There are a lot of places that we can go with this and a lot to cover. I think we talked about breaking it down to starting off very minimal, and what the needs are, and what people are concerned with and then how to address each one of those things.
Some people come in when they're young. They may or may not have crows feet, or some sun damage and it's not easy to break down in age because we have some people that come in that are 25 or 30 and they have worse crows feet and More skin damage than someone who's 50. A lot of it has to do with how much sun exposure you've had, the genetics, and how thin or thick the skin is around your eyelids, and how much muscle and squint motion you have. One of the things I think about all the time, I don't want to name names, but one of our patients never wears sunglasses, she hates them. It's not that she has super intense crows feet, but she hardly has wrinkles anywhere else and there are very distinct lines here because she squints a lot in the sun. Believe it or not, the first thing is, preventing new wrinkles from forming and that is so important. People will spend thousands of dollars treating when if you just prevent further damage you’d save more money. If you do nothing else, wear sunscreen and sunglasses.
People come in complaining of three or four different things when it comes to the eyelids. Probably the number one thing is wrinkling. Botox is a great fix for wrinkling. Skin creams help, they help plump and mask some of the fine wrinkles but most of those eye wrinkles are due to chronic muscle movement at the corners of the eyes. No one is saying you should paralyze the eye muscles totally and not have any expression but doing a little Botox to kind of soften that squeezing action goes a long way. You still have the motion, you still have the ability to squint and move, and do all that. It will just soften the hard lines and wrinkles. I personally do what I call rotating Botox. Where sometimes when I get Botox, I get a lot in the upper part of the crows, the next time I'll focus more on the lower crows so that I'm still moving my face. I let it wear off in between so I can gauge where my expression is. I do just enough that I keep those lines from getting super deep.
If you're not looking to be that intense, a little Botox can actually raise the brow. Tons of our patients will do a couple of units, two to three units of Botox right in the orbicularis muscle, the eyelid muscle, because when that squeezes down it tends to pull the corner of the brow down. For some of our patients, that's just enough. They can postpone any kind of more extreme or more expense intervention for a couple of years until they really need it. Botox in this part of the eyebrow also helps kind of lift because these are muscles that tend to pull down. When we Botox those and they relax, sometimes that will open up the eye too.
We have done Botox in the lower lid very sparingly for patients who have some of that wrinkling here. Sometimes that can help smooth out the skin. You've got to be careful though. Two things, when I did it the first time, way overshot just a little bit. For the first month I felt like I couldn't squeeze my eyes super, super, super tightly shut. When I was in the shower facing the water, I just felt a little uncomfortable. These are just things for people to be aware of I guess. . Now, some people aren't comfortable with Botox, either they know it doesn't work for them or they don't like the idea of it. There are some other ways to address some of those lines and one of those I found out when I was pregnant. You can do the Botox for the stern and the crows, or you can do the Genesis, which would be another option for low maintenance.
During the pregnancy I did Genesis around my eyes. It's a very low level laser that just heats the skin, there's almost no downtime from it. It stimulates collagen. For some people who just want a little softening but want to keep all of their expression, Genesis treatments around the eyes work. But It's maintenance. It's best done monthly but you can do it in a series of six or 12 and get a nice impact and then kind of hold off for a while and use a cream to maintain. Those are some of the simple things people can do. They're definitely more in the lower budget part of it too. If you're just treating crows or you're doing Genesis, you're not going to spend a fortune. You're going to spend $100, $200, $300 max. Every couple of months.
A lot of people come to us and they're concerned about more than just wrinkling. Probably the next thing we get concerns about is the skin texture. crepiness, not crows feet wrinkles but just generalized wrinkling of the eyelid skin.
Botox doesn't always affect that. It will affect the circular muscles that squint down and prevent that motion but when you smile, your cheeks come up the skin creases. If there's any looseness or excess skin, you're going to crease. The best thing I have found for that for patients is, number one you do have to evaluate for extra skin. If you've got excess skin you can pinch, you may be ready for a lower eyelid surgery. If you don't have excess skin you can kind of pinch with your finger, then laser is a fantastic way to deal with those wrinkles and that textured skin.
CO2 LASER RESURFACING
Which jumps into a different type of laser. CO2 laser, it's more of a downtime laser; it takes about a week to recover. It can be done just around the eyes, around the whole face, but it's really nice for stimulating collagen. Yeah, the CO2 laser, I did it last year and it made a nice difference. Not only did it kind of smooth out my lower eyelid skin but it improved some of the discoloration-Plumped. Plumped it a little bit and it did tighten the skin on my upper eyelids just enough that it didn't really bother me anymore.
That kind of leads us into the next thing that people complain of. We've covered wrinkles, we've covered crepey skin, a lot of people feel like they have heaviness of the eyes, lateral hooding meaning the skin that's kind of hanging over the eyelashes at the edge of the eye. Where they're like, "I look so tired, I look sad, I look like Droopy Dog."
They have that upper eyelids or their brows become a problem. For some people their brows are in such a low position you could remove eyelid skin and they're still going to be heavy.
