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Question: I am a 25-year-old woman who has had drooping eyelids since I was a child. Would I need a cosmetic or medical blepharoplasty?
Answer: I would have to evaluate your eyes to assess this situation, but it certainly sounds as if you have congenital ptosis, which involves the lack of a levator muscle. This would be considered a medical problem and I personally would recommend seeing an oculoplastic surgeon for correction of this.
Question: I have heard that Latisse can change the color of your eyes. Is this true regardless of color?
Answer: No, this is not true regardless of color and there is even question whether Latisse can change someone’s eye. The background history is that the medication in Latisse has formally been used as an eye drop and in a small percentage of patients with green or hazel eyes increased dark pigmentation has been observed in patients using that eye drop. This did not occur in patients with blue eyes, as they cannot pigment their eyes. Latisse; however, is not placed on the actually eyeball, but is placed on the eyelash and therefore less than 1/10th of 1% of the actual product gets in the eye itself and to date there have been no observed pigmentation of anyone’s iris using the product Latisse. It is; however, on the insert warning due to the fact that this has occurred in a small percentage of patients using the actual eye drop. So, ultimately if you have brown eyes there is very little risk since increased pigmentation really will not change the eye color much. If you have blue eyes, you cannot cause increased pigmentation and only in hazel or green eyes can you end up with brown spots on the iris, though again this is extremely unlikely with the use of Latisse.
Question: I have creases and small wrinkles below my eyes. Do laser treatments work on the thin skin beneath the eyes? I have permanent crow’s feet that I would like removed at the same time if possible.
Answer: Yes, laser treatments can definitely work on the thin skin of the lower eyelid, but obviously great care has to be taken so that we get the result we want without any complications. Ultimately, you want to see an experienced surgeon that can perform laser resurfacing deep enough to create a significant amount of wrinkle reduction and yet not create any complications such as scarring or pulling of the lower eyelid. Other options, if you have a significant amount of excess skin, would be to pinch the lower excess skin away and place sutures similar to what is performed in an upper eyelid blepharoplasty. The sutures are removed in 3 days and the scar is extremely inconspicuous and is usually less obvious than the wrinkle that had been present in that location. Frequently a combination of the lower lid skin pinch and laser resurfacing is performed with or without a lower lid blepharoplasty.
Question: I have been thinking about filling in my dark under-eye circles for a long time with Radiesse and I am finally ready to do it. However, I am worried that I will have to keep doing it forever. I do not want that. After using Radiesse a while, is it possible that my dark circles will just disappear forever?
Answer: First of all, I would strongly recommend that you do not fill dark under-eye circles with Radiesse. I feel that there is too high of a risk of creating irregularities and bumpiness with Radiesse, and Radiesse cannot be reversed. I therefore recommend hyaluronic acid products like Juvederm Ultra or Restylane as these products are much softer and gel-like and more forgiving in this otherwise rather difficult area to treat. With that being said, these are temporary fillers, whether it be Radiesse or the hyaluronic acid products, and these will need to be performed again in the future though, in the lower eyelid area, these typically last approximately a year.
I would have to examine you to determine the reason for the dark under-eye circles but most patients have these dark under-eye circles due to shadows from bulging fat in the lower eyelid. The fat can be addressed through a lower eyelid blepharoplasty and, in certain patients, this fat can actually be moved into the hollow or groove below the fullness to fill this in and create a more aesthetic cheek-lid junction. Some patients have vascularity and/or pigmentation that is contributing to the dark circles under their eyes. The vascularity is extremely difficult to treat and, in most patients, I just recommend that they cover it with some makeup. The pigmentation, however, can be treated relatively easy with the use of broadband light or intense pulsed light.
Skin creams can also be used to help get rid of some of the abnormal pigmentation but, if the dark circles are due to shadows secondary to the fatty herniation of the lower eyelids, then a long-term solution to your concern would be a lower eyelid blepharoplasty.
Well, I typically break up the eye area into different subunits, one being the nasal side of the eye or glabella area, the other being the outer portion of the eyes or the crow’s feet area, and the third being the forehead region. In the glabellar area, I typically use 16 to 26 units of Botox depending on the muscularity and activity of the person’s corrugator muscles. In the crow’s feet area, I use somewhere between 16 and 24 units also again depending on the significance of the activity of the orbicularis oculi muscle. For the forehead, I typically use a smaller amount as we typically want to just partially relax the forehead muscles and still leave the patient with some eyebrow movement and yet soften or even completely get rid of the horizontal lines in that area. Typically I will use as little as 8 units up to maybe 16 units again depending on the activity and location of the muscular movement. Ultimately I feel that proper injection technique of Botox is a very customized technique and I feel that a significant amount of experience in injecting as well as expertise in facial anatomy is required in order to get extremely good and long lasting results using Botox.
