George Yang, MD

Hi aesthetica2345,

The inner half is hollowing as opposed to the outer half drooping or hooding. The best way to figure this out is to look at younger photos to see how your upper eyelid and brow skin looked when it was ideal. Is it possible that you have developed the hollowness from using eye lash or brow enhancing serums which make them longer and fuller? If so, the first recommendation is to stop them to see if the fat naturally recovers without any upper eyelid brow fillers. This phenomenon is called “Prostaglandin Associated Periorbitopathy”. The fat atrophies all around the eyeball, causing the fat to shrink under the eyeball (lower eyelid fat), behind the eyeball and the upper eyelid/ brow fat pads.

If this is not the case, could it be from weight loss (illness, Ozempic, or stress from work or home)?

If none of these reversible causes are the case, then hyaluronic acid gel implant works well for this area and last years before wanting/needing a touch up.
I have been using Restylane-L gel for upper eyelid hollowing since 2007 and for lower eyelids since 2005. The Restylane lasts years and may be considered a permanent implant when used around the eyes. Juvederm does not work well in this area in my experience. The Restylane is dissolvable with an antidote to wash it away if it is not serving to help our appearance.

The Restylane will not stop aging, so the shape that we like and want will not last forever, however the Restylane implant is likely still mostly (60-90%) there even 5-10 years later.

The nice thing that I like about using Restylane for this area is that it lasts so long and more can be added as they age or lose weight. If they gain weight, then the Restylane implant can be reduced or removed without surgery (Belotero Balance only seems to last about 6 months +/- so I don’t like to use it because it doesn’t last long enough.) Some injectors seem to be using Belotero exclusively even though their patients are flying from far away to see them.

Although I began upper eyelid filling since 2007, I didn’t completely stop fat grafting this area until about 2010. My main gripe with the fat grafting is that when the patient gains weight the fat from their belly or hips which were grafted/injected around their eyes “grow” as if the fat were still on the hips or belly. The combination of the belly/hip fat plus the existing fat around the eyes becomes too much and it can’t be dissolved. If the patient loses weight the same fat shrinks with their weight loss. The filler can be added or subtracted without surgery and the new and old Restylane works well together.

Best,
Dr. Yang

Hi, Belated Merry Christmas. It seems no one is answering this question. The normally full cheek under the cheekbone is called the buccal fat. If this area is sunken, then you have buccal hollowing. I prefer to “reinflate” this buccal area with a medium to firm Hyaluronic filler which can last 18-24 months plus. Depending on whether the patient is continuing to lose more facial fat (face is getting even thinner) then the result may appear to last less than the 18-24 months. I have had patients who had filler back in 2015 and during the pandemic they gained 5-10 pounds and felt to full in the buccal fat area and I dissolved some of the filler from 5 years prior and it still reduced in fullness. Based on these experiences, my impression is that the filler was there the whole time, but the appearance may vary. If I inject 1.0-1.5 cc into this buccal area to reduce the sunken area as well as provide some plumpness if you were to push on the sunken area of the cheek, to provide some “bounciness” like when we were younger.

Since many people are currently in weight loss medications like Ozempic or Wegovy, they may lose even more facial fat ( perhaps another 1.0-1.5 cc per side). This doesn’t mean the filler is gone, but instead more fat was lost. Interestingly, if these patients stop these medications, they may get a rebound weight gain may replenish the cheek fat as in the case of the Covid Weight gain patients and no longer want the filler anymore. Luckily there is an antidote which can dissolve partially or more fully the filler implant. If the patient had fat grafting the 1.5 cc of fat will grow to more than 1.5 cc when they gain weight on top of the facial fat growth, but also shrink when they lose weight in addition to the facial fat shrinkage. The hyaluronic acid implant stays the same size regardless of the patients weight gain or loss and is reversible as well as have the ability to add more into the sunken area to add to the existing hyaluronic acid implant to make it larger if desired.

