Laser, Needle, Knife or Nothing: The Eyes, Part One
Once upon a time, around my the time I turned 40, I flirted with the idea of lying about my age.
I knew if I was going to pull this off, I couldn’t lower my age to the point of suspicion, lest I leave people wondering if I had been “ridden hard and put away wet”.
So over lunch, I explained my dilemma to my friend Z, an agent in Los Angeles who is comfortable doling out brutal truths between mouthfuls of arugula.
“OK, so in New York you could pass for 37. Chicago, 34. London 32. But if you find yourself spending more time in LA…think more like, hmm…42. It’s the crepiness under your eyes.”
After processing the fact that I’m dog years in Hollywood, I realized there was some kernal of truth in Z’s comment.
The problem is, I’ve had mixed results with treatments in the eye area. Eye creams confuse the hell out of me. I can’t tell one from the other.
Botox has been a slippery slope. The first time I did it, I looked beautiful. My brows were arched and lifted just enough to perfectly frame my eyes. But later injections by the same dermatologist (who’s practice became more like Grand Central) left me looking like Dr. Spock. Or sometimes, like someone pulled a shade over my forehead, leveling the eyebrows flat.
Then there was Restylane, which I hoped would smooth out what I thought were bags. Instead I got two puffy bluish ridges that seemed to sit on top of my orbital bone. I later learned this is called the Tyndall Effect and happens when the hyaluronic acid is injected too close to the surface of the skin. Fortunately it was easily dissolved with hyaluronidase, but I was out $800 and out of luck.
Since then, I’ve shied away from aggressively treating my eyes. I don’t mind the life that lives on my face and when words aren’t enough, enjoy the option of expressing surprise, delight or the occasional bitch face.
But at 45, the only thing my eyes seem to be communicating is that I’m tired.
The only way to figure this out is to stop messing around with the Internet and get a few opinions from board certified cosmetic dermatologists and plastic surgeons.
She delivers good news about my upper lids, telling me because my eyes are deep set, she doesn’t think I’ll ever need surgery. But when it comes to my lower lids, she’s more circumspect.
“I can’t decide if your lower lids need peels, laser, or surgery. You’re young, so it makes it harder. If you were older it’d be easier, I’d just pull the skin [surgery]. I don’t know that I see excess skin, but I see a crepe-iness of the skin. Can you squint for me?”
She suggests a touch of Botox around my crows feet, bunny lines (those lines that bunch up around your nose, near your eyes) and a tiny amount high on the forehead would. She cautions that because I have a small forehead and a weaker left eye, Botox needs to be injected with a light hand so I don’t get the uneven brows of my past.
I’m even more thrilled (and surprised) when she recommends an eye cream with a retinoid to strengthen the skin.
“We might think about a light fractional CO2 around the eyes. That’s definitely a winter project and has some down time, but it would freshen the skin there.”
I ask about whether doing CO2 around my eyes would leave a white Lone Ranger mask. She assures me she would feather it down so it blends into my freckles, but pauses when I tell her about the post inflammatory hyperpigmentation I got after a Fraxel 1927 treatment a few years ago and suggests peels as an alternative.
Surprisingly, when it comes to fillers around my eyes, Dr. Day is less enthusiastic:
“No, I wouldn’t do a filler there. You’ll be amorphous. Your problem is crepey skin, not sinking. Your lower eyelids should not blend into your cheek directly. You need a little bit of a change from one part to the other, so you don’t overfill the area. On you that’s not your problem. The mid-face is.”
Wait, what? My face…it’s like figuring out a Rubik’s Cube while falling down a rabbit hole.
“When I do the eyes – and I do them all day long – I do them last. When you take care of the mid-face, it pushes up and it makes the eyes balanced. If you fill it up, you’re not going to have any definition between your eyelids.”
She asks to see the pictures I brought of when I was a young adult. I sheepishly pull out an amateur head shot from 1987, a time when I was regularly abusing shoulder pads, lipliner and Sebastian Ultra Hold.
I tell Dr. Day that I really don’t want to jump into this Hot Tub Time Machine, I just want to look refreshed. Besides, I’m a little worried about getting that overfilled pillow face.
“See how your cheeks are elevated? That’s the cheek I want to give you back. Right behind the cheek bone, you have this as your normal fat pad. You don’t have much of one now. If you don’t address this area, and maybe a little bit in here, then this can be looking too full. You have to actually go behind it and in front of it and it will look better.”
