The Real Reason You Look So Tired

Dr. DeBusk (00:12):
Welcome back to Behind the Double Doors. I'm Dr. Taylor DeBusk. Today on the podcast, we'll answer all your questions about how to address your tired eyes. So when people look at you and tell you that you look tired or exhausted, most likely what they're talking about is probably the dark circles or some of the changes that they're noticing around your eyes, specifically your lower eyes. And we see this in clinic all the time. People want to talk about a blepharoplasty if they start to notice bags under the eyes or dark circles under the eyes. But what we look at is you have to look at the skin separate from any of the deeper anatomy, like the fat bags that people are usually concerned about. So some of the reasons that we can get skin changes or color changes to the skin below our eyes is the skin of our lower eyelids start to thin as we age, we lose collagen, we lose elastin, and as the skin gets thin, we're actually seeing a reflection of the muscle through the skin, which creates kind of a darker pigment to the lower eyelids in order to address that specifically.

(01:12):
It's not necessarily surgical, but more management of the skin directly. And when we talk about management of the skin, we need to do things that thicken our dermis or the deeper layer of skin, as well as the epidermis of the superficial layer of skin. Now, specifically looking at the dermis, we want to do things either procedurally or really your daily skincare routine that helps to thicken that dermis. So I tell everybody, there's four products that should be the foundation of your daily skin management routine at night. You want to be on a retinoid or prescription strength retinol. What that does is again, helps stimulate the thickness of the dermis. The collagen helps to improve the collagen density in that layer of skin during the day. You want to be just on a regular facial cleanser in the morning. After that, you want to use a vitamin C serum.

(02:08):
And I love vitamin C. There's five really key qualities to it that help improve our skin. One is it's a precursor to collagen, so it's kind of like pouring gas on a fire. It helps us really improve the collagen density. Two, it actually inhibits or stops the breakdown of collagen. It stops the breakdown of elastin. It actually reduces the melanosis or the pigmentation of the skin from too much sun exposure, kind of like those brown and yellow spots that we get. And lastly, it's got antioxidant properties. So again, really helps to reduce or reverse some of those sun damage related changes. And then lastly, the fourth product is going to be just a moisturizer that has SPF in it, so it keeps the skin hydrated and then again protects you from those U-V-A, U-V-B sun rays. Again, this is kind of a long-winded answer to address one of the reasons that we developed those dark circles, but I always talk about maximizing our daily skincare routine in order to improve not only the eyelid skin, but the skin of the entire face.

(03:14):
People always ask what products are the best? And to be honest, you just need to make sure you have the active ingredient in that product. There are a lot of different constituents in different products that may not work well with some people's skin. So I always tell people, you kind of have to find a product that works best for you, but the main thing you need to look at is that active ingredient. So one thing we look at the skin is if you start to develop those fine lines and wrinkles. Now, one way to manage it again is managing the skin directly. And one thing I love is laser treatments or even chemical peels because these will help to resurface that top layer of skin. That epidermis helps to thicken it and tighten it to reduce those fine lines and wrinkles. If you're doing laser treatments, you want to do an ablative laser, like an erbium, which is one of my favorites because the recovery is a little bit easier.

(04:04):
The risk profile is a little bit lower. The caveat is you do have to do two to three treatments to maximize the effects of that. Another great laser is a CO2 laser. Same concept, helps to take off that top layer of skin and thicken it and tighten it. Other things you can do are chemical peels like a TCA peel or things like that. Again, the whole goal is to thicken and tighten that top layer of skin. Now, once we start to develop the tear trough deformity or that hollowness kind of at that lid cheek junction, or you start to notice the fullness of the bags that are starting to puff out. Now, those things aren't really managed well with anything other than surgical intervention. So when we look at patients, what I look at is do you need more volume or do you need to address volume excess?

(04:54):
So patients that have an isolated tear trough and don't really have those bags that are poking out or that fullness, now those patients could be managed with fat grafting. So fat grafting into the cheek, into the ligament area to help create a smooth contour or even conservative filler. Now, patients that have the bags or that fullness, the puffiness in the lower eyelid, now those need to be managed surgically with a lower blepharoplasty. The way I like to manage it is I'm not a big fan of taking fat out. I like to do what we call fat repositioning. Pretty much 99% of my lower eyelid blepharoplasties are through a transconjunctival approach or going behind the eyelid, and that allows me to avoid any incisions or scars on the face. And it has a lower risk profile. And with regards to lower eyelid malposition. Now what I do with those, the fat bags that are visible is instead of removing them, I actually reposition them onto the cheekbone.

(05:55):
And what that does is it helps to soften that crease or that tear trough deformity maintains the volume of the cheek and the eye, and then actually helps to lift the cheek to a small degree. Again, with the whole goal is to create a smooth contour from your lash line down to your cheekbone. So a lot of times when I do lower eyelid blepharoplasty, not only do I reposition your fat of your eye, but actually will fat graft or transfer some fat directly into that ligament area. And it's really kind of icing on the cake. A lot of times I like to take the fat from the thigh or the flank or the abdomen. We process it into really small fat cells and then we inject it into the cheek because you don't want a ton of volume, you just want a small amount of volume to create that smooth contour.

