Richard E. Buckley, MD

This is a great question. It is important to first understand what a patient means by under eye lines. One would think that it should be obvious enough but it often is not. For example starting with the lower eyelid lashes and looking below them we can in most of us see some lines and wrinkles. Those are indeed under eye lines but may not be what you mean. That skin I just described is very thin, gets thinner with age and wrinkles easily. The orbicularis oculi muscle is under the skin and our fat pads below that. There is for example no “floor” there and so no fillers can be put there. Putting fillers there would just make for swelling and migration. That skin that I just described, which is immediately below the eyelashes, is often tightened with RF such as Thermage or ThermiSmooth or various lasers both ablative and non-ablative. And the fat pads which bulge forward can be reduced from the inside of the eyelid in an office procedure called a transconjunctival blepharoplasty which requires on stiches. Sometimes we also remove a little pinch of skin starting from below the eyelashes and this is called a pinch blepharoplasty.
Or, do you mean that bit of skin that appears darker, a little depressed and is “U” shaped like a hammock? People often point that area out and say they look tired and they have dark circles under their eyes. If so, we are now talking about the ORL a.k.a. the orbital retaining ligament. The darkness due to the shadowing of the ORL is usually improved by reducing the fat pads, as described above, which are bulging the skin that is above the orbital rim outward. It can also be helpful to support the ORL by placing some filler just below it deep in the naso-jugal groove area. Doing that can lift it a bit and help to smooth out that valley above.
If there is volume loss as part of aging or being an athlete, etc. than a consideration can be made to do some form of filling and tightening in other areas of the face. It is helpful to see what is happening to the entire face rather than simply focusing on the “eye” area. A physician very familiar with facial aging can help you figure out what the best treatment plan would be. Often the plan is best when it is multifactorial. Best of luck!

Thank you for your question about the permanence of a Botox effect. The effect you are describing is actually the effect of areas that were not treated. The untreated or minimally treated areas apparently still have movement and they are the ones lifting your skin to give you the Spock appearance. You should see your physician as they should be able to quickly correct what you are seeing. In our experience Dysport is faster than Botox and correction could be noticed in just a few days. Botox did not create any permanent situation.
Typically providers are reluctant to inject very close to the outer brow as doing so can flatten or drop the eyebrow. You did not give us your age nor did I see a photo, but it is very common with time for the forehead to descend. This makes the area above the outer eyebrows harder to help and may mean that Botox should not be used. Sometimes a filler underneath the eyebrows above the orbital rim will help lift a bit. Sometimes people need a surgical brow lift of some type. The first thing that needs to happen before any treatment is there needs to be an evaluation of the brow looking for the degree of descent. Patients may say they don’t want any surgery but if that is what the problem will require for a proper correction and result then that is the direction the conversation needs to go. By way of example a person who has sun damaged skin, used to smoke and is 70 years old will likely need a brow lift and will not be a candidate for any Botox or other toxin. You will be fine. Good luck!

Thank you for your question regarding over filling of NLF - naso labial folds. A common misconception is that we should get rid of things or fix things. You may often see a NLF on a four year old or a two year old. Obviously they are not looking old and that is simply a normal feature. Much of what happens to the appearance of the NLF over time is due actually to sagging of the mid face skin. As the skin starts to try to drape over the area to the sides of the mouth, above and below, there is a wave like phenomenom. The issue is more the wave itself than where it is going to crash. It is true that the beach (where the fold is headed towards (the lip) , does have depletion of hyaluronic sugars and deflate a little over time. So here is the issue: There is this snow that came off the mountain and is now piled up on the side of the road. And yes, the road did sink down a little, but not much. So what do we do? Shall we only build the road up with asphalt until it is as tall as the snow. Or shall we try to blow the snow off the side of the road and back up on to the mountain where it came from? I suggest we try to improve both of the issues. Whatever will help the skin get off the fold and back up onto the cheeks where it came from will help. What could be recommended would depend on age, sun damage, weight as a function of IBW, etc. Choices might include fillers over the zygomatic arch, in the infraorbital periosteum, at the back jawline, etc. Tightening devices such as RF (e.g. Thermage), highly focused ultrasound (e.g. Ulthera), lasers and more may be considered and give additional different benefit such as tightening and building of collagen. Too often people doing injections put filler in the NLF up and down as if it were a worm under the skin. And then that is what it can look like. There are different concepts of how to make a bridge between the wave coming down from the cheek and the slightly deficient volume in the peri-oral area in other words the NLF and more medially (towards the center of the lip). I think that most things are better viewed and treated as a together complex rather than as separate things. So the NLF can be viewed as the cheek plus the fold plus the lip... You should have a physician who is very experienced with fillers, facial contours and aging see you and give advice. The physician may suggest having your NLF filler partially dissolved and then after waiting some weeks having someone different treatment in the area that is to say something done in a different way. To have a different result, something will need to be changed and be different. This is all art work and not merely injecting. A key thing with all of this cosmetic "work" and treatment is to be patient. You can definitely have a different result and one that you really like. Good luck!

Your vertical line down the forehead is something we see very often and is normal. It appears to be a vein. They are easier to see in slim people or those who have lost a lot of weight. Stress, pregnancy, high blood pressure and other things may make the vein(s) more prominent. Treatment options include long pulsed lasers such as the 1064 nm laser (e.g. GYag), sclerotherapy using a sclerosant such as Asclera (polydocinol), ambulatory microphlebectomy (removing the vein through a few tiny nicks in the skin). Removing the vein with microphlebectomy is definitive in that it is then gone. Laser and sclerotherapy treatment options are likely to take multiple sessions. The goal of the sessions is to irritate the inside of the vessel so that it closes and then the body needs to resorb that vein that is no longer working. After treatments things look worse before the begin to look better. A potential issue is that where the vein used to be can be left indented after the unwanted vein is absorbed or removed. This can be filled in with your own living fat (autologous fat transfer - AFT) after the vein procedure is fully healed. Good luck!

Thank you for your question as to what might be causing the bluish discoloration under your eyes. Even before seeing your photos, your description kind of said it all. You had fillers, some time went by, now you have puffiness and there is a blue hue. The blue appears to be what is called a Tindal sign. What that means is that it is well known what some types of hyaluronic fillers might look like if they have found their way close to the surface of the skin. It makes a difference where fillers are placed. If they are placed superficially they are more prone to migrate. In the under-eye area filler might more often be better placed all the way down on the periosteum of the bone. Someone not really familiar with anatomy and versed in medical details might not know about that or be experienced with that. Plus, fillers can and do migrate from where they were first put. Some, that so-called integrate well into the skin, also migrate well to other places. I have seen this type of thing very often from other practices and we have always been able to help.
You can see a physician versed in treating with fillers for years or decades and they can review recommendations with you. For example, hyaluronic fillers can be dissolved with an enzyme called hyaluronidase. The one I use is Hylenex. As with fillers, it is not an all or none thing. The more filler one wants to dissolve, the more hylauronidase one needs to use. There is craft involved in getting rid of filler. One should then wait a bit, at least 2 wees or maybe longer, before using any more material near the area treated. Also, if your physician feels there is a component of allergy going on they could consider treating that to help reduce the puffiness.
Keep in mind my comments are in general and are not meant to diagnose you nor to give you treatment options, nor treatment. Best of luck.