HISTORY: The patient is a (XX)-year-old female who presents for concerns regarding facial aging. She has been losing weight but plans to lose another 20 to 30 pounds. She states that as she gets older and loses more weight, she is noticing volume loss of her midface, specifically under her eyes. She also complains about dark circles under her eyes and hollowing under her eyes. The patient also complains about wrinkling of her under-eye skin. In addition to this, the patient states that her face is getting thinner as she loses weight. She complains also about excess skin of her upper eyelids. She states, however, that her brows have always been a bit on the lower side, and she has been happy with that. The patient gets frequent injections of Botox into her crow’s feet, glabella, and forehead.
PHYSICAL EXAMINATION: Face: The patient has facial aging appropriate for her age. The wrinkles of her forehead, glabella, and crow’s feet are reduced secondary to previous Botox injections. She has moderate brow ptosis, but she has good arching of her eyebrows. There is severe dermatochalasis of the bilateral upper eyelids. There is mild fat herniation of the bilateral lower eyelids with severe hollowing of the infraorbital region. There is discoloration under her eyes, likely secondary to thinning of the skin and transparency of the skin with visible blood vessels underneath. There is wrinkling of the lower eyelid skin as well. There is midface volume loss, which is severe with moderate nasolabial folds. Lips are moderate to mildly full with mild downturned corners of the mouth. There is moderate lower face and neck laxity. Overall skin tone is fair.
RECOMMENDATIONS:
1. Bilateral upper blepharoplasty: We informed her that we could remove some of the excess skin of her upper eyelids to open them up a bit. We emphasized to her that she does have some brow ptosis, which will not be improved by this procedure. We briefly discussed the possibility of an endoscopic browlift; however, the patient states that she is happy with the location of her brows and would be also concerned with elevation of her hairline superiorly with that procedure. For this reason, we are recommending only an upper blepharoplasty. We emphasized to her that if she does have an upper blepharoplasty, this may preclude her and prevent her from being able to have an endoscopic browlift in the future due to the potential risk of lagophthalmos. She has voiced an understanding of this.
2. Facial fat grafting: The fat would be mainly grafted into the midface, infraorbital region, nasolabial folds, and possibly into the lips. I emphasized to her the unpredictable nature of fat grafting and the fact that a portion of the fat that is grafted will not stay long term. We emphasized to her that she will likely be a bit undercorrected postoperatively. She has voiced an understanding of this. We discussed possible touch-up treatments in the future using Voluma or Restylane.
3. Full-face Blue Peel: The patient will need to be started on a pre-peel regimen, including an exfoliating agent and hydroquinone. We informed her that a full-face Blue Peel can help to enhance her skin by improving sun spots, fine lines, and tightening of the skin. We emphasized to her, however, that several peels are typically necessary for optimal results.
