Botox or fillers for skin bunching when smiling?

Question

I am 26 yrs old and have bunching of skin when smiling. Seems to be getting worse over the years. The 1st picture at rest, I do have concealer on, but I only have deep tear troughs and dark circles. The 2nd picture I am smiling, but trying very hard to not activate the muscles that push my cheek bones/skin up. Bunching of skin is less pronounced. The 3rd picture, bunching of skin happens when I smile naturally. Very self conscious of this. Would Botox, filler or a combination help this?

Nelson Lee Novick, MD · Answer

The problem you describe is actually not that uncommon to the extent that the "bunched" region under the eyes with smiling has been referred to as a "donut roll,"  owing to its resemblance to a thick donut when the hypertrophied (overly enlarged) muscles that ring the orbit under the eyes are activated. Happily, for  many years now, experienced injectors have been instilling a microdroplet or two of Botox (or Dysport or Xeomin) into the center of the belly of these muscles to reduce their overactivity.and shrink their size. This is an advanced injection technique that should be left to experienced injectors and not to those accustomed only to injecting simple crow's feet or frown lines. Make sure that you consult with a board certified aesthetic physician. Best of luck.

Alexander Rivkin, MD · Answer

Hello and thank you for your question.  Based on your photos and your concerns, I suggest doing a combination treatment of both fillers for your tear troughs and Botox in the crows feet.  This combination will help smooth out the fine lines created with smiling, and since you are so young, will help prevent them from worsening.  Fillers, such as Juvederm or Restylane are great for the under eyes, especially when its an issue of hollowness.  The filler is injected deep under the skin to replace the loss of volume and will give a smooth and even transition from under eye to cheek.  Keep in mind that when you smile, there will still be some aggregation of the skin under the eyes even after being treated, but there will be improvement. Be sure to seek an experienced injector who specializes in facial aesthetics. Best of luck!

Martin Jugenburg, MD · Answer

I feel the best treatment for y our issue would be a small amount of botox to the hypertrophic orbicularis muscle or commonly called a "jelly roll". This is best be done by a board certified plastic surgeon or a registered nurse working underneath one.

Richard W. Westreich, MD · Answer

When you smile, many facial muscles are activated. The zygomaticus muscles and levator muscles raise the lips and the malar fat up towards the eyes. Also, most people activate their orbicularis muscle around the eyes and crows feet develop. In patients with orbicularis hypertrophy (excess muscle) in the pretarsal area (jelly roll) this can also bunch up. Botox into the orbicularis for crows feet or jelly roll works great. When there are orbital hollows due to a lack of SOOF (suborbicularis occuli fat) then filler can help to smooth the lid-cheek junction.

Brett S. Kotlus, MD, MS, FACS · Answer

Based on the photos you shared, your cheeks are elevating when you smile (this is normal) and with your anatomy, as the cheek mound moves upward it is accentuating the under-eye hollows.  Dysport or Botox would reduce the "crow's feet" at the outer corners of the eyelids and could reduce the roll just under the eyelashes when you smile but it wouldn't affect the "cheek shelf".  Some under-eye filler can blend the lower lid hollows to the cheek area to a degree but not completely.  Surgically, the lower eyelid fat pads could be repositioned into the hollow area to blend it even more effectively but again, the cheek shelf won't entirely disappear nor should you want it to as you don't want to lose your natural-looking expression.

Farhad Rafizadeh, MD · Answer

When One smiles, a lot of facial muscles get activated. The first group is located deep in the cheek. The most important are levator labi superioris and the zygomatic major  muscles. These muscle should not be treated with Botox at all, because one will not be able to smite or the smile will be uneven. These muscles push the cheeks up and may cause some bunching under the eyes and the lower part of the crows feet. When one smiles harder the orbicularis muscles start contracting and cause bunching in the crows feet area and some times on the lower eyelids. These muscles can be treated with Botox and this will improve the bunching of the skin. The tear throughs can be improved by injection of gentle fillers like Restylane deep under the muscle, and with a microcannula instead of a sharp needle. This would lessen the chances of an intravascular injection that could be very dangerous in that area. All facial injections should only be done by experts with a detailed practical knowledge of the anatomy. An in person evaluation would be necessary to confirm these suggestions.

Ron Shelton, MD · Answer

Sometimes the bunching up of skin of the lower eyelid area is caused by a thicker eyelid muscle but Botox injected here, off-label, should only be done by an expert Botox injector. Some patients get nice reduction but others who may also have some occurrences of swelling of the lower eyelid skin can see this worsen after Botox. Others who have bunching up of lower eyelid skin with smiling is based on their normal anatomy of strong elevator muscles of the corner of the mouth and upper lip that create these folds when we smile strongly. Botox treated in those muscles may reduce the bunching up at a cost of affecting speech, smile and make it difficult to brush ones teeth.
Fillers may not be a good idea for the tear trough if this lower eyelid crease is not very apparent at rest and only with big smiling. The filler in the tear trough would be squeezed with each large smile possibly making it squeeze to the adjacent tissue making a bulge on each side of the crease making the ctear trough look even deeper.
Such concerns should be addressed in person for a three dimensional analysis during animation with a board certified physician well-trained in Botox and fillers.

The information provided in Dr. Shelton's answer is for educational purposes only and is not intended to constitute medical advice.  The information provided should not be relied upon as a substitute for consultations with a qualified health professional who may be familiar with your individual medical needs.

Aldo Guerra, MD · Answer

Botox or fillers?  Thank you very much for your question. Based on your photograph, I believe he will need a combination of Botox and filler. You may not wanna do it all at once. I would start off with Botox at the crows feet area, wait a few weeks and then offer you a dermal filler under the eyes. Or procedures have risk, but generally speaking Botox and  A filler our considered low risk and highly effective. Have a wonderful day, Dr. Aldo

Jason Emer, MD · Answer

Yes, these lines can be improved with Botox. I recommend getting a formal evaluation with a cosmetic dermatologist. It will take 1-2 weeks for final results. Best, Dr. Emer

Leonard Grossman, MD · Answer

The wrinkling of skin around the eyes  is how one can tell if a person is genuinely smiling or happy. Even though you've submitted good pictures they don't show the lower portion of your cheeks which would be quite helpful. If you're lacking volume in the cheek it will cause bunching up of the skin in the lower eyelid and may require some fat grafting. On the other hand you should have an in-person consultation with a plastic surgeon like myself to determine if it's the lower eyelid bags that are creating the effect. Good luck from New York City

Botox or fillers for skin bunching when smiling?

Answers (14)

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