Why Do I Look Angry All The Time? (Part 1)

Episode summary

Why might your face look tired or upset when you feel fine? Brow position, forehead lines, excess eyelid skin and the contours around the eyes can all contribute. In part one of this discussion, Darren M. Smith, MD, a board-certified plastic surgeon in New York City, explains why identifying the underlying anatomy matters before choosing treatment.

Originally published August 11, 2020. The recording reflects treatment approaches and practice preferences at that time. Part two addresses the lower face.

Key takeaways

🔎 Resting and movement lines

Lines visible at rest and lines produced by movement are different findings. Dr. Smith explains why they may call for different approaches.

👁️ Brow position

A descended brow can make upper eyelids look heavy. Removing eyelid skin alone may not address the main cause.

👁️ Upper eyelid anatomy

Upper eyelid assessment includes skin, fat and muscle, as well as whether the eyelid itself lifts normally. Eyelid ptosis is distinct from excess skin.

🔎 Under-eye shadows

Under-eye darkness can involve pigment, contour-related shadowing or a combination. The episode discusses why treatment depends on the cause.

📷 Photography and lighting

Before-and-after photographs should have comparable lighting. Small changes in light can make eye-area shadows and contours look very different.

Questions this episode answers

How do a brow lift and an eyelid lift differ?

A brow lift addresses the position and laxity of forehead and brow tissues. Blepharoplasty addresses selected eyelid tissues. Dr. Smith describes examining their relationship because brow descent can contribute to apparent upper eyelid heaviness.

Are dark circles always a pigmentation problem?

No. The recording distinguishes darker skin pigment from shadows produced by the shape of the lower eyelid and surrounding tissues. It discusses options such as adjusting fat or filling a depression when anatomy supports that approach, without presenting one treatment as appropriate for everyone.

What should I look for in eyelid surgery photographs?

Dr. Smith recommends checking whether lighting is comparable, including the reflections visible in the eyes. Images can help illustrate an approach, but cannot predict an individual's result.

🔗 Related information

Read about brow lift surgery, eyelid surgery, and facial fat grafting, or schedule a consultation to discuss the cause of your concern and the risks and limits of possible treatments.

Educational information, not individualized medical advice. Treatment suitability, recovery and results vary. Show notes updated September 30, 2026.

Original show notes

Board certified NYC plastic surgeon Dr. Darren Smith draws on his expertise in facial anatomy to describe how plastic surgery can get your friends to stop asking you what's wrong. In Part 1 we focus on the upper facial third. We'll tackle the lower facial third in Part 2.

[00:08] I'm Board Certified New York City Plastic Surgeon Dr. Darren Smith, and this is Plastic Surgery Before and After. Your source for the real deal about plastic surgery procedures, news about trends in aesthetic medicine, and candid sessions with industry insiders. We hope you enjoy today's episode. Why do I look angry all the time? First, I'm going to assume that it's not because you actually are angry all the time. And if that's not the case, then there are several anatomic reasons why you may look upset when you're actually feeling just fine. We're going to break this answer into two episodes because there are some anatomic features in the upper facial third that can make you look upset.

[00:54] or angry or even tired and then there are features in the lower facial third that can have the same effect. So in this episode we'll deal with reasons why features of your upper face can make you look angry or tired and in the next episode we'll look at how features of your lower face can have this effect. So in terms of the upper facial third, there are two primary structures that can make you look angry or tired. The first is a heavy forehead or brow and the second are heavy upper or lower eyelids. So let's just deal with each of those things separately and look at the relationship between them so that we can really figure out what's going on and the best way to address each of those concerns.

[01:40] So let's work from the top down. So we'll begin with the brow or the forehead. And there are two things that can be going on with the brow or forehead that can give you a tired or angry appearance. The first is extra wrinkling or line formation on the forehead. The other is tissue laxity of the forehead. In terms of the lines or wrinkles on the forehead, there are two kinds of horizontal lines. The first are static lines. Those are the ones that are there when your forehead is at rest. And the other are dynamic lines. Those are the ones that are there when you're moving your forehead, such as when you raise your eyebrows. Those are the horizontal lines that pop up and you can...

