The Blog

Many patients come in to see us every day and want to look better, but not everyone wants surgery. I thought it might be instructive to show a typical case in the office.

Our patient is a woman in her later 40s who has graciously given permission to share her before and after photos. She has had Bell’s palsy years before and is left with some asymmetry of her upper eyelids. She is wondering about a blepharoplasty. I suggested that we analyze her face first. As we age we lose volume in the face. 

The eyebrows start to descend and the cheeks hollow and descend. The “chin down” view   emphasizes the volume loss. Her left eyebrow is a little deflated and the cheeks are hollow.

The oblique view shows the cheek descending from volume loss and the hollowing giving her “bags” of the lower eyelid.

 The smile view  shows excessive activity of the lateral orbicularis muscles – the ones that cause “crows feet” at the corners of the eyes. It is important to focus our treatment where we will see the best effect. Because we look into the eyes when we talk, treatments in and around this area often give the most dramatic effect. She has had botox and fillers before at a “spa” but not from a plastic surgeon.

The botox map  shows a fairly typical dose of botox to the mid forehead (frontalis muscle) and the frown muscles ( corrugator) as well as the base of the nose (procerus). In a case with as much hyperactivity as she has around the eyes I prefer a stronger dose (lateral orbicularis) as shown here.

The filler face sheet shows a small amount of Restylane L diluted and placed to the lateral brow. This can last for two years but needs to be underdone to prevent a “sausage brow” from overcorrection. A syringe of Restylane Lyft was placed to the cheek bones and another syringe was diluted and placed to the “tear trough” area in the anterior cheeks.

She is shown again 2 weeks after her treatment.

The forehead “strain” is gone and appears relaxed. The volume depletion in the midface and cheeks has been restored. The left brow volume now matches the right and does not appear overdone

The chin down view demonstrates the correction of the volume loss. She is still slightly hollow but appears dramatically better.

The oblique view demonstrates the dramatic correction of the volume loss in the brow and cheek which, along with the botox effect gives her a rested and more youthful appearance

The smile view shows the dramatic improvement of the overactive smile lines.

Taken all together, she says this is a “wow” result and I would agree. It shows after a careful diagnosis of the aging deformity combined with subtle correction in a focused way can give a dramatic effect. Our plan for her is to return in 4 months to repeat the botox and to reassess the volume at that time. The volume in the brow and cheek will typically last around 2 years. It is still underdone, and could be “touched up ” with just a little more volume should she desire. She could also consider some volume to the corners of the mouth and along the jaw line to correct the volume loss in these areas. But our focused treatments around the eyes has given her the improvement that she wanted. It is important to do enough treatment in any given area to obtain a result and not spread out the volume too much and risk not seeing an improvement.