Under eye wrinkles/folding skin - what to do? (photos)

Question

I am 47 years old and I'm noticing substantial wrinkling and skin folding under my eyes when I smile. This is such a bummer to me ~ I'm actually finding myself smiling less because I feel like it makes me look old. I had an upper and lower bleph at age 42, and I get Botox about twice a year around my eyes and forehead. I would greatly appreciate any advice on how I might improve this issue. I really want to get back to smiling freely again!

Goretti Ho Taghva, MD, FACS · Answer

Don’t stop smiling, you have a genuinely beautiful smile on your photo! I understand your concerns about the wrinkles and skin folding under your eyes, but that can be addressed.

Given your history of upper and lower blepharoplasty and regular Botox treatments, you're certainly proactive about your appearance, which is commendable.  However, Botox may not be able to address the skin excess issue effectively.

A potential solution could be a lower blepharoplasty, possibly combined with a mid-face lift. This procedure, performed through the lower blepharoplasty incision, can help in tightening the skin and reducing the appearance of wrinkles and folds. Additionally, a nanofat transfer, which involves using your body's own fat to improve skin quality and add subtle volume, might also be beneficial.

Laser resurfacing treatments are another option to consider. These treatments can improve skin texture and stimulate collagen production, which may help in reducing the appearance of wrinkles. However, it's important to set realistic expectations, as the improvement from laser treatments might not be as drastic as surgical interventions.

Consulting with a qualified board certified plastic surgeon can give you a better understanding of the most suitable options for your specific case. They can guide you through the choices, ensuring that you make an informed decision that aligns with your goals.

I wish you all the best in finding the right solution that allows you to smile freely and confidently again!

Gianfranco Frojo, MD · Answer

I would recommend a skin only lower blepharoplasty.  I would recommend seeing a surgeon certified by the American Board of Plastic Surgery (ideally with 6 years of integrated plastic surgery residency training and ALSO a 1 year aesthetic fellowship accredited by the Aesthetic Society).

Zeshaan Maan, MD · Answer

Based on these images it does look like you have some excess lower lid skin, which can result from loss of cheek / mid-face volume as well as decreased skin elasticity. A combination of facial fat grafting and lower lid pinch blepharoplasty could be an effective option for you, but you should see a plastic surgeon in consultation to be thoroughly evaluated so that a well-thought out plan can be made that will help you achieve your goals.

Lexie Wang, MD · Answer

Hi! You have such a pretty smile, you should not try to hide this!! Your main workhorse is going to be botox. You want to make sure you are getting as heavy of a dose as you can tolerate around the eyes, including carrying the dosage into the inferior orbicularis oculi. I also expect that you will need it more than twice a year as generally it tends to last ~3mo. The goal is to essentially get the muscle here to the point where it can never work hard enough to cause lines there. Once you have that achieved, your next step is going to be on working on building the skin in this area, bc stronger skin can bounce back from wrinkles faster. This means making sure you are absolutely on medical grade skincare including some kind of retinol product and looking into some more aggressive options for skin tightening such as radiofreq microneedling and/or laser.

Ruslan Zhuravsky, DO · Answer

Hello. This is actually a very common issue. I have seen patients ask to treat this with botox, but unless you paralyze the zygomaticus muscle (smiling muscle) it will not help. The reason for the issues is two fold. There is some skin laxity in the area and the skin itself is very thin, with decreased amounts of collagen. When we smile, the cheek raises up and the skin wrinkles as it bunches up. The more conservative treatments would be things like lasers (CO2, fraxel), microneedling (with RF), and nanofat, which can improve the quality of the skin itself, so that the skin itself is tighter and thicker, thus less prone to bunching. These can lead to some very nice improvements, but take time and sometimes multiple treatments. Surgically, you have to be very careful. You cannot simply excise this extra skin and stretch it as that will lead to pulling on the lower eyelid and a complication called ectropion. A lower lid surgery approach would be focused more on elevating the muscle and skin together out toward the corner of the eye. This gets anchored to the boney lining for support and allows for a conservative excision of skin laterally (toward the side). So you have some options and can even try both methods as they address slightly different issues. Hope this is helpful! Good luck!

Kenneth D. Steinsapir, MD · Answer

Don’t get talked into grafted fat in this location. The treatment is never as good as promised and problems require surgery if they are even fixable. Undereye Restylane filler is very good for your issue. The challenge is that you are asking the injector to sculpt you. The “medical technician” in your neighborhood injectors office are likely to not be good at this. The service lasts about 10 months or so before requiring retreatment.

Ronald J. Edelson, MD · Answer

Now is the perfect time for you to have your eyelids done and I would do both upper and lowers. You have excess skin of the lower lids which can be removed by peeling the skin off the muscle and tightening the skin.  There are many ways to do eyelid surgery especially the lower lids so it’s worth doing some online research before going on consults. Also I must say do not get fat injection in the eyelids. It doesn’t work and is risky

Zoran Potparic, MD · Answer

It may be worth of trying something for skin treatment mostly like microneedling or TCA chemical peel. In person consultation with a plastic surgeon familiar with these procedures may help.

Timothy M. Rankin, MD, FACS · Answer

The good news is that if looks like you have some great volume in your cheeks and a wonderful smile. Without a relaxed view, its hard to comment on the fat pads under the eyes. If there is fullness in the fat pads of the undereye, then you benefit from a lower eyelid blepharoplasty. If not, then a fractional laser is probably all you would need to snug up the skin a bit. I thinks it unlikely you would need any external incisions.

David Plank, MD · Answer

Lower eyelid ultraclear laser with PRP
drdavidplank.com
A board-certified plastic surgeon is qualified to address your issues. Board-certified plastic surgeons have spent years of training and have the top level of experience and skill. Seek out a board-certified plastic surgeon for your cosmetic needs.

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