[02:26] hear more about the difference between static and dynamic lines in an earlier episode about injectables and Botox. But by way of summary, static lines of the forehead that are present when your brow is at rest can be dealt with things like filler or with resurfacing treatments like laser or chemical peels or radiofrequency microneedling. and dynamic lines that are present when your forehead is moving can be nicely addressed with Botox, which will selectively weaken the muscles under the forehead, the frontalis muscles, that will decrease the severity of the lines that form when that muscle fires. In terms of tissue laxity or lax skin of the forehead that can kind of make your entire upper facial third essentially descend and make your eyebrows and even upper eyelids look droopy or heavy, this is something that is best addressed in many cases with a procedure called a brow lift. And a brow lift is exactly what it sounds like. It's a kind of surgical procedure designed to elevate the position of the soft tissue on the forehead and remove soft tissue laxity in this region. There are several kinds of brow lift that are best for different kinds of forehead laxity and different severities of forehead laxity. The kind of original forehead lift was what is called a coronal brow lift which is done with an incision going across the top of the scalp and this is used to essentially pull up the entire forehead and get rid of extra tissue. This is now considered an older technique and has evolved in many cases into what's called an endoscopic brow lift where tiny incisions are made in the hair-bearing scalp and Tiny camera is introduced into these incisions. That's called an endoscope. And with this visualization, we can anchor the soft tissue of the brow to higher points on the skull, relieving that tissue laxity. We can also do things like weaken the muscles of the forehead that are causing some of those dynamic wrinkles that we were talking about earlier. But even this procedure has kind of become less popular over recent years because a lot of work has been done to show that truly excellent results can be achieved with a less dramatic surgical procedure. And this procedure is called the lateral temporal brow lift, which one of my mentors, Alan Matarasso, has done a lot of work to describe. Involves removing an oval of skin right at the junction of the hair and the forehead skin and using this skin removal to take up laxity in the brow. And this very direct approach provides truly outstanding results that last a long time and doesn't require as much surgical dissection as the endoscopic brow lift and certainly not as much as a coronal brow lift.

[05:44] We mentioned that a heavy upper brow with significant skin laxity can actually weigh down on the upper eyelids and affect their appearance as well. So moving on to discuss this structure, the upper eyelid, it's important to have a thorough exam by an expert in aesthetic surgery of the face. to determine what the actual anatomic causes are for the tired or angry appearance that you may be experiencing. And there are very specific exam maneuvers that we perform to see if the problem is a heavy or sagging brow or if it's an issue with skin laxity or skin excess in the upper eyelids themselves. So having just discussed what we can do about skin excess of the forehead, Let's move into what we can do to address heavy, tired, or angry looking upper eyelids. And to do this, we will take a problem-based approach, which is something that I really like to do when we're discussing different procedures in plastic surgery.

[06:42] And if the issue with the upper eyelids is that there is extra skin, this is a fairly straightforward thing to deal with with a procedure called an upper blepharoplasty or an upper eyelid lift. And this involves removing a ellipse of skin on the upper eyelids in such a way that we remove the skin excess and manage to hide the scar right in the fold of the upper eyelids. So it's virtually invisible when the procedure is over. On the other hand, if there is fatty excess in the upper eyelids, we'll incorporate some fat removal into our upper blepharoplasty procedure. And similarly, if it seems like there is hypertrophied or extra voluminous muscle, we may excise some muscle as part of that upper blepharoplasty procedure. And really, In all of these cases, we can do this with a scar that's virtually invisible by virtue of the fact that we're hiding it in the eyelid crease. So when your eyes are open, it really literally is invisible, and when your eyes are closed, it tends to fall right into the nice line of pigment a lot of people have in their eyelid folds. So it works out that the scar is extremely hard to see after upper eyelid surgery.

[07:56] It's also important as part of an exam of the upper eyelids to see if the upper eyelid is functioning properly. That is, is the eyelid itself hanging? So maybe there is not an issue with too much muscle or too much skin or fatty excess, but perhaps there's actually something called ptosis of the upper eyelid. And ptosis of the upper eyelid occurs when for one reason or another, the muscles that elevate the upper eyelid aren't doing so sufficiently. And this can actually cause a blockage of the visual field, and this demands a very specialized approach to correct the anatomy and position of the muscles of the upper eyelid to let them do their job again and properly elevate the upper eyelid.

[08:40] And this actually addresses one of the most common questions about upper eyelid surgery, which is that will insurance pay for eyelid surgery? And in the case of ptosis, if you can go to an eye doctor and have a documented deficit or decrease in your visual field, in a lot of cases, your insurance will actually cover upper blepharoplasty surgery or ptosis repair to restore your visual field to what it should naturally be. Problems with the lower eyelid in a lot of ways are analogous to problems with the upper eyelid. Namely, we look at issues dealing with the skin, fat, and muscle of the region and in assessing the structures can determine what maneuvers are necessary to correct problems that may be contributing to a tired or angry or aged appearance.

[09:36] And just like with upper eyelid surgery, if there is skin excess of the lower eyelids, this is something that we would remove and most Frequent way that we do this is with what's called a subciliary incision. This is a very fine incision that is made immediately underneath the eyelashes on the lower eyelids. So this incision and resulting scar is hidden by these fine hairs and does usually work out to be more or less extremely difficult to see. Alternatively, if there is muscle heaviness in the region, or muscle laxity. Sometimes this muscle laxity is dealt with by suspending the lower eyelid from adjacent structures to provide improved tension on the lower eyelid. If there is fatty excess in the lower eyelid, and this can sometimes present as bags of the lower eyelid. This also can be removed in a fairly straightforward procedure. And this can be done, depending on the case, by what's called a transconjunctival approach, which means the incision is actually made on the inside of the lower eyelid so that there is absolutely no visible scarring after the procedure.

