Arnold Zweig, MD (retired)

It is really difficult to tell from your pictures due to the angle (vs. one from directly from the front) as to whether your eyelids are "droopy" or not.  As one of the other doctors indicated, it may be that you have heavy eyelids (but no excess skin).  Sometimes when someone is described as having the "puppy" look or "bedroom eyes", there is a chance that the person may have a condition known as "ptosis" which is a loss of muscle tone or tension that keeps the upper eyelid in the correct position.  I think you are wise to want to avoid a surgical procedure if possible and my advise is to see a board certified occuplastic surgeon.  An occuplastic surgeon is trained to correct conditions such as ptosis and can typically make an aesthetic correction as well if needed. 
 

The wrinkles and creases that are accentuated when you smile are due to the movement of your cheeks "pushing" your skin upward towards the lower lid area. Botox injections in the lower eyelid area are very meticulous and it requires an injector who is skilled and has a done a number of injections in that area with positive results.  I do not recommend injecting Botox in the lower eyelid area as there is a risk that your lower eyelid could pull down leaving you with temporary scleral show (the white portion is visible) as well as dry eyes and this could actually make you appear older if this were to occur after the Botox was injected. 

 As for filler in this area, I routinely inject a hyaluronic filler such as Juvederm to plump up depressions in that area which occur from a loss of natural fat that a leaves a diagonal crease between the lower eyelid and top of the cheek.  My advice is to consult with a Board Certified Facial Plastic surgeon who can determine the best solution for your problem.  You can visit the American Academy of Facial Plastic and Reconstructive Surgery website (aafprs.org) to find one in your area. 

I am sorry that you have had difficulty achieving the result you wanted for your eyelids.  My first piece of advise is to allow your eyelid to completely heal before considering any more surgery.  There is only so much skin that can be removed from the eyelid and still allow you to completely close your eye without any side effects such as a dry eye.  Having three surgeries on the same lid within the span of two years seems rather extreme to me.  You did not indicate if the same surgeon has performed all three surgeries and I am going to assume that it is the same surgeon.  I would advise you to wait 6 months to a year before considering another revision.  Looking at your eyelid it appears to me that you have a condition known as "ptosis" which is a loss of muscle tone or tension that keeps the upper eyelid in the correct position and as you mention the eyelid "dropping" that may another indication that you do have this condition.  My advise is to seek the services of a board certified occuplastic surgeon when you are ready for the next revision.  An occuplastic surgeon is trained to correct conditions such as ptosis and can typically make an aesthetic correction as well.  

Based on your picture it does appear that your nose could be refined however the degree of improvement will depend on how thick the skin is as well as the amount of cartilage underneath the skin.  If the skin is relatively thick and there is very little cartilage to remove then the results will be a minimal change.  When you consult for possibly having this surgery, the surgeon will certainly take into account your unique facial features and make recommendations based on what you need to fit and enhance your face.

My advice is to consult with a Board Certified Facial Plastic Surgeon who will examine your nose to determine how much refinement can be achieved.  You can find a qualified surgeon in your area by visiting the website for the American Academy for Facial Plastic and Reconstructive Surgery (aafprs.org).  When choosing a surgeon you should be able to review before and after pictures of patients who had their surgery with this doctor and have the opportunity to speak with some of his/her patients.  Most surgeons also use video imaging to give you a concept of how you might look after the procedure. 

I agree with Dr. Laverson that the chance of you having "sagging" skin at 29 is most likely not truly loose skin unless your genetics (did your father or mother have a "turkey" neck at an early age?) are causing it.  If it is fat that you are seeing and making you unhappy then that can certainly be improved with liposuction and your skin should tighten up as you are young and your skin should have a great amount of elasticity. 

My advise is to consult with a Board Certified Facial Plastic Surgeon who will be able to tell you what your options are for improving this area.  Best of luck.

In answer to your question regarding tightening your forehead and upper face, the answer is that Botox does not tighten any portion of the face.  The areas treated with Botox may appear tighter due to the lines that were present prior to treatment with Botox no longer being there and the area looking smoother.  Botox is excellent for treating forehead lines, frown lines, and crows' feet around the eyes so if you have concerns with any of those areas then you may want to take advantage of the specials offered to you.  You do need to take in consideration as to who is doing your injections especially when there is a "special".  All doctors pay the same price for Botox so beware of any specials that are advertised at a price that is much lower than the average cost - you may be getting watered down Botox, a non-qualified injector, or not enough units to adequately treat the area which make much of a difference for pre-treatment to post-treatment, or might not last as long.

Based on the picture, it is difficult to determine what you may need if anything.  You appear relatively young and it is hard to imagine that you have any sagging of the skin that would require a surgical procedure at this time.  Best of luck.

