What do you recommend for the wrinkles and crepiness under my eyes when I smile? (photo)

My dermatologist recommended erbium laser, I am concerned it will not be enough. I am curious about laser, injectables, fat injections, or surgery. I currently have Botox around my eyes.

Doctor Answers (3)

Improving the quality of the eyelid skin using regenerative medicine works well with treatments to reduce wrinkles

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In my book I wrote years ago called “The Fine Art of Looking Younger” I discussed that even if you relax the muscles with Botox, lines still form when you physically move the cheek upward. This is because there is a unit movement effect when one part of the face moves.

They are basically two types of wrinkles: static wrinkles - the wrinkles around the eyes at rest, and dynamic wrinkles - wrinkles that occur when there’s activation of a muscle. Even with Botox, the dynamic activity of the muscle around your eyes will still cause wrinkling of the skin.

There are a lot of people who have lines under their eyes such as actors or models, but they are still attractive. There are also younger people who have lines under their eyes but they don’t look bad. This is because people look at other people’s faces as a whole and not the small aspects. Unfortunately, people tend to look at themselves too critically that they notice even the smallest details of their appearance. They pursue the holy grail of smooth, tight, flawless skin to the point that they get laser thereby making their skin thinner.

As a surgeon, I evaluate patients by their overall facial aesthetics. I start at the basics such as the impression their eyes make. I noticed that at rest, there is some puffiness under your eyes. This is probably due to lower eyelid fat prolapse. From my experience, puffiness under the eyes is a big factor in the overall impact on the perception of the individual. When you have puffiness under your eyes, people think you’re tired, older or lack energy.

I address crepiness caused by thinning of the skin using a regeneration technique rather than some type of heat stimulation. I used to do all types of laser techniques however I have modified my approach for years. Presently, I use something called platelet-rich plasma. It is basically the patient’s own blood that is spun down to concentrate the active healing factors called platelets as well as the serum which have growth factors. These are manipulated and injected in a very specific way under the eyes to help improve skin quality and volume. With platelet-rich plasma, it restores lost collagen and vascularity which normally happens in aging skin. In addition, from the top part of the skin, we employ fractional CO2 laser and microneedling. The activity of the muscle around the eyes can also be addressed with neurotoxins such as Botox and Dysport.

I suggest that you take a step back and look at your face as whole. Know how the puffiness and wrinkles on your face play a role in the overall appearance of your face. It is good to get opinions from your friends and family to get a sense of how people perceive your look. I hope that was helpful, I wish you the best of luck, and thank you for your question.


New York Oculoplastic Surgeon
4.5 out of 5 stars 26 reviews

Under Eye Options for Skin Crepiness

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Hi RQ.  To give you a better answer, we would conduct a test call the pinch test.  You can try it at home yourself to give you a better idea of what might work well.  

Using your thumb and forefinger, pinch a small bit of skin under the eye.  While looking in the mirror, release the pinch of skin and look at what happens.  If the skin takes several seconds to return to normal and release the tight bunch of skin, then you may be better off with surgery.  If the skin releases quickly and goes back to the original appearance in less than 1-1.5 seconds, then you may be a good candidate fro Restylane and Dysport (Botox).  Ultimately, an in person exam is a better way to tell, but we would suggest you consider lower eyelid surgery and/or injections.  

Check the photos below for a similar case profiled on our website where we used injections.

Harold J. Kaplan, MD
Los Angeles Facial Plastic Surgeon
5.0 out of 5 stars 6 reviews

There is no substitute for an in depth personal consultation.

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First and foremost, this is a cusp.  You are considering embarking on a new step of cosmetic procedures around the eye.  This is an excellent moment to stop and take stock and ask if what you are currently doing is working.  Apparently the answer from your dermatologist is no, it is not working.  However, before proceeding with laser, fat injections, or surgery, this is a good moment to assess if what you are currently doing is actually causing the problem you are looking to solve.  If this were the case, then you could have help simply by changing the way you are getting cosmetic botulinum toxin for example.

Chasing the line that heaps up in your lower eyelid can be very frustrating.  That is because many of our procedures actually reduce the compliance of the lower eyelid making the lines worse not better.  All of the procedures you mention, lasers, fat, and surgery are associated with increase scar tissue in the  lower eyelid glide planes.  The less scarred these tissues, the better they glide redistributing themselves when you smile.  

I wonder if you are a little over "toxed" at the lateral raphe extending into the lower eyelid.  This can contribute to the heaviness of the lower eyelid lines and a bit of slumping in the lower eyelid in relaxation, which you exhibit.  Before embarking on new procedures, I would encourage you to try a different method of periocular cosmetic botulinum toxin.  I also think that your eyebrows are not well supported by your current treatments.  No forehead lines but a flattened eyebrow is not a great trade-off.  The lower eyelid can also be improved with lower eyelid/midface filler in the form of Restylane.  This type of treatment lasts over a year.  I would need to examine you to have an opinion regarding surgery.

Kenneth D. Steinsapir, MD
Los Angeles Oculoplastic Surgeon
5.0 out of 5 stars 16 reviews

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These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.