The price tag is for the Botox, peel and mid face injections is on the high side, even for NYC, but Dr. Day’s parting words of wisdom are priceless as she advises I drink lots of green juice, snack on almonds, get plenty of olive oil and have lots of sex.
With that I get a B12 shot for all the sex I’ll be having and leave with my TNS Essential Serum, a card for Eve’s Garden and plenty of food for thought.
My next stop is Dr. Ariel Ostad, a board certified dermatologist and dermatologic surgeon, also in New York City.
He explains that with the upper eyes, people either experience “hooding”, an excess of loose skin that hangs over the natural fold of the eyelid, eyebrow sagging, where the position of the brows is starting to sag below the orbital bone or eyebrow ptosis.
Lower eye lid problems can include crepey skin with fine lines, under eye bags or festoons (larger bags that extend down onto the cheek and almost always require surgery) or a combination of everything which is common.
What’s essential though is factoring in the laxity of the eyelid and surrounding skin which makes or breaks some of your treatment options. Think of laxity as the snap skin has to it – when you pinch it, how quickly it bounces back.
“There are so many different medical anatomic issues with regards to the eyes. Each requires a customized treatment. You can’t apply the same cookbook approach to every patient,” he says reinforcing the importance of the right diagnosis.”
OK Dr. Ostad, so what about my eyes.
“Actually your upper eyelids look nice. With your lower eyelids when I look really close, you don’t have wrinkling, but you have a slight kind of protrusion of the fat pads. It’s called a pseudo herniation, meaning you didn’t suddenly develop a fat pad, it’s just that the support is gone so your fat pads are protruding. By putting a little Restylane here, we truly support those fat pads and push them back in.”
Dr. Ostad’s practice offers blepharoplasty and CO2 lasers among others, so I wondered why they weren’t top on his list for me.
“Fraxel CO2 in your case will not do anything, because, you don’t have a lot of wrinkling. FraxelCO2 is a great way to tighten, if somebody has crepey, wrinkly skin, but there is some downtime. For about seven to ten days you have scabs under your lower eyelid, you have to stay home and pat the area with vinegar soaks and Aquaphor. But afterwards it’s nice and tight, with results that get better over six months.”
“Fraxel Restore on the other hand, I will not use at all to improve lower eyelid wrinkling. I’ve had patients come to me who say they had Restore to get rid of fine lines, but it actually got worse. I only use Fraxel Restore for acne scars.”
He’s even more cautious about surgery (blepharoplasty), telling me the mistake he commonly sees is when people remove too much of the fat pad, leaving patients with a gaunt look years later. However, if there is substantial hooding and loose skin, or if a patient can’t have a CO2 laser due a risk of hyper-pigmentation (like me or women with darker skin), sometimes a blepharoplasty is the only option.
Lastly we move back to Botox which he thinks would be an excellent idea for my crows feet and despite my Botox blunders in the past, is confident he can achieve a beautiful, natural result.
“It requires going to a physician who really knows the anatomy of the face. Some people have a long forehead, some people have a short forehead. You have to consider people’s eyelids. If they really have a heavy eyelid, you don’t want to treat their forehead because, you’re going to make this hooding worse. If you don’t distribute Botox evenly, then one area is kind of relaxed, and one area is active. That’s when the ends shoot up.”
I had a full face Ultherapy earlier in the month, and wondered if it would clash with Botox. If Ultherapy takes 3-6 months for results to show up and my doctor is using Botox to correct for the way my face looks now, I don’t want my eyebrows levitating off my face at the end of the summer. He assures me the Ultherapy lift is minimal – about 3mm so there’s little risk of overcorrection.
And away we go. I rather like Dr. Ostad’s light touch. It’s natural, my eyebrows are nicely arched, my crow’s feet are gone and I can make lots of faces.
But the issue of my eye crinkle crepes still remain, and that bothers me more than the mild under eye bag.
Using an eye cream with retinol is a no brainer, but I’m still not sure whether the medical answer lies with fillers, chemical peels or a CO2 fractional laser. Maybe it’s surgery?
To find out, I’ll get in depth about blephs with Dr. Haidah Hirmand in Laser, Needle, Knife or Nothing: The Eye Edition Part 2.