Late 30's and noticing sagging, loss of elasticity, crepey upper and lower eyelids. Hoping for tighter, smoother lids. (photos)

Hi there. In my late 30's I am noticing some changes. My upper eyelids are starting to sag a little, and if you will notice, my left more so than my right. Also, my lower lids seem more crepey, especially when I smile. I've had Botox in several different places to try and correct this, but it's not really working. Going under the knife isn't an option and my skincare regimen is superb. Suggestions?

Doctor Answers 7

Loss of elasticity eyelids

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I suggest a combination approach with lasers, fillers,skin care and possibly PRP. At your age its about prevention rather than seeking a surgical approach. With proper skin care , lasers, fillers, and an expert to guide you.... it should be about making you look " fresh" versus making you look " done." 

Newport Beach Physician
4.9 out of 5 stars 47 reviews

Botox doesn't "cut" it. Think non-surgical options.

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Dear sharky182: 

Thanks for sharing your photos. While a in-person examination is required, you appear to have ancestry with thin, northern european skin, light eyes which is more prone to early aging changes. 

The process of aging is the passive inability for your body’s tissues to repair and regenerate themselves. The act of rejuvenation is to actively reverse and dynamically assist the repair of your tissues on a daily basis. When significant laxity exists, surgical skin and soft tissue redraping or lifting are required.

Facial Aging develops from the 5 different layers of the skin, fat, muscle and bone.
During the first 20 years or so of life, the body genetically determines how to mature and repair a constantly changing “face” including all these layers (as it does elsewhere in the body). Thereafter it remains robust in repairing itself from injury but the accumulation of environmental, health and nutritional exposure will add to the passive inability for the body to care for itself after 30. This is when physical changes such as skin laxity, irregular pigmentation, lines and wrinkles and skin diseases occur. We now have many options to rejuvenate the layer or layers of the face which need care or stimulation to reverse the aging trend.

1. The top layer or stratum corneum of the epidermis is the rough, pigmented layer of the skin; creating most of the depth of the wrinkle.

-Exfoliation is best for this using:
-Retin-A (ZO Obagi Skin Health System), which also renews and regulates improved function of the deeper epidermis,
-Some lasers and chemical peels.

2. The second layer is the dermis which thins with aging. The natural collagen, elastin and hyaluronic acid (which hydrate and toughen the skin) are thickened by the use of:

-fillers (Restylane and Juvederm), or
-Retinoids (ZO Obagi Skin Health System), which also renews and regulates improved function of the deeper dermal skin cells.
-Sculptra properly managed is the latest sensation in stimulating firming and thickening of the dermis
-Thermi RF is a non – surgical option to tighten skin using a micro-invasive technique called ThermiTIGHT.

3.The next layer or fat also thins or droops with age and maybe:
-filled (Restylane and Juvederm), fat grafting or
-redraped (threadlift, short-scar, traditional, endoscopic face / neck / brow lifts / cheek)
- LipoContouring of the face and neck with or without fat grafting may provide the balance and contour you seek without general anesthesia.

4. The muscle which creases the skin into wrinkles and folds is weakened and rebalanced with
-Botox or similar injectable muscle relaxers like Dysport or Xeomin.

5. Bone also undergoes a dynamic process of resorption, thinning and descent. Options for cosmetic enhancements include:
-structural fillers, particularly like Radiesse (bone mineral)
-volumizing gel fillers like Juvederm and Restylane

6. Facelift, necklift and forehead lift are surgical procedures which include:

-an incision along the periphery of the tissues
-a suspension or re-positioning of the underlying soft tissues, and
-a redraping of the skin with removal of skin excess.

A sub-group to the facelift is the mid-face lift. This is used to detach the soft-tissues of the cheek which have descended, separated and lost volume and suspend them to the lower orbital rim. Generally, the fat pockets under the eyes are trimmed or added to the volume of the cheek and the eyelid skin is redraped.
Chemical peels and laser tightening are single, “static” attempts to “jump-start” the repair system into collagen formation. They should be performed every 3 months in order to achieve a more dynamic stimulation of the immune system.

