En español | The face masks we're wearing to protect us from the coronavirus may conceal a jowly jawline or marionette lines around the corners of the mouth, but they also put even more focus on our eyes. Plenty of us don't mind the small wrinkles that come with age, but those who do can find a range of ways to fade lines and tighten skin around the lids, fill in under-eye hollows and hide damage caused by years of sun exposure. It's important to consider cosmetic eye procedures carefully before going forward with one. Some are more painful than others, and all are rather pricey. Here's a rundown of what to expect from each of four common procedures.
Some people choose under-eye filler — injectable hyaluronic acid — “to replace or restore volume in under-eye hollows that give eyes a sunken-in appearance,” says Brian Biesman, M.D., a Nashville-based oculofacial plastic surgeon. Filler can be injected under the eye to fill in that indentation (the tear trough), which may be caused by a fat pad bulging above it. (These dermal fillers have been approved by the Food and Drug Administration (FDA) for use in cheeks, lips, nasolabial folds and hands; doctors often use them off-label on the eyes.)
There's also blepharoplasty, which is the surgical repositioning of the fat pocket, says New Orleans-based dermatologist Mary Lupo, M.D., though filler may be sufficient if you have only mild to moderate puffiness.
Pain: Pain at the injection site can be lessened by using a topical numbing cream before the procedure, so it shouldn't hurt much. There are two ways to inject the product: with a needle, using a series of injections along the orbital rim of the eye; or with a blunt-tipped cannula, which allows multiple areas to be treated through a single injection, to minimize bruising. “Some people aren't fazed; others think it feels kind of weird,” Biesman says of the latter. “It's not really painful — it's more about pressure.”
Results: “You can see results right away, though it takes a couple of weeks for products to completely settle in,” Biesman explains. It's normal to need a follow-up appointment for tweaking. “Usually, you need one session, but if the doctor is conservative, they may have you come back in two to six weeks and put a little bit more,” Lupo says. “It's easier to add than to subtract."
Recovery: Bounce-back time varies for each patient. “At best you'll walk out of the office and see results,” says Jaimie Glick, M.D., a dermatologist based in New York City. “You'll have no bruising, no swelling. You'll look phenomenal and love your doctor. At worst you'll get a bruise, which could take up to two weeks to heal. If your doctor has lasers in her office, you often can come back and get the bruise lasered to speed up its healing. And because fillers contain hyaluronic acid, which absorbs water, your eyes will swell a little right after the procedure or days following."
Longevity of results: It depends on the type and amount of filler that's used. (Restylane and Juvéderm are popular brands.) When the hollow becomes pronounced again, additional injections are required to maintain the effect. “I tell people, typically, at least a year, but I've seen it last longer,” Biesman says. “If it looks great, leave it alone. If you keep injecting just because it's been X amount of time, it can build up and doesn't look right.”
Cost: Under-eye fillers can run from $600 to $1,500 and up, though, as with each of the following procedures, prices vary by region.
Take note: “When it's done well, filler works beautifully,” Biesman says. “But it's a tricky area to inject and can be fraught with all kinds of complications and problems.” Among the potential problems: bleeding or an infection at the injection site, a buildup of fluid under the skin's surface, a nasty rash or, in rare cases, scarring.
Tip: Don't let anyone who isn't an experienced, board-certified dermatologist or plastic surgeon inject the area. “Fillers require really good technique and a knowledge of anatomy,” cautions Glick, who often starts the procedure with a cannula, then fine-tunes with a needle. The good news: Should you not like the results, hyaluronic acid can be easily dissolved with hyaluronidase (an enzyme already found in our bodies).
Years of squinting and frowning leave souvenirs around your eyes, in the form of frown lines and crow's-feet. Injections of small amounts of Botox (a drug made from a botulism toxin) smooth things out. “It works by temporarily paralyzing the muscles under the skin — specifically, the orbicularis oculi muscle, which helps the eyes close and squint — making it harder to make the muscle contraction that creates lines,” Glick explains.
What's more, you can elevate the eyebrows, which tend to sink down over time. This lifts a bit of skin on the upper eyelid, opening up the eyes. By relaxing the “frown” muscles between the brows, along with certain parts of the orbicularis oculi muscle along the eyebrow, which drag the brows down, the forehead muscles can pull up. “You're sort of changing the dynamic between the pull-up and pull-down muscles,” Biesman says.
Pain: Injections aren't particularly painful for most people. You can expect a slight pinch.
Results: That smooth look doesn't appear instantly. “Botox takes time to settle in,” Biesman notes. “Typically, the onset of the effect is three to five days after the injection, though for many it can take up to two weeks to see maximum results.” And keep in mind, results will vary, depending on the depth of your wrinkles. “If the lines are deep and prominent when the face is at rest — without contracting or furrowing the muscles — Botox is not going to take them away,” Biesman says. “You'll probably need to use some filler, as well."
Recovery: You can resume your regular schedule right after treatment. One caveat: Steer clear of the gym for 24 hours after the procedure. Strenuous exercise can result in bruising and, in rarer cases, cause the Botox to shift to other areas of the face.
Longevity of results: “Studies show that Botox wears off about 30 percent every month,” Glick says. “That means, at three months about 90 percent of it has worn off. That's when patients look in the mirror and think, Oh, my eyes are a little bit droopy now. I see my crow's-feet again.”
