Would Restylane for my tear trough and Botox for my crow's feet give me good results? (UPDATED PHOTOS)
Doctor Answers (14)
Would Restylane and Botox be useful for me?
Filler and Botox for you?
Maybe for the Botox and Restylane, would need to see some younger photos.
To figure out what exactly changed over the past 10-15 years, I would want to review photos of you from when you were around 20-25. You may or may not like it based on what you are trying to achieve. I have patients with similar issue, and some patients like it while others don't, even though the results are similar. For the Botox, some patients like the fact that they don't form the crow's feet when they smile, while others think that the botox makes their smile look like a fake smile or a camera smile, but not a genuine smile. As for the Restylane, it can only be used for the tear trough shadow, but it may or may not improve the lines directly under your eyes when you smile big. Botox in my opinion should not be used directly under the lower eyelids, since this may weaken the muscle which is holding the eyebag back, and cause the eyebags to worsen. You can find complaint on Realself about botox directly to the lower eyelid for these wrinkles when smiling and it caused eyebags to form when they did not have them before. So be careful.
I think that some of the changes that you are seeing are related to volume loss/hollowing around the eyes, which can make the wrinkling worse under the eyes as well as crow's feet. The good news is that when you are not smiling, you are wrinkle-free.
I like to explain to patients how I recommend botox, using an ironing analogy. If your facial skin were a white dress shirt, would you iron it if it was wrinkle free when it is on your dry cleaning hangar? Most likely not. As soon as you put on your dress shirt you will notice that there may be some pleating and wrinkling of the fabric, but the key observation is that there are no "set in" wrinkles. Botox can act like a "one-time" ironing session, to smooth out the wrinkles which are setting in. If the wrinkle is not particularly deep, then a single session of Botox will likely smooth it out completely. If the wrinkle is more "set in" then, it may take 2 or more sessions to smooth out the wrinkle. With the muscle inactivity, the skin along the set in wrinkle has time to repair itself, while then skin is laying flatter. With repeated use, set-in wrinkles can often times smooth out completely.
The dilemma is when should you use Botox. My personal belief is based on looking at young faces and how their skin behaves. If you have a small child, teenager, or even a 20 year old, certainly they do not need botox (unless you believe the popular media pushing botox on early 20 year olds i.e. Ashlee Simpson a few years ago.) When they frown, raise their eyebrows, squint or smile genuinely, they can form frown lines, smile lines, forehead lines, and crow's feet. However, the key observation is that when they stop making that expression, there are NO LINES. There skin is plump and healthy, and although they can form the lines with facial expression, the key thing is that when they are not expression the emotion, the lines are not there.
So let's use this observation as a baseline, for botox use. Is it that we really want to eliminate those facial expressions completely? Is that what is wrong with the celebrities that we see as "over-botoxed" or "expressionless." Some patients will regularly have botox, but in smaller doses, so that they still have motion, but the movements are weaker. If the shirt is already "wrinkle free" would you take the time and effort to take out your ironing board and plug in your iron only to iron this shirt which essentially is wrinkle free. In the case of botox, take out the words "time and effort" and insert "time and money." If the patient uses a suboptimal dose of botox, which still allows for some movement, it is like ironing half-heartedly.
I also realize that botox is preventative, since I do not want the patient's wrinkles to get really deep and really get set in either. Most of my patients will get botox on a 5-6 month schedule, and mainly have botox a month before important events. During that first month when the botox is fully active, the facial expressions are obviously less active. If the patient is an actor or performer, I worry that the botox will prevent them from fully delivering the performance that they want to give, since they may need or want to have those facial expressions during the performance. However, when they stop making those expressions, we want the face to be "wrinkle free" like a younger person's facial skin. For these reasons, a month or two after the botox, I think is the best time, since the movement is coming back, and the skin is relatively wrinkle free when they are not expressing emotion.
For regular people, I think the prime times for botox are a month before Thanksgiving, which then rolls into December holiday celebrations, and beginning of summer prior to weddings and graduations, and to help prevent squinting and frowning on the summer sun.
