The Eyes, Part One: Laser, Needle, Knife, or Nothing

2 Jul 2013 at 9:00am

by Becca Smith,

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

Once upon a time, around my the time I turned 40, I flirted with the idea of lying about my age.

I knew if I was going to pull this off, I couldn’t lower my age to the point of suspicion, lest I leave people whispering, “ridden hard and put away wet”. That would be worse. So over lunch, I explained my dilemma to my friend Z, an agent in Los Angeles who is comfortable doling out brutal truths between mouthfuls of arugula.

"OK, so in New York you could pass for 37. Chicago, 34. London 32. But if you find yourself spending more time in LA…think more like, hmm…42. It’s your under eyes, they’re crepey and crinkly. That’s it."

After processing the fact that Hollywood would typecast me as a grandmother on Wizards of Waverly place, I realized Z was right.

The problem is, I’ve had mixed results with treatments in the eye area. 

Eye creams confuse the hell out of me. I can’t tell one from the other.

Botox has been a slippery slope. The first time I did it, I looked beautiful.  My brows were arched and lifted just enough to perfectly frame my eyes.  But later injections by the same dermatologist (who’s practice became more like Grand Central) left me looking like Dr. Spock. Or sometimes, like someone pulled a shade over my forehead, leveling the eyebrows flat.


Then there was Restylane, which I hoped would smooth out what I thought were bags.  Instead I got two puffy bluish ridges that seemed to sit on top of my orbital bone.  I later learned this is called the Tyndall Effect and happens when the hyaluronic acid is injected too close to the surface of the skin.   Fortunately it was easily dissolved with hyaluronidase, but I was out $800 and out of luck.

Since then, I’ve shied away from aggressively treating my eyes. I don’t mind the life that lives on my face and when words aren’t enough, enjoy the option of expressing surprise, delight or the occasional bitch face.

But at 45, the only thing my eyes seem to be communicating is that I’m tired, even when I feel great.

The only way to figure this out is to stop messing around with the Internet and get a few IRL opinions from board certified cosmetic dermatologists and plastic surgeons.

Today, we’re starting with the dermatologists.


My first stop is Dr. Doris Day, a board certified cosmetic dermatologist in Manhattan.

“Hmm…I can’t decide exactly what to do around the eyes. Not so much the upper eyelid, because I think your upper eyelids are quite perfect, and you have deep set eyes. I don’t think you’ll ever need your upper lid done.

It’s the lower eyelids that I see as the area that’s a little bit complicated. I can’t decide if that needs peels, laser, or surgery. You’re young, so it makes it harder. If you were older it’d be easier, I’d just pull the skin. I don’t know that I see excess skin, but I see a crepe-iness of the skin.  Can you squint for me?”

I squint while she examines how my face animates in relation to my crows feet.

“Your crows feet don’t extend all the way down. A little bit of Botox there and in the bunny lines, and in the middle and on the forehead. Very high up because your forehead is little, but only a small amount. The left eye’s weaker, that brow’s lower. You have to be very careful that way.

I’d use an under eye cream, like the TNS Essentials Serum, and put it on the lower eyelids and a retinoid, for sure. That will help strengthen that skin and make it less crepey.

We might think about a light fractional CO2 around the eyes. That’s definitely a winter project and has some down time, but it would freshen the skin there.”

I ask about whether doing CO2 around my eyes would leave a white Lone Ranger mask, but she assures me she would feather it down so it blends into my freckles.

However, she pauses when I tell her about the post inflammatory hyperpigmentation I got after a Fraxel 1927 treatment a few years ago and suggests some peels as an alternative.

Surprisingly, when it comes to fillers around my eyes, Dr. Day is less enthusiastic:

"No, I wouldn’t do a filler there. You’ll be amorphous. Your problem is crepey skin, not sinking. You have a little bit of a fat pad more on your right than your left.

What people don’t understand is that your eyes, these little folds, are two functional separation areas of your face. Your lower eyelids should not blend into your cheek directly. You need a little bit of a change from one part to the other, so you don’t overfill the area. On you that’s not your problem. The mid-face is.”

Wait, what?  My face…it’s like figuring out a Rubik’s Cube while falling down a rabbit hole.

“When I do the eyes – and I do them all day long – I do them last.  When you take care of the mid-face, it pushes up and it makes the eyes balanced.  If you fill it up, you’re not going to have any definition between your eyelids.”

She asks to see the pictures I brought of when I was a young adult.  I sheepishly pull out an amateur head shot from 1987, a time when I was regularly abusing shoulder pads, lipliner and Sebastian Ultra Hold.

I tell Dr. Day that I really don’t want to jump into this Hot Tub Time Machine, I just want to look refreshed.  Besides, I’m a little worried about getting that overfilled pillow face.

