Best Treatment for Under Eye Wrinkles: Fillers, Surgery or Laser?

Many people come into my office and demonstrate how pulling the skin under the eyes outward results in smoother skin. “Can you do this doctor?” they inquire.”. With a mirror, I demonstrate how the areas around their eyes become distorted, and how the level of tension they use with their fingers cannot be sustained long-term with surgery. Nonetheless, surgery to treat under eye wrinkles is still very common, and the risks of this approach can be quite severe. I’ll go over how I treat under-eye wrinkles in my practice.

As a cosmetic eyelid surgery specialist, I regularly perform all types of cosmetic eyelid surgeries for under eye bags, hooded eyelids, as well as revision work to correct complications from other surgeons, such as eyelid skin removal to treat wrinkles causing rounding of the eyes, lower eyelid retraction, and even ectropion where the inside of the lower eyelid is exposed outward.

Under Eye Wrinkles Misconception

Excess skin is thought to be the cause of wrinkles under the eyes. People pulling on the skin and observing how it does not snap back into place quickly reinforces this perception. This reflects a decrease in skin quality rather than an increase in skin quantity.

The skin on the eyelids is the thinnest in the body, measuring about half a millimeter. It’s important to remember that this extremely thin skin has a low tolerance for overly aggressive treatment. In addition to skin quality, the appearance of the eyelid skin is influenced by lower eyelid tension.

The lower eyelid functions as a suspension bridge, with the lateral canthal tendon serving as an especially important point of support. If this tendon becomes lax for any reason, the eyelid margin may sag and the skin may appear loose and redundant. Laxity of the lateral canthal tendon is common with aging, but I also see it in people who suffer from seasonal allergies.

Under Eye Wrinkles Fillers, Surgery, or Laser?

Laser

It has been well established that removal or ablation of the epidermis and the upper part of the dermis using chemical peels, or lasers can result in smoother looking skin. Thermal energy delivered to the dermis causes collagen production, which can improve the foundation for the epidermis. After a chemical peel or laser treatment, the new epidermis appears smoother. I’ve used ablative CO2 and erbium lasers as well as fractionated CO2 and erbium lasers in my practice.

The challenge has always been to be able to perform an under-eye wrinkle procedure without the typical one-week downtime. Keeping this in mind, I’ve been using a long pulsed Erbium fractionated laser for the “smooth eye” procedure. This procedure takes only a few minutes and is performed in my exam room using only topical anesthetic.

The patient has no downtime and comes in for three sessions, one month apart. If a patient’s eyelid skin is crepey and thin, I frequently use PRP to help the skin to better tolerate any laser procedure. If the thin eyelid skin is weak, I believe it should be ready to respond effectively to any laser procedure, which is referred to as “skin rehab” by me.

Radiofrequency and Botox

If a patient has darker skin so they are not a candidate for laser, I use radiofrequency technology to induce collagen remodeling instead of laser. People with thin lower eyelid skin frequently have wrinkles around the eyes, such as “crow’s feet” lines. These dynamic wrinkles become deeper with expression and can be reduced with regular injections of botulinum toxin such as Botox or Dysport.

Topical skin care such as the use of retinols and moisturizers with some active ingredients can be beneficial for maintenance. This appearance and behavior of lower eyelid skin is often seen with other changes such as the prolapse of lower eyelid fat pockets.

Surgery for Under Eye Bags, and Wrinkles

Transcutaneous Blepharoplasty (Why it is Not Advised)

Lower eyelid blepharoplasty is a surgical procedure that is used to treat puffiness under eye bags. Transcutaneous blepharoplasty is the most commonly used procedure for treating under eye bags.

A transcutaneous blepharoplasty involves making an incision just below the eyelashes, then elevating and separating the skin and muscle to address the fat that causes eye bags. Eyelid skin is typically trimmed and sutured to tighten the skin. Transcutaneous blepharoplasty procedures can cause skin shortage due to excessive skin removal, as well as compromised lower eyelid support due to the separation of tissue layers that were previously stronger as a unified structure.

Lower eyelid skin is a component of the layered structures that provide lower eyelid support. The orbicularis oculi muscle, which acts like a hammock and is attached to the bone by a structure called the lateral canthal tendon, is located just beneath the skin. When fat pockets are accessed through an external incision, these support structures are compromised.

Common Complications with Transcutaneous Blepharoplasty

Patients who have had this surgery come to see me every week complaining of lower eyelid rounding, retraction, and even ectropion due to skin shortage after skin removal. To restore the compromised anatomy in these cases, I perform advanced reconstructive procedures such as skin and tissue grafts.

Transconjunctival Blepharoplasty (Why it is Recommended)

In my practice, I perform a procedure called transconjunctival blepharoplasty for under eye bags. I sculpt the fat responsible for the eye bags from the inside of the eyelid, eliminating the need for an external incision. Transconjunctival blepharoplasty is a more complex and specialized procedure, but it enables preservation of the anatomic structures that support the lower eyelid.

For under eye wrinkles, I use fractional CO2 and erbium laser with PRP. This combination has shown to be both safe and effective in reducing the appearance of under-eye wrinkles without the need for skin removal. Again, I’m concentrating on improving the skin’s quality.

Fillers (Appearance of Cheeks and Eyes)

I’ve noticed that the eyelid skin appears redundant, especially in people who lack cheek projection, when it’s simply sagging from a lack of support. Instead of removing skin, I use long-lasting hyaluronic acid fillers like Juvederm Ultra Plus and Juvederm Voluma to restore volume in the cheeks. These fillers will not weigh down the skin because I place them at the bone level, just like a facial implant with a procedure called Structural Volumizing. Structural Volumizing is very effective in restoring balance between the cheeks and the eyes.

I use local anesthesia with minimal IV or LITE sedation to perform transconjunctival blepharoplasty and most other cosmetic surgeries. My patients recover quickly and are able to return to work within a week. In contrast, recovery from the effects of general anesthesia alone can be unpleasant and physically draining.

Conclusion:

If you are concerned about wrinkled skin under your eyes, understand that skin quality is more important than skin quantity in your treatment strategy. It’s also important to consider the other anatomic factors that can make the skin under your eyes appear redundant.

I cannot emphasize enough the importance of understanding the delicate structure of the eyelid skin, to avoid overly aggressive procedures that can make the skin look worse, and even jeopardize the integrity of the lower eyelid. Although limited skin removal, such as a skin pinch procedure, can be tolerated, in my experience, the underlying qualitative issues are more important.

Doctors who recommend eyelid skin removal may believe they are doing their best to help, but you must be certain that you can maintain the natural shape of your lower eyelids. I hope this information was useful to you.

Under Eye Wrinkles Treatment in Manhattan, NYC and Garden City, Long Island, New York

Dr Amiya Prasad is a Board Certified Cosmetic Surgeon and Fellowship Trained Oculofacial Plastic Surgeon. He’s been in practice in Manhattan, NYC and Garden City, Long Island for over 25 years. To schedule a consultation fill-up the form below or call our offices at (212) 265-8877 for Manhattan, New York City; (516) 742-4636 Garden City, Long Island; or (703) 356-1336 for Vienna, Virginia.

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