhythm of my salt intake, are presenting more of a dilemma. After consulting with two well-regarded cosmetic dermatologists, I got two very different opinions. One thought the best course of action was a fractional CO2 laser with some filler in my mid face (yes the mid face) to rejuvenate the eyes. While the other prioritized Restylane to push the fat pad back in, but didn’t think I had enough wrinkles to justify the fractional CO2. If not a silver bullet, maybe a silver scalpel?

To find out, I visited New York board certified cosmetic plastic surgeon, Dr. Haideh Hirmand.  If the name sounds familiar it’s because she’s the surgeon responsible for the remarkable transformation of Ally Wentworth’s lower eye lids, which Wentworth then went onto video blog about for the better of woman-kind everywhere.

Walking into Dr. Hirmand’s Park Avenue office is like entering a luxurious vanilla colored cloud. I’m met by a team of assistants with complexions so flawless, it only further convinces me there are secrets within these walls that must be unlocked.  The exam room is more like a scrupulously clean Four Seasons than a run of the mill doctor’s office.

I curse myself for not wearing the good bra when asked to slip into an exam gown. Fortunately, Dr. Hirmand is as down to earth as her office is posh, (even though I’m pretty sure she floated into the room).

She pulls my hair back, hands me a mirror and investigates my eyes with the intensity of Sherlock Holmes looking for clues. She asks me to smile, squint, swivel left, swivel right, look up, look down and follow her finger.

“The number one thing that I see is that the skin has gotten thin, so when you animate, you see every little line.  But, you don’t have enough extra skin to really say, you need to cut the skin off, although that’s an option. You’re bags aren’t big enough to definitively say, let’s take your bags up.  You have a little hollowness, so we could inject, but that’s not going to solve the crepey issue so much.”

SEE ALSO: LASER, NEEDLE, KNIFE ... OR NOTHING ON JAW, NECK & CHIN

Dr. Hirmand tells me I’m somewhere between the “not yet zone” and the “no brainer zone."

This means surgery wouldn’t be inappropriate for me, and is often the choice made by actresses, models and public personalities in my “zone”. If I’m not ready to commit the time or money though, I could compromise with some non-invasive procedures, although the results would be less dramatic.

Either way, I’m told that because my issue is thin skin, my first order of business is to use a topical antioxidant under the eyes every day (she recommends SkinCeuticals AOX+ Eye Gel) followed by a retinoid at night to thicken the skin.

Onto the surgical evaluation.

“Let’s look at the elasticity of your lower lids. Look straight ahead and don’t blink, relax, blink a few times, don’t blink.  I see a little looseness, very mild.”

While I’m blinking like a POW sending Morse code, Dr. Hirmand explains she’s gauging the looseness of the lower lid.  During the healing process, gravity can pull on the ligament and make the eye look more rounded if not supported.  In my case, the elasticity is looser on one side than the other which means she’ll need to support the ligaments with a tiny, soft suture.

She also looks at the prominence of my eye (meaning how far the eyeball sticks out) because the eyelids sustain different forces depending on deep set or protruding the eyeball is.

“What we can do to make you look fresher is to take a little a bit of that crepey skin off.  A very gentle lower lid blepharoplasty that would trim back about 2, 3 maybe 4 millimeters max, and then do some right orbital fat contouring.  Just a tweak on this fat bag because we don’t want to hollow that out. You would be left with a very fine line on your lower lid."

She explains the lower blepharoplasty would address the little bag, the looseness of the skin and the laxity. However, Dr. Hirmand tells me she doesn’t want to pull the skin too tight, because when skin isn’t elastic, it goes thru a process called stress relaxation.  When this happens, skin can actually become looser faster.

I’m also told that while the lower blepharoplasty will go a long way to make me look refreshed, I’ll likely need a 20% TCA peel afterwards to help soften the fine lines.

SEE ALSO: INTRODUCING LASER, NEEDLE, KNIFE ... OR NOTHING

Ok, but what are my non-invasive options if I’m not fully ready to commit to the scalpel?

The first thing she notices is that I seem to have a hollowness in something called the A frame of my upper eye.

“You have a pretty nice, full brow here, but when you get here,” she says pointing to the inner and under part of my right eye, “it sort of hollows in here. The question is did you look like this before or did you always look like this?”

She takes a look at pictures of me from ages of 19, 29, 34 and today to  see if this is how I always looked, or if the hollowness is a result of aging. The pictures say it all; it’s aging.

In my case, adding a little filler to the hollowness of the upper eye could be a nice way to subtly freshen my eyes.

“Revolumizing in the upper lid is tricky, but it’s really a fantastic way to rejuvenate” says Dr. Hirmand.  ”But not everybody with volume loss in the upper eyelid (which is pretty much everyone aging) is a candidate for injections in the upper eyelid either.  Much like not everybody is a candidate for having injections in their lower lid but the upper lid even trickier. For example if the skin is hanging or sagging, a brow lift may be a better option.”

Dr. Hirmand reiterates though that revolumizing the A frame is a highly specialized, complex procedure and should only be done by a board certified plastic surgeon or dermatologist with a core aesthetic practice and special interest in the eye area.

“When I teach this injection in my course, I don’t allow non-physicians, not even PA’s to attend. Not only is it tricky aesthetically, it’s the highest complication area of injections around the eyes” says Dr. Hirmand. “It can get lumpy.  They can get the contour wrong, and if it’s over injected, it’s hard to fix. Also, the upper eyelid has a direct channel to the central retinal artery.”

SEE ALSO: LASER, NEEDLE, KNIFE ... OR NOTHING ON JAW, NECK & CHIN

Not sure if your doctor qualifies? Google them and look for peer reviewed publications and presentations on the topic.

As far as my lower lids, there’s a minor tear trough deformity that filler could address.  She tells me that because I got the Tyndall Effect with Restylane under my eyes, that the new filler, Belotero would be a nice solution.

“The thing that we see in Belotero is that a higher percentage of people come back in a month needing more filler than Restylane. It’s compressible and so I can’t predict if the muscle is going to compress it down too much, which is why I always put a little Botox at the insertion of the muscle there.”

Ninety minutes later, my head is swimming in all this eye rejuvenation goodness, so I ask for her recommendation on what she would prioritize.

“My guess is your level of satisfaction with the compromise procedure is going to be like 60%, whereas if you did the conservative lower lid blephoraplasty, the 20% TCA peel and the fillers, you’ll probably going to be approaching 90%."

SEE ALSO: LASER, NEEDLE, KNIFE ... OR NOTHING ON LOWER EYELIDS PART 2

Fair point. The cost of that 90% loveliness though is north of $10K, which isn’t unreasonable by New York City standards, but lands with a sobering thud nonetheless.

Knowing my livelihood doesn’t rest solely on my face and that my budget doesn’t have $10K worth of sway, I’ll earmark the surgery as a 2015 project or whenever the “no brainer zone” hits, whichever comes first.

Meanwhile, I leave with my vial of SkinCeuticals AOX+ Eye Gel and Retinol 0.5 Refining Night Cream. A relative bargain at $130.