What is the best treatment for under eye wrinkles/fine lines under the eyes? (photos)

Thank you for your question. You’re 29-years-old, and you submitted two close-up photos of your eyes: at rest, and with expression. You state you’ve been doing Botox® since you were about 24-years-old. You’re asking about the best way to improve the lines under your eyes; if it’s a laser you want a specific answer, and also ask about a commercial microneedling device.
I can share with you my approach in developing a treatment plan for patients like yourself in my practice. A little background: I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I have been in practice in Manhattan and Long Island for over 20 years. Helping people improve the appearance wrinkles around the eyes is something we do every day, all day long in our practice.
In the absence of a more in depth history and a physical examination, I would start by first inquiring. When I see someone young like yourself about some of the potential causes of this degree of wrinkling, which from my experience is greater than what I would expect from someone who is young. Often, there is history of excess sun exposure, maybe a history of using tanning beds consistently and extensively, and perhaps smoking history. I’d also ask about medical history and other issues, as well as the genetics of these types of wrinkle issues in the family from ethnic background. People who tend to have lighter skin tend to have fine lines and wrinkles at an early age as opposed to people with darker skin types. I also look into other medical issues from diet, medications and other factors that could contribute. I’d also look into whether a person has extensive seasonal allergies, and other issues that can cause issues with eye swelling and eye rubbing. The point of asking those questions about history, is if there are variables that I can do something about with guidance about what to do, or what not to do. Prevention is very important, and you’ve been doing that with Botox® to try to minimize the muscle activity that’s causing the fine lines and wrinkles to occur.
To share with you my general approach with someone who’s young, and with the tools that we currently have, is what do the technologies do to help improve wrinkles. With wrinkles, there’s one major issue which is loss of support in the skin, which is generally focused on one major protein called collagen. Collagen is important, and all of the devices that are very openly and aggressively marketed from lasers, thermal energy devices, or microneedling are all focused on induction of collagen. One of the things we have to be mindful of is degree of trauma and its consequences in the short and long-term. After doing this for over 20 years, I have seen results of very aggressive treatments on patients as they age where the skin can actually become thinner, so it something I would caution you about. Often, people believe the more powerful laser, the more aggressive microneedling procedure, or a very aggressive thermal energy device such as a focused radiofrequency ultrasound are good things because they would induce maximal collagen. However, there is a balance, and sometimes you actually cross the line and accelerate collagen breakdown.
In my practice, what was always the gold standard for under eye wrinkles for lighter skinned individuals was some kind of laser such as Erbium or CO2. Currently for a situation like yours, again without the benefit of a history and physical examination, I would consider fractional CO2 laser to get the benefit of collagen induction and some thermal contraction. That’s different from microneedling that causes collagen induction without the thermal element.
I would also suggest the use of PRP or platelet-rich plasma. This is derived from your own blood, and is a concentration of the wound healing growth factors and elements that help stimulate collagen. The reason why I use it a lot for many years now is that with the goal of stimulating collagen, and understanding there is a limit when it comes to different devices, you can inject PRP under the skin with regularity and no fear of a negative consequence related to heating devices on the skin. If you’re looking at the foundation of the skin being improved, we can constantly do that. You can’t keep doing lasers over and over. You can’t keep doing microneedling beyond a certain level, and the same goes with radiofrequency which are to treat, then wait, and see how your body responds.
We’ve learned a lot in our practice about the art of balance where a thermal energy device like a CO2 fractional laser to resurface some of the skin, induce collagen induction, and at the same time, minimize and narrow the risk so you don’t have to be overly aggressive since PRP complements the process of inducing collagen, which we can do with consistency.
The thing about any strategy in cosmetic dermatology is having a little understanding of the concept of observation - you treat, then observe, then make decisions based on the skin’s response. Often, whether it’s non-physicians or medispas, people get locked into a treatment schedule, a protocol, or a process that doesn’t involve a lot of thinking. I would argue that if a physician who understands this and thinks critically with a greater depth of knowledge and experience, you can have a more customized approach. Botox® would also play a very important role in ongoing maintenance.
I recommend you meet with qualified, experienced doctors who do this type of work a lot, and learn about the strategy of using a device that stimulates collagen in conjunction with PRP. From my perspective, that’s probably a good strategy for you.  I hope that was helpful, I wish you the best of luck, and thank you for your question.This personalized video answer to your question is posted on RealSelf and on YouTube. To provide you with a personal and expert response, we use the image(s) you submitted on RealSelf in the video, but with respect to your privacy, we only show the body feature in question so you are not personally identifiable. If you prefer not to have your video question visible on YouTube, please contact us.

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. 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

The delicate skin under the eyes requires a customized approach for effective rejuvenation without damaging the skin and tissue. Your choices might include a collagen induction therapy like fractionated laser or RF microneedling. These procedures create micro-channels in the skin that trigger the body to produce more collagen. As collagen levels increase, the skin becomes thicker, smoother, and firmer. Another option would be tear trough fillers, which would add subtle volume under the eyes and smooth away the wrinkles. I recommend scheduling a consultation with an experienced, board-certified dermatologist who can evaluate you in person and create a customized treatment plan just for you.