Thank you for your question.
You’re 33-years-old and you’ve submitted several photos, one with your eyes at rest
and then three with expression.
And you’re interested in, as you described, to freshen-up your upper eyelids by removing
what appears to be excess skin and to make them more symmetric.
You also state that you don’t like the hollowness, pouching and creasing of the lower eyelids.
And you’ve gone to a surgeon who suggested that you have an upper eyelid blepharoplasty
and lateral canthopexy to deal with lower eyelid laxity.
And you’re looking for some input on other options such as fillers, grafting, lasers,
radiofrequency treatment, lower lid blepharoplasty, Botox®.
Essentially, you’ve described a whole host of solutions that are used to rejuvenate eyes
and certainly, I can understand why this can be a little bit overwhelming.
Well, I can certainly help you with understanding my approach and some of the logic that I apply
behind the basis of what I do.
A little bit of 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.
Rejuvenating eyes has been the core of my career over the past 20 years as I mentioned.
And certainly, I would say that when we look at all of the many solutions that are available
to us, it’s certainly understandable why there can be so much confusion.
And the point of me saying this is that every doctor you go to will bring to the table and
bring to your concerns their experience and personal biases as well as their own perceptions
of an aesthetic outcome that they feel that is desirable.
And what’s key is that you and the doctor have the same mission and understanding.
So to begin with, I’ll start with your upper eyelid concerns.
Certainly, it is clear to see that there’s a difference in the folds of the upper eyelid.
Now of course, this is in the absence of a physical exam but I would be just concerned
that at a relatively young age, how much skin redundancy is there.
And the best way to determine that is with your eyes closed and to actually do the drawing
and actually squeeze a little bit of the skin using an instrument to see how much extra
skin there is so that you can have an outcome where the appearance of redundant folds would
look improved.
Now to just to offer a different perspective, one can also consider in a situation like
yours, the possibility of even adding filler to the brow area, the sub-brow area, the area
which is above the eyelid crease and that relative hollow.
It’s just a perspective because for some people, that aesthetic is more desirable of
having volume there.
Now that being said, I would say that if you do have extra skin over the upper eyelids,
an upper eyelid blepharoplasty is probably reasonable.
The key in your situation is that the eyelid crease has to be very nicely healed because
there won’t be any skin folding over to basically hide that incision and so the design
and the execution of the procedure is critical.
Now that being said, discussing the lower eyelid, I think you have more options to consider.
To begin with, I would question the degree of benefit there would be with a canthopexy.
And why is that?
Well, when you’re young, at 33, and you have relatively prominent eyes, the question
that would come to my mind is how tight can you really make the lower eyelid?
Can you really tighten it enough so that you would feel better about the pouching and creasing
that you observed with your lower eyelids which is seen in 3 out of the 4 photos from
your expressions?
My perception is that it would not make that much of an impact, that I think that what
you are dealing with really is more about muscular activity.
The muscle that I’m referring to is the orbicularis oculi muscle and that muscle,
when you smile or you squint, bunches and creates that pouch.
So generally speaking, the treatment that I would apply for that area would be Botox®
to relax the muscle.
Now the challenge here is that Botox® can only relax the muscle so much.
You don’t want to do it too much to create laxity or worse, ectropion.
But also, there’s also an accordion effect when you smile.
Basically, when you smile, the cheeks shift upward and the skin folds like an accordion.
And therefore, you have to look at any type of intervention with a neurotoxin as not being
a 100% but really about improvement.
Now, when your eyes are at rest, the area of your tear trough certainly has a look that
a lot of patients come to us for which is relative hollowing.
And this area, my approach is generally to use a soft filler such as Restylane and placement
into the tear trough.
And this way, that area can have a little bit of volume and look a little bit nicer
and less hollow.
Now for skin quality, we also employ something called platelet-rich plasma.
Platelet-rich plasma is derived from your own blood and it’s used to stimulate the
collagen and the blood supply and improve the texture and skin quality of the skin and
it has worked out very well.
There are times we do this in combination for the best outcome.
So, as far as the other ideas such as lasers and radiofrequency, I think that more than
likely, the thermal energy devices or anything that causes an ablation, at this stage of
your life and your skin type, I would not go for it at this point.
As far as the lower lid blepharoplasty, understanding that lower lid blepharoplasty aims to reduce
fat pockets, any skin redundancy and laxity.
I’m not so sure that that would make enough of a difference just to justify that surgical
procedure.
Again, in the absence of a physical exam, it’s very difficult to make that decision.
However, if there is any tightening to be considered, I would say that you would also
might benefit from something to support the lower eyelid which may be more involved than
is beneficial in terms of the overall outcome.
That’s another discussion that actually is more relevant when you do a physical examination.
So in summary, essentially, if you don’t like the redundant skin in the upper eyelid,
upper eyelid blepharoplasty does make sense.
Again, in the absence of a physical exam, through measuring and determining whether
or not that would be effective.
As far as the lower eyelids are concerned, fillers, PRP and then possibly Botox® for
the orbicularis muscle pouching or the lid roll as it’s often referred to.
Meet with more doctors.
If you don’t feel comfortable with this doctor’s recommendation, get additional
opinions and get a sense of how comfortable you are with those options.
But I would say that it is probably worthwhile to think of less significant procedures as
a way to see if you can get the improvement you want before you move forward with more
aggressive surgery.
So I hope that was helpful, I wish you the best of luck and thank you for your question.