[10:53] On the other hand, if we're removing extra skin or suspending muscle at the same time, we'll often use that same subciliary incision to remove the fatty excess that we were discussing earlier. Another very common complaint about the appearance of the lower eyelids and the surrounding region are dark circles under the eyes, and I'd refer you to a blog post that we have on this topic, but to briefly summarize here, the dark circles under the eyes can be caused by any number of factors, but they can essentially be broken down into structural issues or pigment issues. And there are some people that do have dark pigmentation in the lower eyelid region, and this can be dealt with with a number of topical approaches, ranging from different skin creams to light-based therapies and other modalities as well.

[11:44] But we often find that a large part of the issue has to do with the structure of the lower eyelid region such that shadows fall in the area and cause the appearance of dark circles. And these shadows can be dramatically reduced by decreasing the depth of the valley under the eyelid. And this can be done either by reducing the fatty excess in the region like we just described as part of a lower blepharoplasty, or alternatively, depending on the anatomy, actually filling in the depression in the area. And this can be done very nicely with fat grafting. You can hear more about this in a recent episode, or in some cases we'll use filler to handle this issue, which is often frequently referred to as a tear trough deformity. There are a couple reasons why I really like fat to deal with tear trough deformity. And the first is that it's all natural and it is more or less permanent. Once we harvest a little bit of fat through liposuction and graft it into the region, about 60% on average of the fat that we place there will stay there forever. So it's a really nice natural permanent fix sometimes it will take more than one round of fat grafting to get the desired result because again Not all the fat that we put there will stay there So we'll often take a stepwise approach to kind of get a nice gradual natural result. The other thing that's great about fat grafting for dealing with tear trough deformity is that there are active stem cells in fat grafts and these adipose derived stem cells or these fat cell derived stem cells actually have growth factors in them that will improve the overlying skin quality and address any pigmentation issues that may be present that are contributing to the appearance of dark circles under the eyes.

[13:42] There is one fairly new treatment that does a very nice job in handling mild to moderate skin laxity issues of the brow, the upper eyelid, and even the lower eyelid. And that is radio frequency skin tightening with the Accutite device. And this is also something we've discussed in an earlier episode. But essentially, this is a device that requires no more of an incision than you would get by making a puncture with an 18 gauge needle, which is very small, about one to two millimeters. And we pass one end of the device into this incision. And the other portion of the device follows above the internal portion of the device. And radio frequency energy is fired across the skin from the portion of the device that's internal to the portion of the device that's external. And that heats the skin, which causes a tightening of loose skin with the production of collagen and elastin. So for folks that don't quite need full-blown excisional surgery for the upper eyelid, the lower eyelid, or the brow, radiofrequency-based procedures with the Acutite device may be a good option. So now I'd just like to address some common questions about eyelid surgery.

[14:59] The first is, is eyelid surgery safe? And the answer is that when eyelid surgery is performed by an expert, such as a board certified plastic surgeon or a board certified oculoplastic surgeon, these are very safe procedures. But like any surgery, they do have certain inherent risks. And it's a good idea to discuss your individual case with a surgeon of your choice so that you can come up with a good understanding of the risk benefit ratio in your specific situation. Another thing we frequently are asked is, is eyelid surgery painful? And this is a very reasonable question because the eyes are certainly a very sensitive area of the body. But the good news is that it is fairly straightforward to effectively anesthetize or make numb the tissue around the eye and eyelid region so that some of these procedures, particularly those involving simple skin excision of the upper eyelid, can be performed under straight local anesthesia without your having to be sedated or asleep at all. And of course, if you do decide to have some form of sedation or general anesthesia, you really won't feel anything. And we'll close out the episode with one piece of advice when you're looking at blepharoplasty before and after pictures.

[16:21] especially in the age of Photoshop and social media when we're having all kinds of practitioners posting results, it's very important to make sure the lighting conditions are the same in the before and after pictures because subtle differences in lighting can cause a dramatic difference in the appearance of these results. So a good way to do this is to concentrate on the pupils and look for how light is reflecting in the before and after picture and make sure that it's the same in both of those images. And I'd refer you to one of our blog posts. There are actually two blog posts that we have on this topic.

[16:53] looking at fake before and after pictures and how to identify them. So this concludes the first part in our two episode discussion of the question, why do I look angry all the time? And we're looking forward to your joining us for the next part where we'll explore how features of the lower facial third can make us look tired or angry and see what we can do about that as well. Thanks for listening and don't forget to subscribe, share the show, and head over to garonsmithmd.com for more real world plastic surgery talk.

Original Captivate episode. Original release date: 2020-08-11. The recording is the source for the transcript and episode discussion. Later context in the written summary is identified separately.

• brow lift surgery
• eyelid surgery
• facial fat grafting
• schedule a consultation
• Related episode: Why Do I Look Angry All The Time? (Part 2)
• Related episode: How Can I Get Rid of Loose Neck Skin Without Surgery?
• Dr. Smith’s background and training