I tried to include an Instagram post from 2018 if it will work. This patient has not had a refill in her buccal area since her original filling before 2015.

Last point is that I would not place any filler on your cheekbones which would further pop out the cheek bones which would make your face even more bony and skeletal. Most injectors seem to recommend injecting cheekbones when the patient’s face loses cheek volume. This never made any sense to me.

The goal is to soften the face and create fuller cheeks from the cheekbones down to the jawline. The firmer cheeks we are trying to achieve is where an aunty or grandparent would pinch a child’s firm cheeks below the cheekbones. The grandparent is not pinching the bony part of the child cheekbones.

Hope this helps to answer your question.

Best, Dr. Yang

Hi Smokyeyes,
Yes, upper eyelid filler can be done to add back volume to your brow fat pads. I have been performing upper eyelid fillers since 2007 and fat grafting to the same area prior to 2007. I stopped performing the fat grafting after 2010, when I felt the results of the upper eyelid filler was better than the fat grafting. It also turns out after 16 years of experience performing this procedure, that the hyaluronic acid filler implant lasts many years and does not go away after 1 year as reported by nearly all of the new upper eyelid filler providers. I have patients who are 9-10 years out without refilling, with the average around 3-6 years coming back for a partial touch up. If the upper eyelid filler only lasted 6-12 months, I would have likely continued with the fat grafting.
The upper eyelid is actually the skin between the upper eyelashes and the upper eyelid fold. The skin above the upper eyelid fold is really brow skin and not really upper eyelid skin. Upper eyelid surgery trims back the brow skin to reveal the upper eyelid (AKA upper eyelid platform). Although you already had upper eyelid skin removal, you still have the “appearance” of loose skin above your upper eyelid platform. The best way to figure out what to do next is to review your younger photos to see if your younger eyes were more hooded (Brow skin to upper eyelid platform ratio of 55-85% to 45%-15%) meaning you had more brow skin fullness and brightness above the eyelid than the amount of eyelid actually showing. If so, upper eyelid filler implants (brow fat pad implants) will help to restore that appearance. When reviewing the younger photos, you should also note whether or not your eyebrows were actually higher or possibly naturally lower. If so, then my philosophy is to try to make the patient look more like their younger selves, then I would not recommend a browlift without seeing someone’s younger photos, otherwise that would be a cookie cutter approach. If in fact your eyebrows were higher, then an eyebrow lift would make sense.
After analyzing thousands of older people, compared to their younger photos/appearance, I have come to the conclusion that when people are younger, there is no evidence is the bony edges of the eye socket, both when the eyes are open and even more so, when the eyes are closed. The upper eyelid/brow filler implants help to camouflage the eye socket/skull edges as well as the visibility of the eyeball within the eyesocket. Take a photo of yourself with your eyes closed and then look for images of young people with their eyes closed or looking downwards. These can be found in clothing catalogues or pictures of models in fashion magazines. You can see the eyeballs with the socket more in the older models/people versus the younger models. By really observing the true aging process, can we make better decisions on how to reverse it and still look like our younger selves.
The state of current surgical techniques seem to make people look less haggard and less tired looking, but not necessarily (sometimes it happens) making them look anything like their younger selves. Starting from the beginning (younger appearance) can we better find our way back there.
Best, Dr. Yang

Hooded eyelids look good when there is enough brow fat pad hiding the rim of the eye socket bone. If you raise you eyebrows when looking in the mirror, you may notice that although your upper eyelid skin is hooding towards your eyelashes, when you raise your eyebrows, you see much more upper eyelid than you did when you were younger.

The amount of upper eyelid skin (in actuality is it brow skin) is that same as when you were younger. The volume loss in relation to the amount of skin for hooded eyelids make the skin look loose. Notice that the loose skin disappears when you raise your eyebrows. So a browlift would give you the same look as raising your eyebrows, but without forehead wrinkles. If you like the look of the amount of eyelid you see when raising your eyebrows, then skin removal, skin tightening, or browlift will give you that look.