No, under eye Restylane really should not be noticeable when smiling if it was performed by an experienced injector. Typically it only takes rather small quantities of Restylane or Juvéderm to improve the trough or groove under the lower eyelid and if it is performed by an experienced injector, this should be a very natural appearing improvement in the lower eyelid area and should not be noticeable when you smile. An added bonus is that the result typically lasts approximately one year in most patients, which is significantly longer than other areas of the face.
That really depends on the patient’s ultimate goals, finances, and ability to tolerate downtime. For patients with limited finances and the inability to tolerate any downtime, I would recommend the hyaluronic acid fillers as they are instant in their gratification, they are relatively low cost, and come with virtually no downtime. Their only disadvantage is that they are temporary, but around the eyes, they typically last close to one year. In the lips, however, they tend to resorb within approximately a six-month period and would need to be reapplied. Fat transfer, on the other hand, is quite successful in the under eye area when performed by experienced facial plastic surgeons. There certainly is a great risk of creating irregularities and bumpiness in the lower eyelids with fat transfer and that is why I stress the importance of an experienced injector. Regarding the lips, I actually prefer using hyaluronic acid fillers as I can then do a very artistic augmentation, which will provide the patient with extremely natural results and though it is not a permanent fix, it is very consistent in my hands. Fat transfer, on the other hand, I feel has some inconsistencies with it in that some areas of fat will resorb while others will survive and lumpiness is not uncommon when injecting fat into the lips. I therefore only inject relatively small quantities of fat into the lip so that these irregularities can be minimized. Overall, both of these alternatives are extremely good at treating the under eye hollows and for lip augmentation and it really depends on the patient’s desires as to which procedure I would therefore recommend.
Overall this generalization about injectables is true. Botox, for the most part, is very effective in the upper portion of the face including the forehead, glabella or area between the eyebrows, as well as the crow’s feet area where as fillers are more effective down in the area of the smile lines and lips and marionette lines. However, there are some patients that would benefit from fillers in the upper third of the face as well as Botox in the lower third of the face such as patients that have very deep creases between the eyebrows. These creases can be filled with hyaluronic acid fillers though one has to be quite judicious in the amount that is applied to these areas due to the fact that significant complications can occur when performed inappropriately. I therefore recommend patient seek someone with a significant amount of experience using fillers in these types of areas. Furthermore, fillers can be used in the lower eyelids quite successfully, but again, this area is fraught with complications when performed by an inexperienced injector. Furthermore, Botox can be used in the lower portions of the face such as into the depressor anguli oris that can help lift the corners of the mouth and prevent the downturned look. Furthermore, it can be placed above the lips in the levator labii superioris to prevent a gummy smile. Botox or Dysport can also be placed in the bands below the chin, which are caused by the platysma muscle and the relaxation of this muscle will visibly diminish these lines or bands. In summary, Botox typically is used in the upper portion of the face and fillers are typically used in the lower portion of the face, but when highly skilled injectors evaluate patients, we can use these products in areas that cannot only enhance one’s appearance and significantly rejuvenate the patient, but can also be used in an extraordinarily safe manor when compared to a more inexperienced injector.
Retin-A is a wonderful product that I recommend to virtually every one of my patients; however, I do not recommend it for wrinkle reduction and certainly would not recommend it for under eye hollows. Retin-A essentially increased the cellular turnover of the skin. It can provide a very small amount of very fine wrinkle reduction, but this would be very difficult to really appreciate visually. Fillers; however, are excellent at filling in depressions in the under eye if placed extremely precisely and carefully. Products such as Restylane or Juvéderm Ultra can do a wonderful job of filling in these troughs or depressions in the lower eyelid and this will essentially give the illusion that the lower eyelid bag has disappeared. This can create a very natural rejuvenated eyelid appearance without surgery. The only two drawbacks are that it is not a permanent solution, but will last approximately one year. The other drawback is that if not placed properly, can actually create a worse problem than the original under eye hollow. Fortunately any sort of difficulties with over injection of these types of products can be treated rather easily and therefore any complications from filler material in the lower eyelids can be corrected with injection of hyaluronidase.