(06:41):
And by really processing that fat, it helps to avoid any irregularities, lumps or bumps and just maximizes our results. So with the upper eyelids, we always see people complaining of some of that extra skin that's really, it can be so aggressive that it's touching the eyelashes, but it's not always just the upper eyelid skin in isolation. Because about 90% of the time when people are ready for an upper eyelid surgery, they would also benefit from a brow reset or lifting that brow. Most oftentimes when people are concerned about the eyelids, they always point to the outer eyelid or that lateral hooding. Most oftentimes, the majority of that hooding is actually from the brow fat pad or the eyebrow itself that has started to fall and created fullness on the outside of the upper eye. Upper eyelid surgery is a little bit more straightforward than lower.

(07:34):
Most oftentimes addressing the upper eyelid, we're just removing the extra skin. Sometimes if patients have fullness, usually by the nose we reduce and remove some of that fat. If the glands which are on the outer portion of the upper eye are prolapsed or creating some fullness, we'll tuck those back up and help to reestablish a more youthful contour. Now, the browse, there's several different ways to address the brows depending on where the heaviness is, if it's toward the inside by the nose or just on the outside. But the two main ways I address brows are either we call a temporal brow lift just to lift the outside of the brow in isolation or do an endoscopic brow lift, which is four small incisions in the hairline. And that helps us to elevate the brow in its entirety with the goal really just to make a three to five millimeter elevation, which is great because not only does it improve the overall aesthetic of the eyes, making the eyes look more open, patients more awake, but it helps to reduce the movement of the forehead muscle.

(08:36):
When our brows are heavy, our forehead muscle compensates for that heaviness and is always has some tone to it, and that's what creates those wrinkles in our forehead. So after a brow lift or a brow reset, patients notice that they have smoother foreheads or they can use more Botox in their forehead than they were able to before because they no longer have that brow heaviness and no longer need their forehead muscle to keep their brows in an ideal position. So age with eyelid surgery is really like any other facial rejuvenation surgery. It really just depends on your anatomy. You have some patients that have genetically heavy upper eyelids are extra skin, so they may need a surgery in their thirties, early forties. Some patients don't really have much laxity of skin even into their sixties and seventies of their upper eyelids, but they've got heavy brows just because of gravitational related changes.

(09:29):
So it really just depends on the anatomy. I've done brow lifts and eyelid blepharoplasties in patients as young as 28. And again, that's not because of gravitational related changes, but more because of their genetics. So filler plays a specific but great role in addressing lower eyelid issues. People that benefit the most from filler are those that really just have a tear trough or a hollow along the bony rim, and they don't have that fullness of those bags that are poking out or creating that puffiness of the lower eyelid. So if you just have a tear trough with no visible bags, those patients really just have a volume deficit over that ligament, and you can inject a small amount or a conservative amount of filler to create a smooth contour. As soon as you start to develop the bags and the eyes, then it's not necessarily a volume deficit issue.

(10:23):
It's you need to redistribute some of the volume that you have. Anytime you inject filler, there's always a risk that you put filler into a vessel. And then if that happens, then you're concerned about skin loss or even blindness, depending on where you're injecting in the face filler in the long, the lower eyelid or the orbital rim can be very safe if you're doing it in the right place and you have a skilled injector. Now, there's different ways to do it. You can do it with a cannula, and the cannula is not sharp, so the risk of it getting into a blood vessel is very low. Or if you're using a needle and you inject directly on top of the bone than the likelihood of you getting into a vessel is also very low. So I would say it is a very safe procedure to have done, but like any procedure, you want a skilled provider who's experienced with it.

(11:16):
All these things really help to reduce or minimize any risk. With lower eyelid surgery, there's no visible scar or visible incision. Everything's under the eyelid, and that's a mucosal surface. Those incisions really heal within a matter of days. So there's no incisions, nothing visible on the face with the upper eyelid. The incision hides beautifully in the natural crease that we all have. So by the time you hit that four week or that two three month mark, those incisions are virtually invisible. Now, with the brow lift, all these incisions are placed in the hair, are right at the edge of the hairline. So again, incisions nobody ever sees. For me, when I see these patients at three, especially at six months, it's extremely difficult to even find these incisions. So if these are placed in the right position, right place, nobody will ever know, even I won't even be able to find these incisions. Eyelid surgery. Like any rejuvenation surgery, the face, what it does is it turns back the clock. We can't stop gravity. We can't stop those age-related changes. But again, we kind of hit a reset when I counsel patients and tell most people that we're looking at probably about a 10 year longevity with these rejuvenation procedures.

Announcer (12:36):
Basu Plastic Surgery is located in Northwest Houston, in the Towne Lake area of Cypress. To learn more about the practice or ask a question, go to basuplasticsurgery.com/podcast. On Instagram, follow Dr. Basu and the team @BasuPlasticSurgery. That's BASU Plastic Surgery. Behind the Double Doors is a production of The Axis, theaxis.io.