Concerned about lower eyelid wrinkles? When a patient wants to improve their lower eyelids, it almost always involves the bags and the wrinkles. I spoke of bag improvement by means of lower eyelid fat treatment in another blog post way back in 2012. The wrinkles are demanding equal time!

Wrinkles are caused by either excess skin, overactive muscle, skin that has lost its collagen, or a combination of these. Let’s consider each:

• The patient with excess skin typically has skin bunching up in folds. This excess skin of the lower eyelid can be trimmed away via a small skin incision hidden just beneath the eyelashes. In years past, lower eyelid surgery was done by such a skin incision. The skin and the underlying attached muscle were then lifted, the fat bags exposed, and then removed as needed. Nowadays this approach has been replaced by one that involves an incision inside the lower eyelid that prevents the pulling down of the lower eyelid that would sometimes occur with the skin incision technique. The fat creating the bag is easily identified through this inner eyelid approach and is then removed or repositioned. Once this is done, any excess skin can be trimmed away via an incision just beneath the eyelashes, leaving the underlying muscle untouched and thus minimizing any pulling down of the eyelid. The resulting scar is usually virtually invisible.

Overactive muscle in the lower eyelid can lead to wrinkled skin. When anyone squints, the skin will wrinkle but quickly returns to normal when the muscle relaxes. We call this “dynamic wrinkling.” The repeated folding of the skin by muscle, however, can lead to wrinkles that are present even at rest, termed “static wrinkling.” Dynamic wrinkles can become static wrinkles when the skin is creased enough times, much the same way that a credit card eventually cracks when folded enough. Treatment of dynamic or static wrinkles is done with Botox. It relaxes the muscle and thus prevents dynamic wrinkles. If this relaxation can be maintained for a number of months, the body may even form new collagen to repair static wrinkles.

In this technique, a very small amount of Botox (1 or 2 units per eyelid) is injected just beneath the eyelashes. For comparison, treatment of crow’s feet at the corner of the eye is done with ~ 10 units. The lower eyelid treatment should only be used in those patients with relatively tight lower eyelids. You can test for this on yourself by using the “snap test.” Pull your lower eyelid down with your finger. If it snaps right back, you have a positive snap test and may be a candidate for Botox injection. This Botox treatment usually lasts for about three months, but should be used carefully lest there be drooping of the lower eyelid in those cases with a negative snap test.

• As for the patient whose lower eyelid skin has lost its collagen and is thus wrinkling, resurfacing of the lower eyelid works well. These patients have a “criss-crossed” appearance to the wrinkles, often referred to as “crepey skin.” Resurfacing techniques range from light chemical peels to Erbium or Carbon Dioxide laser resurfacing. Typically the peel or laser treatment is done under local or sedation anesthesia. After the laser treatments, a sticky tape dressing is applied for 5 days, after which it is removed, leaving the skin pink but smoother. Chemical peel treatment usually does not involve a dressing, instead allowing the skin to crust over for about a week. The deeper the treatment, the longer the skin will remain pink, but the greater the improvement. This pinkness can be easily camouflaged with makeup. After several months, new collagen begins to form under the skin leading to even greater improvement in the wrinkles. Skin creams such as Retin-A work in the same way by increasing the collagen in the skin. The peels and laser treatments just lead to greater amounts of collagen formation than cream treatment alone.

Which treatment or combination of treatments is best? This should be decided by your plastic surgeon. The lower eyelid skin is thin and delicate and too much treatment can have undesirable consequences!

Should you have further questions, please contact my Encino Plastic Surgery Center at (818) 981-3333.

George Sanders, M.D.