“Your under eyes are essentially the same there as they are now. See how your cheeks are elevated though? That’s the cheek I want to give you back.
Right behind the cheek bone, you have this as your normal fat pad. You don’t have much of one now. In front of it, as you can see it sinks, but also right there. If you don’t address this area, and maybe a little bit in here, then this can be looking too full. You have to actually go behind it and in front of it and it will look better.

You address some issues, but there are some lines and changes in your face that I think are age appropriate and normal. You may not be sunken, but you don’t look right. My goal is to make you the best version of you. Not to get rid of every line, or wrinkle, or brown spot, but to enhance your best features.”

Despite the typically high NYC price tag for the Dr. Day eye rejuvenation plan, her parting words are free and priceless.

“Stay fit, drink lots of green juice, snack on almonds, get a daily does of olive oil and have sex, lots of sex."

With that I get a B12 shot for all that energy I’ll need and leave with my TNS Essential Serum, a card for Eve’s Garden and food for thought.

My next stop is Dr. Ariel Ostad, a board certified dermatologist and dermatologic surgeon, also in New York City.

“There are so many different medical anatomic issues with regards to the eyes.  Each requires a customized treatment.  You can’t apply the same cookbook approach to every patient,” he says reinforcing the importance of the right diagnosis.

He explains that with the upper eyes, people either “hooding”, an excess of loose skin that hangs over the natural fold of the eyelid, or eyebrow sagging, where the position of the brows is starting to sag below the orbital bone.

Lower eye lid problems can be to either fine, crepey skin with fine lines, under eye bags or festoons which are larger bags that extend down onto the cheek and almost always require surgery.

Complicating this is factoring in the laxity of the eyelid and surrounding skin which makes or breaks some of your treatment options.   Think of laxity as the snap skin has to it – when you pinch it, how quickly does it bounce back.

OK Dr. Ostad, so what about my eyes.


“Actually your upper eyelids look nice.  With your lower eyelids when I look really close, you don’t have wrinkling, but you have a slight kind of protrusion of the fat pads. It’s called a pseudo herniation, meaning you didn’t suddenly develop a fat pad, it’s just that the support is gone so your fat pads are protruding. By putting a little Restylane here, we truly support those fat pads and push them back in.”

Dr. Ostad’s practice also offers blepharoplasty and CO2 lasers among others, so I asked whether or not I would be a good candidate.

Fraxel CO2 in your case will not do anything, because, you don’t have a lot of wrinkling. FraxelCO2 is a great way to tighten, if somebody has crepey, wrinkly skin, but there is some downtime. For about seven to ten days you have scabs under your lower eyelid.  You have to be home and pat the area with vinegar soaks and then apply Aquaphor.  But afterwards it’s nice and tight, with results that get better over six months.

Fraxel Restore on the other hand, I will not use at all to improve lower eyelid wrinkling.  I’ve had patients come to me who say they had Restore to get rid of fine lines, but it actually got worse.  I only use Fraxel Restore for acne scars.”

Regarding surgery, he cautions that the mistake he commonly sees is when people remove too much of the fat pad (in upper and lower blepharoplasties), leaving patients with a gaunt look years later.  Still, for others blepharoplasty is often the only options, especially for those with darker skin tones (no CO2), heavy hooding or too much loose skin.

Lastly we move back to Botox which he thinks would be an excellent idea for my crows feet and despite my Botox blunders in the past, is confident he can achieve a beautiful, natural result.

“With Botox if you put a little too much into the forehead, because, these muscles are elevators of the brow you can really knock them out too much. Your eyebrow sinks down and then you get accentuation of the hooding. If you don’t distribute Botox evenly, then one area is kind of relaxed, and the other area is really active.  Then things at the end shoot up.


It really requires going to a physician who really knows the anatomy of the face; some people who have a long forehead.  Some people have a short forehead.  There’s some people who basically, you have to sort of look at their eyelids.  If they really have a heavy eyelid, you really don’t want to treat their forehead; because, you’re really going to make them angry and upset; because, you’re going to make this hooding worse."

I ask him if having Ultherapy earlier in the month would clash with Botox.  I mean, I don’t want my eyebrows levitating off my face.  He assures me the Ultherapy lift is minimal – about 3mm so there’s little risk of overcorrection.

And away we go.  A small amount of Botox in my forehead, bilateral canthus, nose and glabella.

I rather like Dr. Ostad’s light touch.  It’s natural, my eyebrows are nicely arched, my crowsfeet are gone and I can make lots of faces.

But the issue of my eye crinkle crepes still remain and I’m not sure if its fillers, chemical peels for under the eyes or a CO2 fractional laser.  Heck, maybe it’s surgery?

I find myself a little frustrated but also humbled.  It reinforces that medical beauty is just as much art as there is science.  Sometimes even the experts disagree, they may not know, or there isn’t one right answer.  What I do know, is that I glad I’m getting multiple opinions and exploring my options in the hands of good doctors and not winging it at a med spa.

Next week, I dig deeper with fillers and get in depth about blephs with Dr. Haideh Hirmand.