Rejuvenation for Under Eye Wrinkles, Eye Bags, and Hollowing Need Separate Treatments

Author: Amiya Prasad, M.D.

42 year old with horrible under eye hollowness and severe wrinkles. What would be the best procedure to fix them? What would be the best procedure to fix my horrible under eye hollowness and wrinkles? Please see the attached pictures. I feel very unattractive and cannot stand looking at myself in the mirror. Thank you for your time.

Thank you for your question! You’re 42 years old and you submitted two photos, one with your face relaxed and one with your face with expression and you expressed in your question about how to address the under eye hollows and wrinkles. Well, I think I can certainly give you some guidance. I’m a cosmetic oculofacial plastic surgeon, practicing in Manhattan and Long Island for over 20 years and periocular or aesthetics around the eyes is something that is a specialty of mine. And certainly, your situation is something we deal with every day. Just to analyze your photos, I’m just going to give a little bit of understanding of terminologies so that you can get a sense of the approach to the solutions by defining the problems because you really have to break it down to understand otherwise you would be jumping around in a Hodge podge or solutions. So to begin with, let’s start with the hollowing and express what that situation is. First of all, hollowing has to do with typically with genetics and aging.

When you have naturally a thin face, as we get older, we lose volume. We lose bone muscle and fat. And so in the under eye area, particularly in the eyelid to cheek junction, there is an area that we refer too often as the V-deformity, there’s a relative hollowing there. The cheek volume, what’s considered as the apple of the cheeks also loses volume. Whenever I look at people’s eyes, I always look at their whole face. I do facelifts, I do cheek implants, I do a lot of things to help rejuvenate the face and I always think of everything in isolation but also in relationship with the other areas because the whole is always greater than the sum of the parts. So with that understanding, we have to think about volume replacement.

Okay, now that’s one definition. Two: the wrinkling. When you look at your expression, you notice that there are wrinkles when you create expression and there are wrinkles when you don’t have expression. So the wrinkles when you create expression are called dynamic wrinkles.

Rejuvenation for Under Eye Wrinkles, Eye Bags, and Hollowing Need Separate Treatments

Those are wrinkles that are activated when the muscles contract. The wrinkles that are at rest are called static wrinkles. So now then we have two things that also have two different modalities to approach.

Now, I also noticed that when your face was at rest, that there is puffiness under your eyes. So that puffiness is actually lower eyelid fat prolapse. So I don’t want to necessarily add to your longer list but it’s very important to understand how each of these factors contributes to the overall appearance.

As a cosmetic surgeon, patients come to me often with a particular concern that’s high in their priority list. And very often, when I sit back and have them look at themselves from a broader view, they learn that it maybe something that’s important to them in terms of their perception, how much it contributes to their overall facial appearance, it may be at a lower tier. So when I look at someone like yourself, at rest, it’s important to at least acknowledge and address that you do have puffiness under your eyes. So puffiness under the eyes, we usually perform a surgical procedure. And the procedure of choice most likely for you would be something like a transconjunctival blepharoplasty.

Now this is a surgery but is performed in our office for patients like yourself under local anesthesia with LITE™ sedation which means you’re not under general anesthesia and there’s a nicer quicker recovery and I think that if you want to assign it in a hierarchy, I would say that that is your number one issue is that when your face is relaxed, you look tired. Now that doesn’t in any way, reduce the importance of other areas with issues. So let’s go to the issue of volume loss.

Volume loss under the eyes particularly in the eyelid to cheek junction and the cheek area, typically we address with either fillers such as Restylane, Radiesse, Juvederm or the use of a more permanent solution like a cheek implant. Now it has been my experience, particularly for people who are new aesthetics that they don’t want to hear about cheek implants the first time they meet you so sometimes, it’s worthwhile doing a trail of using injectables and very often, there is a value to the convenience of doing injectables in comparison to surgery. Now as far as wrinkles are concerned, wrinkles again fall into 2 categories: static, at rest and dynamic, when activated. Well, static at rest, we use combination modalities. We use platelet-rich plasma which is derived from your own blood and has growth factors that stimulate collagen. And static lines basically represent loss of collagen. So we use platelet-rich plasma and we also use lasers such as the fractional CO2 laser.

Now these are not intended to make you look smooth or porcelain but to improve the appearance of lines and wrinkles. When it comes to dynamic wrinkles, well many people have heard the drug such as Botox™, Dysport and Xeomin. These are injectables that actually reduce the activity of the muscle in the area that you want to enhance including areas around the eyes, the forehead or the frown lines and these will be certainly effective. The one thing to be mindful of is that when you smile, the cheek goes vertically upward and it creates almost like an accordion effect. So there will always be skin bunching up in that area. I always try to help my patients understand that when they look at themselves at a global perspective, we can improve their appearance by taking little bits and pieces of different issues and combine them. Now very often, the results can very nice and can be an improvement.

We can’t stop the aging process but we can certainly help you look your best by addressing a lot of these genetic and aging issues. At this point, I think that it’s best to meet with qualified, experienced cosmetic surgeons. I say surgeons because it’s very important, from my experience, that someone who’s a surgeon does other things that fall in the preview of dermatology and other non-surgical specialties. At the same time, we can also provide you with surgical solutions. I think it’s very important that you figure out the things that are important to you and have a real clear communication with your doctor about expectations. The thing about the injectables, I should also mention, is that they aren’t permanent which means that they do have to be maintained.

I always explain to patients who are addressing this type of transition in their life that if you think about it, it’s kind of like being in a gym membership or something to maintain your appearance because it’s important to you and you necessarily have to budget time, money etc. To be able to feel and look the way you like. So I hope that was helpful, I wish you the best of luck and thank you for your question!.

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