Would you recommend Botox, Juvederm, or both for eye area?

Dr. Dean Kane Q & A.

Q. I was initially considering Botox for my crow's feet but now I'm thinking that Juvederm may be a better option for the under eye area. Or should I consider both - Botox for the crow's feet and Juvederm for the under eye area? What would you suggest and how much do you think would be needed?

A.  ​​​​While:

1. Botox for dynamic lines (such as the crows feet), and
2. ​Fillers for folds (such as tear troughs)

is not 100% true, it is a guideline.
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​Dynamic lines are those created by active underlying muscles such as those around the eyes. Botox is great for crows feet relaxation but will not fully erase the etched dermal skin lines and a fine filler such as Silk works well synergistically with Botox at this site.

​Botox for the lines along the lower lid should be used very judiciously. Relaxing these muscles will soften the lines but eventually weaken the lower lid tone, "rounding" the eyelid.

​Separation of the soft tissues and muscles between the cheek and eyelid creates the tear trough. This passive process will not be helped with a muscle relaxer (and may worsen it) but must be filled. Depending on the skill of the injector, different layers of the tissues will fill out the depression of the fold. I have used and recommend deep tear trough filler using Voluma, Perlane or Juvederm Ultra Plus. More superficially, consider Restylane or Juvederm Ultra. Silk that may migrate onto the lower lid skin may create too much swelling and if used must be injected very sparingly.
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​With so many choices, it is best to consult with a well experienced, Board Certified Plastic Surgeon, Facial ENT Surgeon, OculoPlastics Eye Surgeon or Dermatologist.
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​I hope this has helped. All the best!

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This is my first time using Botox. Is this normal?

Dr. Dean Kane Q & A.

Q.  I just had Botox for the first time. I am 37 with minimal wrinkles. I wanted to try Botox in the "crows feet" area and asked if it would help with slight wrinkling under my eyes when I smile. Injector asked me to smile, made a couple of marks and injected me 3x below each eye (25 units) and said "you're done". She didn't inject anywhere near the "crows feet" area and I'm wondering if my injection site is normal?
A. Botox is a muscle relaxer which when injected properly will help many but not all active (directly created by a muscle) lines and creases.
​Crows feet are the radiating lines created by the thin, circular muscle (called the orbicularis oculi) under the skin surrounding the upper and lower eyelids, upper nose, brow, lateral orbit and onto the upper cheek. Since this muscle attaches to the inner corner of the eye next to the nose (called the inner canthus), it contracts and:

1. Closes the eye,
2. Pulls the brow inward and downward,
3. ​Creates lines radiating from the inner canthus onto the nose,
4. ​Creates lines radiating from the outer eye called crows feet
5. Will lift the upper cheek

When properly injected along the outer radiating lines, Botox will relax the downward pull of the outer brow allowing it to raise and soften the crows feet.
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​If placed under the 4:00 position of the left eye, or 8:00 position of the right eye, side-effects due to relaxation of the orbicularis and other muscles in this area include:

1. Creation of swelling and fat bags
2. Rounding of the lower eyelid margin
3. ​Loss of ability to drain tears
4. Passive lowering of the upper cheek
5. ​Possible drop in the upper lip

Botox or like muscle relaxers are science and art.
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​It is best to discuss your concerns with your injector. You may also consider a second opinion from a well experienced, Board Certified Plastic Surgeon, ENT Facial Surgeon, Dermatologist or Ophthalmologist.
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​I hope this was helpful.
All the best!

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My smile has completely changed after Botox on forehead, frown lines, crows feet, & under eyes. Any suggestions?

Dr. Dean Kane Q & A.

Q.  My top lip doesn't lift enough. When smiling with lips together it looks normal but when smiling or laughing with lips apart my top lip isn't lifting so looks like half a smile. My injectant didn't inject low down on crows feet but could it still have an effect on my smile muscles?

A.  Botox is a miraculous drug when used correctly. It is extremely artful and injector dependent on his or her skills.

Thank you for sharing your photos. When Botox or any of the muscle relaxer injectibles is not specifically targeted, adjacent muscles may be affected causing relaxation and therefore an imbalance on facial appearance. It appears that the muscles of your eyelids, your right lower lip and your cheeks received a dose of Botox during your injection session causing your eyelids and upper lip to drop and your right lower lip to raise.