Having said that, my interest in adding volume back around the brow area began in 2006, when observing patients after upper eyelid surgery. The goal of aged hooded eyelid surgery is to remove the loose skin, However, when looking at these patients younger photos, I did not see much eyelid “platform” the eyelid skin below the upper eyelid fold. All that I saw was a lot of “brow skin” or skin between the eyebrow hairs to the top of the eyelid fold. What I did notice was that the eyelid fold was “parallel” to the eyelash line curving softly in a parallel manner. At no point on young looking eyes is there a straight line area to the curve, which makes the amount of eyelid showing less than the inner corner of the eyelid which is usually more (AKA A-frame deformity).

For upper eyelid filler, reviewing the patient’s younger photos is crucial to determining what exactly to next. Many times the hooded area is actually not the problem and the A-frame area is actually showing too much eyelid. By adding volume to the inner corner of the brow skin area will hide more eyelid and help to curve the eyelid fold more in the inner corner, thus making the eyelid fold parallel. The results are see as the volume is adding back and shown to the patient between incremental additions of volume.

The results can last many years, the longest without a touch up is already up to eight years, but results may vary. It depends on if we are catching the volume loss early and immediately replacing it before it full hollows. By performing the upper eyelid filler, does not “stop aging” or stop the fat loss from continuing to happen. For these patients, then will need a touch up earlier. For other patients, who had eyelid surgery, or non-surgical skin tightening which “cooks off” more fat underneath the skin from the heat of the non-surgical procedure, then the results may last longer, since the fat was prematurely shrank on purpose. For my family members and my patients, I prefer than they keep as much natural fat as possible and I will try to maintain their “look” as is changes in the future. For this reason, I don’t recommend energy, heat, RF or laser to “tighten” the skin since I don’t see that as the actual problem to solve.

In fact, if the original problem fat loss causing the hooding, then cooking the skin and fat more will shrink more fat and show even more eyelid than when they were younger. If you prefer your younger hooded eyelids, it will turn Blake Lively’s eyelids into Nancy Peloso eyelids as more skin and fat keeps getting reduced.

I would rather maintain the look instead. During consultations, I show many more examples than are shown on the website. Most patients who have had upper eyelid filler done with me, don’t appear to have had anything done, and they don’t want people to know, hence I don’t push my patients hard to show their photos on social media like other practices.

Best,

Dr. Yang

Best,

Dr. Yang

Hi Sarah, A submentoplasty is similar to liposuction under the chin (submental liposuction). The prefix sub- means under and mento/mental means chin. Plasty means plastic surgery. The difference between submentoplasty and submental liposuction is the addition of a midline Platysmaplasty (AKA corset Platysmaplasty) with likely subplatysmal fat reduction before the platysma muscles are sewn together. In your case liposuction may help to reduce the Subcutaneous fat (fat under the skin) but will not reduce the subplatysmal fat which will keep the profile blunted. If for some reason liposuction actually reaches the deep fat that could result in loose platysma muscles which could cause Platysmal muscle bands (vertical muscle bands on the front of the neck) in the future. Why? The subplatysmal fat has stretched our the platysma muscles under the chin. After removing this fat the the loose muscles need to be tightened to “hug under the chin”. Then the loose skin will contract down to the corseted platysma muscles for the desired results. For younger people they may not need any skin removal, only a 1/2-3-4” incision under the chin where the natural double chin crease forms. Hope this answers your question. Cheers, Dr. Yang

Hi, when asked to do a botox browlift, I injected the crow’s feet area with an extra drop under the outer 1/3 of the brow to replace the brow depressor muscle (orbicularis oculi) which can pull the eyebrows down when contracting. I use 20 unit total for both sides. When people complain of forehead wrinkles or overactive eyebrow lifting, the forehead itself is injected with botox (or Jeuveau/Dysport/Xeomin). This dosage is also around 20 units for a starting dose. This will lower the eyebrows and smooth the forehead. The forehead muscle we are injecting is called the frontalis and it needs to be active to lift the eyebrows. So the frontalis is the eyebrow elevator muscle. The eyebrow is like the bow/ribbon in the center of a tug of war. On one team is the eyebrow elevators and the other team is the eyebrow depressors. To make the elevator team win, we only need to botox the depressor side a little bit and the elevator team will win. If I botox both teams, more money will be spent, for a draw. On the upside, you will be very frozen, so no wrinkles. Hope that makes some sense. Best, Dr. Yang

