Excess skin, hollowness, troughs. What procedure is best? (photo)

The first thing I will let you know is that no treatment will really reliably address your biggest concern which is how the lower eyelid wrinkles when you smile. I will also strongly caution you regarding the so-called "ponytail lift," which is a proprietary example of a more general type of surgery that combines a temple lift approach to elevating the lateral tail of the mid face. I manage many patients after these types of surgeries. When I see patients after these types of procedures, it means they are having an issue with their surgical result. That does not at all mean that every patient has an issue. Again, these approach, augmented with grafted fat or not, will not control how your lower eyelid wrinkles when you simile. However, dissection from the temple, lifting the lateral tail of the malar fat fat, can be associate with a very unnatural hollowing of the out line of the orbital rim in the track of the surgical pull. It is my belief that the hollow is due to surgical damaged of a than layer of fat that normally functions to isolate the eye area from the temple. This trace fat cushion helps the gaze of others stay on our eyes, effectively making them more attractive. Loose this cushion from surgical dissection and you will immediately understand the change is not helpful. I recommend you carefully study Ariana Grande's images before and after what seems to be recent facial surgery. I do think that you can have help with the lower eyelid fullness with a transconjunctival lower blepharoplasty and arcus marginalis release surgery. That in behind the lower eyelid surgery take move the herniated lower eyelid fat as a living pedicle from the lower eyelid space and places it in the under eye circle. That is a reliable surgery but again the effect on how the low eyelid wrinkles is not predictable. An alternative to surgery can this time is the injection of Restylane in the under eye circle. I encourage you to study my website to see what is possible with the fillers. I suspect that you could have success with this very fussy under eye filler treatment for at least a decade before resorting to eyelid surgery. Less is more. Somethings can be made worse with surgery so start with treatments that are reversible. The type of filler used in the area is very important. I only use the very high G prime filler Restylane for this area. Do not have lower G prime fillers for the under eye circle. They are prone to drifting and are not helpful in this part of the face in my opinion. There is no substitute for a detailed in person assessment.

You may benefit from a brow lift. This will lower your hairline and raise the eyebrows higher. You will also need an upper blepharoplasty. The lower eyelids might be treated at first with some Botox to see if that will soften up the muscle.

Best Wishes,

Gary Horndeski, M.D.

This is a pretty complicated area to both assess and treat.
Fundamentally the problem is based on facial skeletal structure with insufficient support of your soft tissues in the midface area or the maxilla.
Correcting facial skeletal, structural issues is not easier or straightforward.
Because this is a complex problem That’s based on skeletal structure soft tissue approaches sometimes leave something to be desired. Period.
Still, soft tissue approaches are usually the way to go.
Do you understand the problem? Let’s start by understanding what the ideal facial structure should look like in this area.
In a young attractive face, the contour should be tight and snug along the lower eyelid with plump fullness in the upper part of the midface.
As we age, sometimes these volumes reverse.
In the age to face, we sometimes see fullness in the lower eyelids and lack of volume in the upper midface.
These two volume problems are immediately adjacent to each other, and this adds to the complexity.
It’s helpful to differentiate if bulging of the lower eyelids is primary or loss of midface volume is primary.
A Treatment approach should be aimed at first treating the primary issue and then possibly treating the secondary issue.
Sometimes both are contributing.
Treatment options can include lower eyelid, blepharoplasty, surgery, midface, volume restoration, using implants, fillers, Fat transfer, or a midface lift.
Each of these treatment options has advantages and disadvantages.
None of them are ideal or great.
Expect to hear different opinions from different providers.
This is often the case when the problem is complex and there are no simple, straightforward treatment options.
There are treatment options. It’s just not easy or straightforward to get consistent quality results unless you find a really good provider.
Fillers of the midface very good results, but it needs to be done by the right provider.
Fillers done by someone who is not sufficiently talented isn’t going to do the job and can make you look like you’ve been treated without fixing the problems.
To get an idea of what can be accomplished I suggest you look at some of the before and after pictures of Dr. David Mabrie, MD. In San Francisco.
This website doesn’t allow me to include links to outside websites so you’ll have to look up his information on your own.
David is a facial plastic surgeon whose practice is devoted exclusively to facial volume restoration using fillers.
His work is the best I’ve ever seen, and I consider his outcomes to be the gold standard of what can be accomplished using Fillers.
I’m not suggesting people flight to San Francisco to get fillers.
I do think that looking at its results can be a powerful educational tool to understand what can or cannot be accomplished using fillers.
This can give you a baseline of judging results of other providers.
All the treatment options. The ones I would stay away from our fat transfer and lower eyelid blepharoplasty if it includes removing skin.
It’s possible to get good results and the chance of getting a quality outcome depends on finding the right provider.
Finding the right Plastic surgeon is not easy or straightforward.
It generally requires having lots of in person consultations.
Start by getting a complete set of proper facial pictures.
Look at how plastic surgeons take before and after pictures to get an idea.
They should kind of look like mugshots.
Bring those pictures, preferably imprinted format with you to every consultation to use as a reference when reviewing before and after pictures.
Ask providers to open up their portfolio and show you their entire collection of it before and after pictures of previous patients who had similar facial characteristics.
Best,
Mats Hagstrom MD