Dr. Jasmine Mohadjer

A sagging brow can be fixed via a direct browlift, which is an incision hidden in the eyebrow hairs to elevate the brow. It can be done endoscopically to raise the entire forehead. If the sagging is minimal, it can even be done with Botox or other similar neurotoxins, which is also a great treatment of wrinkles. If the skin of the brow is a concern, laser skin resurfacing with fractionated CO2 laser or other modalities can also be a good option.

Many times this is due to herniated fat. Our eyeball is cushioned by fat all around the socket. We have special membranes we call the septum that help to hold it back, but with time, these tissues thin and the fat bulges forward and is more obvious. We call this a pseudo-herniation. People with some conditions, such as thyroid eye disease, have a lot more of this than most and it can be visually disturbing. This fat is addressed generally by excision or reposition.

A lower eyelid blepharoplasty is used to address these concerns. I generally do this procedure through the lower eyelid to sculpt and reposition the fat. Older techniques were focused mainly on removing the fat, but then we noted that people became more hollow or skeletonized as they continued to age and the cheek descended further. Now instead of cutting it all out, we reposition it to hide some of the hollowness that becomes more apparent. Excess skin can also be removed under the lash line and a laser skin resurfacing on the lower lids makes a dramatic difference to the skin.

I generally do a lower eyelid blepharoplasty procedure through the lower eyelid to sculpt and reposition the fat in that area to hide some of the hollowness. Other options to consider are to inject hyaluronic acid fillers such as Juvederm or Restylane to the lower eyelids to mask the “hill” of fat next to the “valley” of hollowness. This can make a dramatic difference and is much less invasive than surgery, but this is not permanent.

Botox and laser skin resurfacing.

It depends. All eyelid surgeries changes the shape, especially ptosis repair. After careful examination with an oculoplastic surgeon, options can be discussed based on specific concerns.

We can make them appear larger by changing the eyelid position.

It depends on why they are red. They eyes could be dry or irritated. The redness could be caused by an allergy or from previous eyelid surgery not allowing the lids to close all the way or an addiction of the eyes to Visine. Depending on the reason, there are definitely some options.

It can improve peripheral vision in cases where the lids are so low they are obscuring the side vision.

It is related to a glaucoma drop named Lumigan that they found to cause lashes to grow. Independent studies just applying to lashes showed that it was safe and efficacious to use for this cosmetic indication. It works by causing the lashes to increase the time in their growth phase, and allows the lashes to become dramatically darker, thicker and longer, and it is the only FDA approved lash enhancer. And it works! It is awesome!

Juvederm and Restylane are very similar. Perlane is a thicker form of Restylane that tends to last a little longer and is placed a little deeper. These products are all hyaluronic acids and add volume to areas of the face. They are used off-label all over the face, including the cheeks, hollow temples, lower eyelids, lips, chin, jowels, etc. They are FDA approved to fill in the nasolabial folds, the lines from the nose to the face (or parenthesis as they are sometimes called). Restylane is also FDA approved for lip augmentation. They work great in VERY, VERY, VERY small doses around the eyes. I like them a lot because they naturally dissolve, are very well tolerated, and if there is an issue, can be dissolved immediately with a product call hyaluronidase. Radiesse is a little different. It is a product composed of calcium-based microspheres and gel that is placed deep and is used as a scaffold to build your own collagen. It is great for shaping the face, especially the mid-face. It does not go near the eyes or in the lips.

These are purified proteins that temporarily reduce the wrinkles and lines around the eyes as we squint, smile or raise the forehead. They are very similar products and last 3 to 4 months and each has its specific pros and cons based on the location of the injection. These neurotoxins are amazing products and can reverse and prevent dynamic lines if maintained.

Yes, I use a fractionated CO2 laser to tighten the skin, improve texture and tone, and improve scars. These do great around the eyes; however, patient selection is very important. I also use IPL laser on the face to improve pigmentation, vascular lesions, and acne.

Yes, use them all around the eye (I do). They don’t all work, so be sure to get a high-grade, medically rated eye cream for the best result. My favorite is Obagi’s ELASTIderm that has shown with biopsies to improve elasticity when used twice a day.

Facial peels come in a variety of types, some are better for acne prone skin, some better for pigmented skin. Some are lighter with little downtime, and some are deeper with up to a week or more of downtime. They work to create a controlled damage or removal of the top surface of the skin, so that when it heals back it is tighter, smoother, and more even in pigment and texture. Depending on the strength of peel, either my aesthetician or I do the peels and generally they are customized to the patient and his or her desires, concerns and downtime availability.

Although eyelid surgery allows for a significant improvement in appearance, it is certainly not ALWAYS cosmetic. In fact, many of the patients I see truly have visual compromise that affects their daily activities, and they may not even realize how much. Often times patients come in with their foreheads raised high and complain of headaches and heaviness of the lids, or their heads tilted back to see through the eyelids, and may complain of neck pain. Many patients have trouble reading and driving. As the lids sag across the eyelid margin, the peripheral vision is certainly affected, and this becomes a functional, or medical, issue, not just a cosmetic one. More than even central, or straight ahead vision, the loss of peripheral vision is related more directly to falls in elderly, and loss of independence. After these types of procedures, my patients almost always remark at how much brighter things are, how much longer they can read, how much more confident they are driving, and certainly their quality of life has increased. And on top of that, they look great and have increased confidence and energy.

There are certainly options for improving lower eyelid hollows.  First of all, a thorough examination in person by a qualified oculoplastic surgeon would be necessary to fully evaluate the area to see if there's anything specifically contributing to the hollow appearance.  Hollows can be addressed by lower lid blepharoplasty with fat repositioning, hyaluronic acid fillers, or fat injections.   There are pros and cons to each procedure and depending on your specific exam, one option may be more appropriate for you than another.  However, an evaluation would be necessary to be more specific.