42 year old with horrible under eye hollowness and severe wrinkles. What would be the best procedure to fix them? (Photo)

I’m a cosmetic oculofacial plastic surgeon, practicing in Manhattan and
Long Island for over 20 years. Periocular or aesthetics around the eyes is a
specialty of mine. Your situation is something I deal with every day.



Hollowing is due to genetics and aging. As people get older, they lose
volume composed of bone, muscle and fat. In the under eye area, particularly in
the eyelid to cheek junction, there is an area that we refer to as the
V-deformity. There is a relative hollowing in that area, and the cheek also
loses volume.

Whenever I look at people’s eyes, I always look at their whole face. I
do facelifts, cheek implants and a lot of things to help rejuvenate the face. I
think of everything in isolation, but also in relationship with the other areas
because the whole is always greater than the sum of the parts.
You also notice that there are wrinkles when you make facial expressions.
These are called dynamic wrinkles. Those are wrinkles that are activated when
the muscles contract. There are also wrinkles at rest called static wrinkles. There
are two different modalities to approach these issues.



I have also observed that when your face was at rest, there is
puffiness under your eyes called lower eyelid fat prolapse. This is typically
addressed with surgery, and for you the likely procedure is a transconjunctival
blepharoplasty where fat is removed from the inside of the eyelids to avoid an
external incision or scar. This is performed in our office under local
anesthesia with LITE™ sedation which means you’re not under general anesthesia.
It has a quicker recovery. I would say that this must your number one issue.



For volume loss under the eyes particularly in the eyelid-to-cheek
junction and the cheek area, we address them with either fillers such as
Restylane, Radiesse, or Juvederm. or the use of a more permanent solution like
a cheek implant. Most of time, people don’t want to hear about cheek implants
the first time they meet you, so it’s worthwhile doing a trial of injectables.
There is value to the convenience of doing injectables in comparison to surgery,
but injectables aren’t permanent which means that they have
to be maintained.



As far as wrinkles are concerned, for static or wrinkles at rest, we
use a combination modalities composed of platelet-rich plasma (PRP) and
fractional CO2 laser. Static lines represent loss of collagen. PRP, which is
derived from your own blood, has growth factors that stimulate collagen. We also
use lasers such as the fractional CO2 laser. These are not intended to make you
look smooth or porcelain, but to improve the appearance of lines and wrinkles. When
it comes to dynamic wrinkles, we use Botox™, Dysport and Xeomin. These are
injectables that reduce the activity of the muscle in the forehead or the frown
lines. The one thing to be mindful of is that when you smile, the cheek goes
vertically upward, so there will always be skin bunching up in that area.



It’s very important to understand how each of these factors contributes
to the overall appearance. As a cosmetic surgeon, patients come to me often
with a particular concern that’s high in their priority list. I often let them
look at themselves from a broader view. They learn that it may be something
that’s important to them in terms of their perception, but they must consider
how it contributes to their overall facial appearance. We can improve their
appearance by taking little bits and pieces of different issues and combine
them. We can’t stop the aging process, but we can certainly help you look your
best by addressing a lot of these genetic and aging issues.



At this point, I think that it’s best to meet with qualified,
experienced cosmetic surgeons. I say surgeons because they can do other things
which dermatologists and other non-surgical specialists can do, and . at the
same time, they can also provide you with surgical solutions. It’s very
important that you figure out the things that are important to you and have clear
communication with your doctor about expectations. I hope that was helpful, I
wish you the best of luck, and thank you for your question.



This personalized
video answer to your question is posted on RealSelf and on YouTube. To provide
you with a personal and expert response, we use the image(s) you submitted on
RealSelf in the video, but with respect to your privacy, we only show the body
feature in question so you are not personally identifiable. If you prefer not
to have your video question visible on YouTube, please contact us.

There are many ways to treat dark circles, as well as under eye wrinkles and bags. It is important to note however, that the majority of times the cause for discoloration is genetic and due to the viability of the blood vessels below the skin. A combination approach is always needed to get the best results in this area and this includes: topical skin care, laser and/or radiofrequency treatments, and fillers if placed appropriately.  All my patients are on topical lightening agents, typically a vitamin C serum product in the AM and a brightening agent and/or a vitamin A based product in the PM. Sun protection is essential.Resurfacing and tightening are essential. My patients get offered a menu of options, for which a combination gives the best results. Light salicylic acid peels help give textural and pigment improvement; nonablative lasers (Fraxel or Clear + Brilliant) can be used to tighten and improve fine lines/wrinkles and crepe skin; fractional radiofrequency devices (Sublative, Viva) are cutting edge and improve texture, tone, and wrinkles with very little downtime; radiofrequency with pulsed electromagnetic fields (Venus) are amazing for puffiness and bags, in patients who do not want eyelid surgery; appropriately placed fillers can replace lost volume, cover up the vessels and fat pads below improving the appearance -- patients should pick a well experienced practitioner to prevent complications such as Tyndall (blue discoloration) and irregularities, one that uses a cannula for injection will help give results with little bruising or swelling; microsecond Nd:YAG laser treatments (Laser genesis) has produced dramatic improvement in discoloration in some of my patients and is safe in dark skin types, similar to the radiofrequency devices. For lifting, ablative laser resurfacing such as co2 laser combined with monopoloar radiofrequency deep heating (thermage) give amazing results. The key is for a patient to see a cosmetic dermatologist with experience in all the latest devices and techniques so the persons goals can be met by a combination approach of individualized treatments and skin care. In some cases, those who smile and have crepe skin or under eye wrinkles, a small amount of neurotoxin (botox, dysport, xeomin) strategically placed in the lower eyelid skin can improve wrinkles dramatically and give the eye a more "open" appearance.

Most expert experienced artistic plastic surgeons have a
variety of procedures, both non-surgical and surgical, at their disposal to
produce excellent cosmetic results in the appropriately selected patient:
temporary fillers, micro-fat grafts, and blepharoplasties. Each has
benefits and drawbacks and depends on desired outcome and individual anatomy.

In a patient with your inherited anatomy, a
blepharoplasty and micro-fat grafts or fat repositioning to fill the hollows will produce the best and longest lasting cosmetic result.

Following the advice of anyone who would presume
to tell you what to do without seeing photos and without taking a full medical
history, examining you, feeling and assessing your tissue tone, discussing your
desired outcome and fully informing you about the pros and cons of each option
would not be in your best interest. Find a plastic surgeon that you are
comfortable with and one that you trust and listen to his or her advice. The
surgeon should be certified by the American Board of Plastic Surgery and
ideally a member of the American Society for Aesthetic Plastic Surgery (ASAPS).
You should discuss your concerns with that surgeon in person.

Robert Singer, MD FACS

La Jolla, California