Cost: Between $200 and $800 per session, sometimes more
Take note: “I've been injecting Botox for 31 years and still think it is one of the trickiest procedures we do,” Biesman says. “People can respond differently to similar doses of the drug. If it's poorly done, you could end up with a lopsided appearance, drooping of an eyelid or an eyebrow, or both.” And, Biesman notes, “As opposed to, say, hyaluronic acid fillers, which can be dissolved if you don't like how something looks, Botox can't be removed or reversed.” You have to wait it out — typically 10 to 12 weeks — until the neurotoxin wears off.
Tip: Many coupon services run deals for cheap series of Botox. Resist those too-good-to-be true deals. The Botox they're using could be expired. What's more, says Lupo, “if you go to a place that has really cheap Botox, the odds are, they get bootlegged products and buying it illegally off the internet — and “they're doing other things that are not the standard of care of a medical facility.” Also, there is an artistry involved in the technique, so be sure your physician is highly experienced.
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Ablative lasers, such as the CO2 (or carbon dioxide) laser, use high energy levels to treat fine lines and wrinkles, tighten sagging skin and eliminate age spots caused by sun damage. “Many people think that ablative CO2 resurfacing around the eye is probably the most effective procedure, short of surgery,” Lupo says. With this skin-resurfacing technique, short, concentrated pulsating beams of light are directed at wrinkled or discolored skin, removing upper layers of skin, one thin layer at a time. During healing, the skin that takes its place is firmer and smoother. One advantage is the precision that a laser offers: “I can make changes in the amount of energy I'm delivering in a very precise manner,” Biesman says. “I'm frequently adjusting the various parameters in the laser, depending on what part of the lid that I'm treating, to get the best results, while avoiding complications.”
Pain: Usually, a topical numbing anesthetic is used to tame discomfort, though some people may experience a mild prickling, itching or burning sensation. “We're usually very good about numbing or sedating the patient,” says Lupo, who points out that the eye area tends to be one of the less painful areas of the face to treat.
Results: It depends on the type of laser, the laxity of the skin, and the repair you're trying to achieve. Most people need only one procedure, says Lupo, “but if you have severe wrinkles around the eyes, you might do one and get a certain amount of improvement, then, maybe six to 12 months later, you might do a second one.”
Recovery: In the few weeks it takes to recover, your skin will be red and swollen (like a nasty sunburn) and may be itchy and peel, or, sometimes, blister or ooze. During this period, protect skin with a broad-spectrum sunscreen and keep it well moisturized with a gentle topical, such as Aquaphor or Vaseline.
Longevity of results: Results can last for two years — and that's a conservative estimate. Exactly how long you can expect your skin to stay smooth and line-free depends on several factors, such as genetics, UV exposure and protection (use sunscreen faithfully), and skin maintenance.
Cost: The average price of laser resurfacing is $2,000 to $2,500.
Take note: This type of treatment is especially good for fair skin types. But, warns Edidiong Kaminska, M.D., a Chicago-based dermatologist, those with darker skin tones should proceed with caution, since ablative lasers can cause hyperpigmentation and discoloration. The American Board of Cosmetic Surgery recommends working with a physician who has extensive experience in treating darker-skinned patients. Other possible side effects — for all skin types — include infection and, in rare cases, scarring.
Tip: Experts have a wide array of lasers at their disposal to treat different skin issues, Biesman says. For those who have dark, bluish-purple discoloration beneath the thin skin under their eyes, for example, vascular lasers can be used to target the blood vessels behind those circles.
A high-tech treatment, Thermage uses a noninvasive device to deliver radiofrequency energy to tighten and lift the skin and soften fine lines. “We send radiofrequency heat to melt or break down collagen in the dermis, inducing it to rebuild to tighten,” Glick explains. Beneath our outer layer of skin is the dermis, the thickest layer of skin, which is made up of a grid (or matrix) of elastin and collagen that holds the skin together. As we age, this matrix loosens, resulting in sagging skin. When the dermal tissue is heated with radiofrequency energy, the skin layer beneath the surface tightens. Over time, new collagen forms. Thermage is an all-purpose player. “It's the only device FDA-approved for use inside the orbital rim and safe on all skin types,” Lupo says. Indeed, you can treat upper and lower eyelids, the periorbital area and the brow.
Pain: When Thermage was cleared by the FDA and first became popular, in 2002, it was pretty uncomfortable, mostly due to the amount of heat involved. But the process has improved a lot since then. Depending on your pain threshold, you may feel mild warmth or a hot sensation with each application of energy. The device delivers cooling “bursts” to the outer layer of skin to make the procedure more comfortable.
Results: Improvement occurs gradually. “It takes about three months to see the maximum benefit,” Glick says. “That's how long the collagen takes to regrow.” Thermage is usually a one-and-done procedure, though most patients return every year or so for maintenance. “You typically do one, then reevaluate in three months and decide if you need another treatment,” Lupo says.
Recovery: The procedure involves little or no recovery time; plus, there's no reason to hide away afterward. You can even go back to work after the treatment. “It's not like a laser procedure, where you're going to have redness around the eye area,” says Glick. “You might have slight swelling or a little warmth in the area.”
Longevity of results: up to two years, possibly more
Cost: The cost of Thermage depends on the size of the area you want to treat. Typically, a face treatment costs $2,000. “Just for the eyelids, somewhere around $2,000 to $3,000,” Glick says.
Take note: Although this is a noninvasive treatment, heating the layers of skin can lead to blistering, burns and the formation of scabs — all of which should disappear during the natural healing process. Excessive heat may also lead to discoloration and hyperpigmentation.
Tip: Thermage's uses extend beyond the eyes. It can help tighten saggy jowls, flatten skin on your belly or arms, and treat those wrinkles above the knees.