The good news is that if minor amounts of Botox reached these muscles, the waiting time for the muscles to return to normal function is shorter than the average 3 months. It will also return to full function.

You may consider discussing the eyelid droop with an ophthalmologist as there is a eye drop than can help if seeing is a problem. You may also consider widening the area of placing your lipstick to camouflage the reduction in lip opening.

If you have concerns with your injector, consider another opinion by a well experienced, Board Certified Plastic Surgeon or ENT Facial Surgery injector to review these problems.

I wish you the best!

I'd like to improve my eye area upper and lower. Would fillers and/or Botox would be a good combination?

Dr. Dean Kane Q & A

Q.  I'd like to improve the look of my eyes without a large expense. I'd like to get rid of the bags and wrinkles under my eyes, the crows feet and my frown lines.

A.  ​I will answer your request in a very comprehensive way. As you point out, cost and maybe recovery time are an issue and this may determine your satisfaction for the goals you set and expectations you have.
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​Thanks for sharing you photo. This is helpful but you will need a in-person consultation to examine you and review your options.

Various options for facelifting, minimally and non-invasive facial enhancements and skin texture improvements are available according to the skin laxity and areas of lift or tightening you wish or need. Both surgical and minimally invasive / non-surgical options are listed below.

Surgical lifts would be likened to pulling the bedspread and or top-sheet of your bed up to the head-board and removing the excess material.

Minimally invasive procedures such as fillers provide volume such as adjusting a pillow under the bedspread. Botox and Dysport act by pulling the top-sheet which drags the bedspread upwardly. If the bedspread (or skin) continues to fall to the foot of the bed despite fillers, Botox or Dysport you will need to consider a facelift.

Non-invasive options such as laser and light therapies, skin tightening products and technologies perform their tightening and smoothening of the skin similar to sending your bedspread to the dry cleaners. A more refreshed, even colored, glowing smoother and tighter spread covers the surface of the bed.

The most popular of the fillers, Restylane and Perlane, a jelly-like clear skin filler is used to fill lines, wrinkles and folds. Juvederm and its longer lasting "cousin" Juvederm Ultra Plus are similar skin fillers, used to soften and fill the nasolabial ("parentheses") and marionette folds, the brow ("number 11") lines and fill and lift the cheeks and lateral brow or chin. Voluma is the longest lasting, up to 2 year duration HA filler. Each one is used to expand or volumize the loss of tissue associated with expression, weathering or aging. All the fillers come with numbing anesthetic!.

Non-surgical facial contouring is possible with fillers such as Radiesse, a bone mineral for the nose or cheeks, jaw and chin as well.

Scuptra is the latest of the injectibles stimulating collagen at different levels of the skin adding volume but primarily firming and adding resistance to the formation of wrinkles, folds and descent.

Botox and Dysport too have been found to rebalance excessive facial expression, provide a non-surgical brow lift and lip lift and reshape the nose, as well as reducing wrinkles!

Your photo does show significant dry skin, loss of elasticity, folds and wrinkles.

Dr. Obagi's new, second generation ZO Skin Health programs may be added to personalized chemical peels, light and laser resurfacing and tightening and will, smoothen and even the color of your skin. It is the basis for all skin rejuvenation in our practice.

IPL and fractionated lasers such as CO2 and erbium and now RF (radiofrequency) are additions to smooth the texture of the skin, tighten and reduce red and brown uneven pigmentation.

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​If you can pinch more than an inch of skin along the jawline in front of your earlobe, you should consider a surgical option to redrape and remove extra skin.

​You may consider: a traditional face and neck lift, short scar face and / or neck lift.

The recent resurgence of the S-Lift (created in the early 1900's), also called by other names as the Quick-Lift, Lifestyle-Lift, Swift-Lift, Soft-Lift, MACS-Lift and others; are a single modification of the S-lift targeted to elevate sagging lower cheeks jowls and lateral upper neck. The shorter scar, limited undermining and second layer lift achieve the "quicker" procedure but not necessarily the quicker recovery or the improvement you desire.

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​Face lift and / or neck lift or any of the other procedures and their combinations should be discussed following a proper examination by a Board Certified Plastic Surgeon who performs all of these options so you will not receive a biased approach because he or she is limited in their skills.

I hope this was helpful!