Hollowing around the eyes
In general, I think the eyelid area can be improved with volume, but this does not mean it will look exactly as it did when you were younger. I think that the actual facial aging process is much more complex than simply injecting Restylane into the tear trough area.
Injecting Restylane/fillers to the lower eyelid/tear trough area is one of my favorite procedures. I think that it really helps people who have a "tired look." In fact, I think that the order of injecting fillers between smile lines and tear troughs, currently backwards. Most injectors know how to inject smile lines, but not all of them know how to inject the lower eyelid area.
Patients who come into our office with a "tired appearance" usually complain of the shadows or dark circles below their eyes which essentially "splits" the cheek into a long lower eyelid and a shorter cheek, as opposed to a very short lower eyelid and apple cheek. Using very small amounts of filler can help to blend the dark circle, so that the longer lower eyelid is blended into the shorter cheek, and the small lower eyelid which accentuated when smiling is still there. They often also complain of their smile lines, which I think may have already been present prior to the dark circles. Because both the tear trough lines and the smile lines are diagonal, visually these lines reinforce each other, and makes the smile lines look worse, as well as the dark circle/tear trough.
If the tear trough shadows and smile lines are visually playing off of each other, is there a more important line to smooth out first? If you believe the Juvederm "Parentheses" commercials and ads, you would choose to smooth out the smile lines first. I think this thinking is too simplified and perhaps why some of the celebrities look weird and puffy. If we examine the face below the eyes, there are really three sections, the right cheek, the left cheek, and the mouth area.
What is the natural visual divider between the cheeks and the mouth area? The smile lines AKA nasolabial folds. The FDA approved area for Restylane and Juvederm are the smile lines. Restylane added lip augmentation as an FDA approved area in November of 2013, which means that lip injections using Restylane were actually off-label prior to 11/2013. Juvederm is currently being injected to the lips "off-label," but is the market share leader for filler injections for lip augmentation, because of its smoothness to inject. Probably the only reason the Restylane applied to the on-label use for lip augmentation was to reclaim some market share.
Lower eyelid/tear trough injections are off-label use for Restylane; however, from a facial rejuvenation strategy I think it makes more sense to blend the lower eyelid/cheek junction, before filling the smile lines (which is actually on-label.) Would it make sense start blending the cheeks and the mouth area together, below the dark circles/tear troughs which are left intact? Often times after the lower eyelid tear trough area is filled, these patients are less bothered by their smile lines, and it visually looks like normal smile lines.
The appearance that I try to avoid are the overly filled cheeks and smile lines, yet the lower eyelid area is not treated. To fill the cheeks and smile lines, use much more volume to make a visible difference than simply filling a shadow which is the tear trough/dark circle. Now that Juvederm Voluma is approved for cheek augmentation, I suspect this may reinvigorate that trend. I suspect that some patients get their smile lines and cheeks filled, which makes some improvement, yet they don't really look that much younger or refreshed. Since they did feel there was some improvement, they go back for more of the same smile line filler and cheek filler. At some point, their face starts to get bloated, and the media term is "pillow face."
Using less volume: "More bang for your buck"
Using 0.5 to 1cc of volume to the tear trough can keep the face slim and sculpted without adding much volume to the overall face. Yet visually the cheeks appear more "whole", more "apple-like" as well as making the cheeks appear "higher" which is an optical illusion. Without the dark circle/tear trough splitting the cheek and making the lower eyelid longer and the cheek shorter, the cheek appears higher since you can't really tell where exactly the lower eyelid is located or it makes the lower eyelid much shorter. Above the tear trough shadow, there is usually a second line or shadow, which parallels closely with the lower eyelashes. This secondary line cannot be filled using the tear trough technique. If you follow the Web reference link below, there are some good examples from my website's photo gallery, with the patients looking straight, upwards, and downwards, at a 45 degree left view, front view and 45 degree right view, for a total of 9 photos per series.
I don't know if this answered your question of whether you will get good results from Restylane and Botox, but I think the answer is more complicated than a yes or no answer. The other doctors on Realself will give you a more succinct answer, but this hopefully sheds some light into how I approach facial rejuvenation.
Good luck on your facial rejuvenation journey.
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