Everyone needs one or more layered improvement and in personalized combinations to achieve their optimal result. You can understand why it takes a talented individual, preferably a Board Certified Plastic Surgeon or ENT Facial Surgeon with great experience to evaluate your needs and find a plan that works best for you.
All surgical, minimally invasive and non-invasive procedures and their combinations should be discussed following a proper examination with a well versed, Board Certified Plastic Surgeon who performs all of these options so you will not receive a biased approach because he limited in his skills.

Dean P. Kane, MD, FACS
Baltimore Plastic Surgeon
4.9 out of 5 stars 103 reviews

Combination and ongoing treatments Are best

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Although botox are dysport are great, they don't always work perfectly in under the eye area, where you seem to have most of your wrinkles. In a fair skin person like your self, its not uncommon to get early crepiness, loss of elasticity and volume, resulting in wrinkling anddroopy  eyelids. Based on your pictures, i suggest the following: 
  1. Botox other dysport in crows feet and under the tail of the brow for a "chemical lift"
  2. Filler in temple area and under brow tail by an experienced injector to elevate brow and replace lost volume
  3. Based on how much down time you can afford, a series of microneedling treatments, lasers or radiofrequency treatments around the eyes, such as pelleve or exillis(no down time), fractional resurfacing lasers (2-3 days), or a single session of an aggressive ablative erbium or co2 laser such as the ones by sciton.
  4. Dont forget a good eye cream containing retinol, and always use sunscreens and wear protective sun glasses.

Neda Vanden Bosch, MD
West Palm Beach Physician
5.0 out of 5 stars 21 reviews

Fillers, Lasers, RF for aging eyes

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Botox is great for active wrinkles such as crow's feet but treating aging eyes typically involves a combination of non-surgical treatments such as fillers for the under-eye/cheek transition, lasers for skin tone and texture and an RF treatment such as ProfoundRF for skin tightening. 

Kouros Azar, MD
Thousand Oaks Plastic Surgeon
4.9 out of 5 stars 38 reviews

Synergy and Consistency

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There are many non-surgical options available to you in your fight against the aging process. In my practice, the process begins with a consultation with one of our experienced medical aestheticians to determine your areas of concern and create a customized treatment plan based on your needs, budget and desired results. Neurotoxins should help alleviate some of your concerns but I believe you are dealing more with collagen and volume loss in the areas surrounding the eyes and that is why you are not finding full satisfaction with your Botox. If you receive a consultation from another injector be sure to tell them when you last had botox so they can objectively evaluate your concerns.

Volume loss is commonly corrected with various dermal fillers; Bellafill is commonly used to correct dark under eye circles, sunken eye troughs and/or hollowed temples. When getting fillers or neurotoxins of any kind to enhance your natural features it is important to be reflective of your more youthful self and be sure to see an experienced injector who knows the difference between enhancement and augmentation.

Collagen loss is often treated with successive laser treatments combined with regular facials and medical grade skin care products that include retinol; laser treatments can also correct discolorations of the skin (age spots) and soften wrinkles. I wish you luck in your battle against time; keep up that stellar skin care routine and don't forget to wear your SPF! 

Crepey lower eyelids

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This is a frequent concern that is best addressed by a combination of treatments.  Lower eyelid TCA peels can be done in isolation without treating the entire face. The lower eyelid skin usually peels quicker, but there is still about 5 days of downtime.  I combine this with Dysport in small (diluted) doses and PRP.  All of these are not done at the same time, but over time depending on the ability to have down time.  I know you mentioned your skin care is the best, but I would also recommend using HA5 over your skin care products for instant hydration and continued improvement. 

Jennifer Parker Porter, MD, FACS
Bethesda Facial Plastic Surgeon
5.0 out of 5 stars 24 reviews

Dark Circles, Eyelid Wrinkles/Bags Treatment -- Restylane or Belotero with Cannulas, Clear+Brilliant, Eclipse Micropen, Viva

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I suggest a combination approach with lasers, fillers,skin care and microneedling/PRP. Please seek an expert for a consultation. Best, Dr. Emer.

Jason Emer, MD
Los Angeles Dermatologic Surgeon
4.8 out of 5 stars 207 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.