What to do for dynamic smile wrinkles under eyes & on upper cheek area? (Photos)

Question

Hi! I’m hoping to get recommendations on treatment for my under eye / upper cheek area. I’ve had botox a few times and works fine for crows feet but not dynamic wrinkles by cheeks. I’ve gone and had extra units put in and doesn’t help. I’m a smiler but I hate how I look with the wrinkles. I’ve also done exilis which helped minimally. Not sure if filler or micro needing or something else would be recommended? I’ve gone to 2 dermatologists which only recommend Botox.

Raffy Karamanoukian, MD, FACS · Answer

Fractional laser is an amazing and highly effective treatment in our office. We use the laser treatment to help with acne scars, large pores, fine wrinkles, tissue collagen loss, scars, sebaceous hyperplasia, active acne, and for brightening dark pigmentation. Although there are very strong fractional lasers such as CO2 laser, we use lighter treatments for corrective skincare and maintenance of results. Our Thulium fractional laser, clear and brilliant laser, and Ultra Thulium laser are excellent options in our clinic. We also perform CO2 fractional and erbium depending on skin tone and tolerance for downtime. Patients do have to use a Melarase cream before and after treatment to help further reduce pigmentation after laser.  Melarase AM, Melarase PM, and Melapads can seriously improve surface sun damage and UV related pigmentation. Dark spots can improve with these treatments. I recommend fractional laser for incisional scars as well, especially after plastic surgery.  
Best,
Dr. Karamanoukian 
Realself100 Surgeon

Jonathan Kulbersh, MD · Answer

Thank you for submitting your question and photos. The wrinkles you’re referring to may be caused by volume loss, which can be restored with either dermal filler injections or an autologous facial fat transfer. 
Hyaluronic acid dermal fillers can increase volume to diminish the appearance of wrinkles and smooth the transition between the lower eyelid and upper cheek, with results lasting up to a year or more. A facial fat transfer uses your body’s own fat to rebuild volume in the face, producing youthful results that can last for over three years. I recommend scheduling an in-person consultation with an experienced, board-certified facial plastic surgeon or injector. They will be able to discuss your aesthetic goals with you and determine the best course of action.

Jason Emer, MD · Answer

The eye area needs significant combinations to get improvement. Lasers like erbium, co2, halo, profractional/contour, or Fraxel can all be used to build collagen long term. Plasma pen is a newer less invasive option but will take many treatments and require proper skincare. Plasma Pen is focused electrical plasma energy to tighten skin, producing small columns of energy just above the skin, allowing the skin to tighten to help improve wrinkles. This area will have 3-5 days of small “dots” that will then scab and peel, then the skin will tighter and brighter after. Numerous treatments are needed over lasers where only one or two give a bigger result, but more downtime. After plasma pen you NEED peels 2 weeks like later Cosmelan, enlighten or aerify, see emeragecosmetics (link). At home derma rolling should be started weekly even after plasma pen or lasers to further increase collagen, see emeragecosmetics AERIFY x anteagemd stem cell ampules. To properly heal you need light Stim red LED, EmerageSkin refit face, refit eye; AnteageMD serum, silagen silicone gel, jan Marini bioshield, EmerageSkin enzymatic polish, and EmerageSkin hyla b and AOX, and Sente dermal repair. Otherwise there is EXTREME risk of pigmentation issues and “dots” in the treatment area. at home peels like cosmelan, enlighten and aerify along with dermarolling (AERIFY emerageskin roller with Anteage MD ampules) should be started now regardless for antiaging, sun damage, and wrinkle prevention. There are many things you can do to treat under eye hollows and dark circles. A surgical option to remove skin and/or fat will such as eyelid blepharoplasty with or without fat pad repositioning (if doing lower eyelid surgery) will be the best long term. There are many things you can do to treat under eye hollows and dark circles without surgery. Non invasive less downtime options such as fillers, lasers, microneedling/PRP, cosmelan peels, and microneedling RF like Fractora, PiXel8 or morpheus can all help give some improvement. Accutite can often be used or stronger lasers like erbium or co2 spot treatment can tighten the skin and give very quick improvement in wrinkles and texture. I suggest you get a formal consultation to see what is best for you and your goals. Best, Dr. Emer.

Nelson Lee Novick, MD · Answer

The problem described here is fairly common in my experience. The Botox can work well for the usual dynamic crow's feet lines, but injected lower down on the cheek (where these lines very often extend) risks affecting the smile. The use of a resilient, cohesive, low viscosity HA filler fanned through properly through the area can help to diminish this considerably without affecting the smile or making the mid-cheeks look too full or apple-like.  Microneedling is best reserved for addressing superficial, surface texture and color issues and would be unlikely to do much for this dynamic wrinkling. And, as you have found out the hard and likely expensive way, "bells and whistles" light and energy-based devices are backed more by marketing hype than hard science. So, exercise a whole lot of buyer beware before going that route again. Make sure to consult an experienced, board certified cosmetic dermatologist, and best of luck.

Geeta Yadav, MD · Answer

Hi there! Dynamic wrinkles in this area of the face typically need a combination of treatments in order to see improvement. Botox along the eye area will work to minimize crow’s feet, while expertly-placed filler along the midface can also improve lines by adding volume. Additionally, I’d recommend treatments like chemical peels or microneedling to minimize the appearance of fine lines and improve the quality of the skin. Hope this helps!

Leonard Grossman, MD · Answer

Even though the lines of your face are truly dynamic, it’s not that the Botox is not working, it’s the fact that as a person ages, their face loses, volume in terms of fat primarily and additionally loss of muscle. If you can imagine balloon, it has a lot extra rubber on it once deflated, and as you move one portion of that balloon upward, it collapses the extra rubber into folds or wrinkles. This is exactly what’s happening to your face. You can easily correct this problem by means of fat grafting. Fat grafting uses your own fat which get placed in to the key areas of the face. When done by an expert fat grafting plastic surgeon like myself the procedure will produce natural results which are permanent. The best part is that you will look like you used to some 15 to 20 years younger and just like your self without a wind tunnel appearance.  I hope this helps and good luck from New York City Plastic Surgery.

What to do for dynamic smile wrinkles under eyes & on upper cheek area? (Photos)

Answers (6)

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