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Blepharoplasty Lady

PST 022: Targeting Fine Lines on the Eyes, Mouth, and Forehead — Read the Transcript

August 27, 2018

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Hello and welcome. Dr. Stephen Mulholland here at SpaMedica in Toronto, Canada, with Plastic Surgery Talk. Welcome to another installment of our very popular podcast series. This one is on the sub-identity and treatment of various facial wrinkles. Delineating their cause, their treatment, and their ongoing maintenance and prevention.

One of the most common wrinkles we see are eye wrinkles. Eye wrinkles, eye lines, aging eyes. Where do we get them? We get them usually on the sides of the eye called crow’s feet. We get them under the eye, those Cobblestone wrinkles that happen under the eye. Sometimes, we even get them above the eye in the upper eyelid, horizontally. These are annoying and vexing wrinkles. They can also provide character.
For many men to eliminate completely the crow’s feet is not the goal but to soften them. They give you a weathered but an engaging, happy face. So we don’t want to eliminate lines and all areas the face want to soften. So what’s the first step for under eye wrinkles? Is Botox Injectable. Small amounts of Botox Injectable to treat the muscle around the eye called the orbicularis oculi. By softening, you can really soften the lines. The second step if that isn’t enough is using soft tissue fillers. Special small fine fillers, the sugar gels, hyaluronic acid sugar gels like Juvederm, Belotero, Juvederm Volbella, Restylane. These are just some of the products you can use under the eyes to help plump up fine lines.

But some of the most effective treatments for under eye fine lines are lasers. Here’s where lasers can eliminate virtually every line. Various fractional carbon dioxide lasers, fractional erbium lasers, fractional YSGG lasers, fractional radiofrequency ablative devices. Can all almost eliminate and tighten the Cobblestone-looking, crepe-y, lose lower lid wrinkled skin. So by those three things, the dermal fillers, Botox Injectable, and fractional lasers, we can eliminate almost all the lines from the under eye and have them looking smooth and youthful again.

Of course, there are some surgical options. A blepharoplasty or a lower blepharoplasty is a small incision under the eye where we remove some skin, physically remove. Like a facelift of the lower eyelid. Remove some skin through a fine well-concealed line under the eyelash line. But that’s generally a little more aggressive and some patients want to start with the non-surgical options we talked about. Fractional lasers, fractional radiofrequency devices. Basically, fractional thermal simulation of the line and wrinkle, Botox Injectable, and filler. That’s the place to start.

When do these eye wrinkles appear? Generally, it depends upon your genetic code, the thickness of your skin, how much animation, about sun damage, smoking, weight loss, weight gain. But on average, around the eye wrinkle start to become a problem, a concern on or about the age of 40. Whereas frown or forehead lines can happen in the 30s. The eyes start to get wrinkly a little older, a little aged around age 40. The early treatment, again Botox Injectable and dermal fillers to soften animation of the orbicularis oculi to plump up the fine lines. As those wrinkles advance, fractional laser resurfacing using lasers or radiofrequency devices to selectively burn away the lower lid wrinkles.

Some of the older techniques like chemical peels of the lower lid and non-fractional lasers are not used as much anymore because they’re not as accurate or precise. But some thermal or chemical denaturization of the collagen ,you stick to thermal stimulation and fractional laser, and it can give you a tremendous improvement in lower lid lines and wrinkles, together with Botox Injectable and filler to protect your investment.

By far, the most common wrinkle complex we treat as cosmetic plastic surgeons, dermatologists, facial plastic surgeons are forehead lines and wrinkles. Two directions of forehead lines and wrinkles depending on the muscle anatomy under them. Number one are the number 11s, the up and down verticals between the eyebrow. Number two, horizontal lines along the forehead itself. What causes the horizontal fore lines? Something called the frontalis muscle, the lifting up muscles. As it lifts up, it crinkles. The causes of the number 11s, horizontal contractions, which is called the corrugator muscle mass. So frontalis and corrugator, the two culprits for those lines. How do we treat them? Botox Injectable.