For a woman, your brows are supposed to be a centimeter or about a finger above your brow bone. You put your finger on the brow bone, your eyebrow should be just above that. It's okay for some people if it's at the rim because that can genetically just be where some people live and not everybody wants a super high brow, but if your brow is starting to come down and you're not ready to think about surgery, Ultherapy is a great fix.
Ultherapy is not a laser. Briefly, it is called Micro Focused Ultrasound. It's an ultrasound probe kind of like you get if you have a baby and they put it on the surface. It's a little uncomfortable but we give patients a pain pill to take.
To me, it's really considered a no downtime. You may be a little puffy or swollen the next day but it's nothing dramatic. I went back to work and nobody even knew I had anything done. It's gradual; it’s a delayed gratification. I'm turning 40 this year and I am pretty much planning on full body Ultherapy because I just want to prevent myself from getting any older looking than I am now. Even though I'm a plastic surgeon and I do all these dramatic things, I don't have downtime, I don't want to think about doing dramatic things so I would much rather do Ultherapy on the brow. I did it last year and I got a nice, along with the CO2, it was a nice fix. It made me feel much more refreshed, much more awake.
UPPER BLEPHAROPLASTY/ EYELID SURGERY
Eventually people will get to the point where there's just enough loose skin that no matter how many of these minimally invasive things you do, it's just not going to happen.
I've had patients come for blephs at thirty and I've had patients come for blephs at 60. It's not all about age; it's a lot about your genetics, and your anatomy, and what you're bothered by. The number one complaint I get from people who are ready for eyelid surgery is that when they put on their eye makeup, there's no crease to put it in, and their mascara gets all over their upper eyelid. They're taking it and stretching it so high up, and then pulling it down to try to find a place to put it on.
Upper eyelid surgery can be done under local anesthesia. Which is awesome. We use a numbing cream, and then after the numbing cream is on we use a Botox needle to numb the skin. There's a week of downtime, but it's just cosmetic. We had a hairstylist who went back the next day, with sunglasses on. It's one day of downtime. With a big pair of sunglasses, you can hide everything. It's a pretty easy recovery. Most patients find that it's a pretty straightforward, quick procedure.
What to do about Dark Circles?
We've talked about wrinkles, we've talked about skin texture, and we’ve talked about loose skin but what about puffy under eyes or dark circles under the eyes. Those can be related, but they're often two different things.
We all have a ligament that holds our muscle and our skin very tightly against the bone here. When we start to lose fat in our face, starting at age 24, that area where the muscle is tightly connected to the skin can become more obvious, your trough, and that's usually the shadow that people see. In combination with that, we all have fat around our eyeball to cushion it and it's held back by this little film called the orbital septum. Over time, just like everything pooches and stretches, the orbital septum pooches and stretches over time. Some people will notice, in addition to this deep hallow, they have a puffy bag on top of it. Early on, filler can be used right in that tear trough just to kind of blend those contours.
At a certain point though, if it's genetic and there's just extra fat there, eyelid surgery is about the only thing that can take care of that. It can be done for people without excess skin through an incision on the inside of the eye so there's no visible scarring externally. If there's extra skin, you can do an incision on the outside.
Some people, as early as 20 say, "I have these bags, I have this puffiness." Preparation H, oddly enough it does work. It's called a vassal constrictor; it constricts the blood vessels so less fluid will accumulate in that area. The problem is, although it's a good quick fix, it's not healthy for the skin long-term. Over time, it will thin the skin and make the problem worse. It's a good quick fix if you're going out to dinner or you want to look good for a day, but it's not a good long-term plan.
There are some eye creams and products that have ingredients that are actually good for the skin and make the skin a better quality. There are some that just make you look better for the duration of having them on and don't actually do anything to make your skin healthy.
One thing I want to talk about, because I know it's always kind of a concern when patients come in with the festoons, where it's not really technically your eyes but people are like, "I have these swollen bags." Talking about where some people get puffiness that are right here along the cheek lines. It's not the bags under the eyes, it's literally-It's cheek skin On the orbital bone.
They're called malar bags, or festoons. Those are very genetic and they're very tricky. Eyelid surgery doesn't really address them. When they're really bad you can cut them out directly. You've got to be really bad to put a scar there. Most of the time, we focus on tightening the skin over top with laser or any other means that stimulates collagen, Fillers. Fillers can be really good along the cheek to kind of balance the volume and camouflage You've got to be careful with those too because if you inject right into that malar bag, it can puff up. More skin tightening I think is affective for those areas.
I always say when a patient comes in and I'm meeting with them and they're like, "Well, I've never done anything, my face is a concern and my eyes are really the concern but I kind of want to do this, and this, and this." I'm like, start with your eyes because eyes say so much about your face. They say whether you look tired, whether you're rested, whether you're youthful. You can be happy as you want but your eyes can look like you're miserable and grumpy.
There are a lot of people that feel like they need a full facelift or something very dramatic. If you just take care of the eyes, you get about 50% of the way there believe it or not.
If you have eye concerns know there are so many roads and options you can take, even if you're just ready to kind of just dap your little toe in the water, you can do that and get a good result, and a good outcome. There's something for every budget and something for every stage of person. There's people looking for prevention, there's people looking to dramatically overhaul.