Hi, Yes, I do see that your left earlobe looks pixied. The right one is slightly elongated, but your original earlobe hangs down slightly lower than the attachment point of the earlobe which creates a slight hang of the lobe. On your left earlobe, the lowest point is the attachment of the earlobe rather than the earlobe itself hanging lower than the attachment point. For some people their earlobes are attached and naturally do not have a hanging earlobe, yet I wouldn’t call those pixie ears. Those would be attached earlobes versus hanging earlobes. Interestingly, some people don’t like their hanging earlobes, because they think it makes their ears look large, and during a facelift may ask to have their earlobes reduced or make them look more attached. Since your right earlobe turned out well, I’m sure it wasn’t intentional, and potentially could be repaired. Speak to your surgeon about getting it fixed. Wishing you the best. Dr. Yang

Hi, Your eyelashes appear longer and fuller on after photo on the right. If this is due to eyelash enhancers/conditioners such as Latisse, Grande Lash, Rapidlash, Vegamour or other non-prescription lash/brow enhancers, it can be a side effect of these treatments. Longer lashes but less fat around the eyes. There is a YouTube video of a woman who stopped using the eyelash enhancer and her fat recovered. The lashes went back to its original length and density. One of the described side effects is darkening of the skin around the eyes. In the past, I thought the treatment was "staining" the eyelid skin, but if you look carefully at the fat around the eye and under the brow, you can see that there is a change in the fat configuration, and along with it some darkening of the skin. When the fat recovers, then the skin color lightens since the recovery of the fat causes the skin to become more plump. Hope you found this helpful. Good luck. Best, Dr. Yang

Hi, a revision is possible, but instead of pleats, you would have horizontal incision which would cross from the back of the ear into the hairline. Since you wear glasses, the incision would be hidden by the back tips of the glasses. One thing I would anticipate is that the pleated skin may have heal into that pleated shape. What do I mean? Imagine the skin as a piece of tape. If I pinch the tape so that it sticks to itself, it will create a pleat. If the incision behind the ear is incised again and the incision is taken horizontally across to meet the back hairline, then the pleats can be smoothout. However, since it has been 3 years, it would be important to try to "unpleat" the skin so that the skin can lay flat again. Using the tape analogy, the tape that has stuck to itself needs to be carefully released so it can lay flat. It would require using the tip of our surgical scissors to spread the pleated skin so it is not sticking to itself and then lay the flat skin back into the incision. Trim any excess skin and carefully resuture the incision. Hope you found this helpful. Good luck. Best, Dr. Yang

Hi, it appears to be a forehead vein which can bulge when more blood accumulates in the vein. Usually this is seen more in people with leaner faces, but can be seen in other people. In one of the Google images, the caption asked if the vein popped out after botox. I don't think that botox will make the vein go down. If you look at the photos for Angelina Jolie Forehead veins, it also shows a few more celebrities, and they are all smiling very hard as shown in your own photo. Yet in other photos of Angelina, we don't really see the vein. When getting a blood test, the nurse will place a tourniquet on your bicep area, and ask you to pump your fist to cause the vein to pop out so it becomes easier to draw the blood. In these photos, the face is contracting hard for the smile and perhaps their is a blockage to the drainage of the forehead vein because of the facial muscle contraction. Soon after relaxing the face the vein usually goes away. It doesn't make sense to have a cosmetic procedure done for something that comes and goes for a moment in time. I hope you found this helpful. Good luck. Best, Dr. Yang