Botox Injectable is wonderful, it’s been made for the brow. It can keep your brow smooth and youthful for the rest of your life. So Botox Injectable, just enough to soften the line but generally not enough to remove all animation. You want to look serene and wrinkle reduced but not un-animated like some 1990s, Conan O’Brien character, where all that moves is the mouth. We want to have some animation but we want to soften those lines and wrinkles. With men, we want to be a little more assertive because they get very deep lines. Women, leave a little movement, elevate the tail of the brow a bit.

So the brow and the frown lines of the forehead and the worry lines are the most common things that we use Botox Injectable to treat. Forehead lines both horizontal worry lines, frontalis lines and corrugator vertical lines or the number 11s, commonly appear in your 30s. You start to see faint evidence of their presence especially if you’re extremely expressive. Therefore, if you want to start treating and eliminating, you start the age of onset, which should be in your 30s. So not uncommon to start with very, very small amounts of Botox Injectable in your 30s to prevent the formation of the very forehead lines that you just don’t want to form.

Some of the most annoying lines and wrinkles because they age you dramatically are the perioral lines or the lip lines or the smoker lines or the barcodes. Many different names for these vertical lines that descent from the base of the nose, down to the upper lip. There’s also lines and furrows that form at the corner of the mouth. I call it the sad mouth lines or the marionette lines. Those vertical lines of the lower lip. Then the ones from a smile, when you smile the lines that form around the cheek. As you get older and you lose some of your soft tissue volume and substance when you stop smiling, they’re still there.

Then there’s the deeper folds, the furrows above the mouth called the smile lines or nasolabial folds. When do you start to see these perioral around the mouth lines? Well, with smile lines, it can develop quite early if you have a hereditary predisposition. In fact, have smile line is natural and normal. Many nine, 10-year-olds have smile lines, they still look pretty youthful. So you don’t necessarily age because you have a smile line, we just don’t want to see a very deep furrow as the smile line. They’ll often form in your 20s and start to look a little deeper maybe in your 30s.

Smoker lines if you happen to be a smoker, extremely expressive or you have a very strong projected dental arch, you can start to get these little the vertical animation lines. Generally in your 30s, early 40s. The downgoing mouth part are the marionette line and the horizontal, they’re a little parenthesis lines are on the corners of your mouth. They usually start in your mid to late 40s. So smile lines, late 20s, early 30s. Smoker lip lines, late 30s, early 40s. Marionette lines and permanent smile, parenthesis smile lines, usually in your mid to late 40s.

What are the treatments? Well, think of the cause. If you’ve got excessive animation, you can certainly use Botox Injectable to decrease that really corrugator effect of your orbicularis oris. That’s the name of the muscle, the orbicularis oris. Just like your forehead, we can use some Botox Injectable to really soften that. But in fact, it becomes so un-animated that you end up talking like this and you have no lip competency. So we can’t lose all the expression around our mouths. So Botox Injectable, you have to drop back and be very cautious around your mouth because although it works, you’ll have no movement. So a little bit of Botox Injectable and here’s where we use a lot of filler. Not to create a ducky lip like Goldie Hawn in First Wives Club but to soften the animated lines and wrinkles from the bottom-up of the rare lip, the wide row and the wide lip using dermal fillers.

Here’s a great area like the lower lid for fractional CO2 ablative lasers, fractional ablative radio frequency devices to virtually reduce 85% of all lines and wrinkles through new collagen production up the upper lip and the perioral areas. So a combination of dermal fillers, Botox Injectable, and aggressive fractional ablative devices can significantly reduce that perioral wrinkly look.

So thank you again for joining me, Dr. Stephen Mulholland here, Plastic Surgery Talk and our latest podcast installment on the specific anatomy and treatment of various facial wrinkle complexes. The brow, the perioral and periocular areas. I hope you found this interesting, informative, and entertaining. If you did, please share this on all your social media channels and we’ll look forward to seeing you at our next podcast soon.

Dr. Stephen Mulholland, MD
Posted by Dr. Stephen Mulholland, MD
has been practicing plastic surgery for over 20 years. He is one of Canada’s most renowned and best plastic surgeons in Toronto with his wealth of experience, artistry, and humbleness towards his patients.

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