As my colleagues have indicated it is difficult to give advice without seeing your photo, however based on your description of the amount of skin you are "pulling" it appears at a minimum a lower facelift is required to solve your problem.  You did not indicate your age or any other factors such as if you have ever smoked, had significant sun exposure, etc.  You did mention you now have a thin face whereas it used to be fuller which would indicate you have lost weight and this could result in sagging skin depending on the amount of weight lost.  Typically when we see excess neck skin there are also jowls (irregular jaw line) and these would need to be addressed at the same time as the excess neck skin as all of this skin is connected and you would be unhappy with just correcting the neck.  So in answer to your question there is not a correction for you that is non-surgical.  Please seek the advice of a Board Certified Facial Plastic Surgeon in your area for a consultation.  You can visit the website of the American Academy for Facial Plastic & Reconstructive Surgery (aafprs.org) to find a qualified surgeon in your area.

As my colleagues have stated it is not unusual for patients to travel to areas further away for cosmetic surgery.  To answer your question regarding staying in a hotel or outpatient center, all of my out-of-town patients (and some of my in-town patients) have either stayed at nearby hotels located within 1/4 - 2 miles from my surgery center or stayed with a friend or family member who happens to live in the area.  For our patients who do not know any one in the area, the hotels nearby have been a wonderful option and we are able to offer extended care to them if they do not have anyone to stay with them the first two nights of surgery.  If you are staying in a hotel, you will want a private entrance and options for a ground floor, non-smoking room with a small refrigerator and amenities within the hotel such as a restaurant or area to purchase food or drinks you may desire during your recovery. 

For your post-operative recovery I recommend staying in the area for at least a week since you should be having 3-4 post-operative visits within the first week of surgery if you are having a complete face and neck lift alone.  If you are having multiple procedures then you may have more visits involved depending on the procedure(s) that are performed.  After the first week, you should be able to return home without fear of complications arising that would warrant seeing your surgeon.  You will have to return at least one more time to have any remaining sutures removed that require a longer healing time.   Your surgeon will want to see you at periodic post-operative appointments to monitor your healing.

The city where you have surgery should not be your greatest concern - having a qualified surgeon who you trust and feel comfortable with is the most important factor in making your decision.  My advice is to seek a Board Certified Facial Plastic Surgeon.  You can visit the American Academy of Facial Plastic and Reconstructive website (aafprs.org) to locate many qualified surgeons.  Once you find the one you like then ask to see examples of their surgical skills and speak to patients who have had the same type of surgery performed by the surgeon.  I would recommend specifically asking for a patient who traveled from another city, state, or country to talk to so that you feel more comfortable about what to expect as far as the post-operative accommodations. 

The hollowness under your eyes is most likely due to a loss of fat in this area which is not uncommon as we begin to show the signs of aging.  In my opinion, the best treatment to improve this problem is the use of an injectible filler such as Juvederm or Restylane. I do not recommend a filler such as Radiesse for this area due to the color and denseness as it could show under the thin, delicate skin in this area. Using your own fat harvested from another area of your body to inject is a more permanent solution however I am cautious in using fat in this area. I have performed this procedure numerous times in the past and the success rate has varied from patient to patient. I have found over the years that the injectible fillers are much more predictable for obtaining the desired results with the least side effects.

The other concern of fine lines in this area may be helped to a degree by plumping the area with a filler or your own fat however it will not eliminate the lines.  My recommendation is a chemical peel (phenol peel) for a great and long lasting result.  I do not recommend the peel for everyone due to the risk of hyperpigmentation which is greater for those who have an olive complexion or have darker skin.   If you elect to do the chemical peel you should be aware that you will not be able to cover the area with makeup for a period of 10-14 days due to the healing that will need to occur.  The skin will have a deep pink to red color that will slowly fade away over time - usually within 3-6 months - and can be camouflaged with makeup until the skin returns to the pigment it was prior to the peel.  The results are smoother, tighter skin making you appear less tired and more youthful.

You indicated that you have always had the puffiness under your eyes to some degree and have attributed it to fluid retention.  As my colleague indicated you do need to know if this is entirely fluid retention, bulging fat or a combination of both.  One question I ask my patients with this issue is if the puffiness is always present or is it worse in the mornings when you wake up and is not as noticeable as the day goes on.  The puffiness caused by fluid retention cannot be corrected with a Blepharoplasty but if it is caused by a bulging fat pad then it can be improved by removing the fat pad (s). 

Your other issue is that you do have the development of a tear trough depression or deformity which is common for most people as they get older.  The best treatment to correct this is the use of an injectible filler such as Juvederm or Restylane.  I do not recommend a filler such as Radiesse for this area due to the color and denseness as it could show under the thin, delicate skin in this area. You may find discussions of using your own fat harvested from another area of your body to inject as a more permanent solution however I am cautious in using fat in this area.  I have performed this procedure numerous times in the past and the success rate has varied from patient to patient.  I have found over the years that the injectible fillers are much more predictable for obtaining the desired results with the least side effects.   As my colleague indicated the use of a filler in this area will help to camouflage the puffiness and you may find that you will want to postpone any surgery (if it is indicated).