T he eyes have been described as a window to the soul, and we use them to convey a wide range of emotions. Often, a person’s eyes are the first feature you notice when meeting someone new. Since our eyes are so essential to our overall appearance, it’s not surprising that rejuvenation of the periorbital area is so often requested. Here, we’ll detail strategies for changes of the periorbital area early in the aging process — for patients in their third and fourth decades of life. Aging of the Periorbital Area Redundancy of the skin of the upper eyelids often starts to manifest in the third decade. Early changes are characterized by loss of crisp definition of the palpebral lines. In time, the skin progressively sags and comes to rest on the eyelashes by the time patients reach their 60s and 70s. By the fourth decade, lateral canthal rhytids and accentuation of the lower eyelid folds are apparent at rest. These changes usually develop earlier and progress more rapidly than herniation of fat pads noted in the lower eyelids. The cumulative effect is a very tired, hooded appearance. Typically, only mild periorbital fullness, redundancy of the upper eyelids, and rhytids are apparent in patients in their third and fourth decades. Fortunately, we have a variety of treatment options for rejuvenation of the periorbital area for patients in this group, such as resurfacing, blepharoplasty and permanent eyeliner. With the recent FDA-approval of botulinum A toxin (Botox) for glabellar lines, popularity of this procedure has escalated. While Botox certainly has its place in periorbital rhytids as well, we’ll discuss this treatment option in a future article. Here, we’ll discuss treatment options and post-operative maintenance. Resurfacing Options Resurfacing of the periorbital area is often the first intervention of choice. Options for resurfacing include a superficial- to medium-depth chemical peel, erbium:yttrium-aluminum-garnet (Er:YAG) laser, or the carbon dioxide (CO2) laser. Resurfacing may improve fine- to medium-depth rhytids, as well as improve the photodamage that’s commonly present. • Chemical Peels. A common regimen for chemical peeling is trichloroacetic acid (TCA) 35% to 50% for the periorbital areas, depending on the extent of photodamage and depth of rhytids. When opting for this treatment, first thoroughly degrease and dry the area you’ll treat and have a rinsing agent readily available for the procedure. Use a cotton-tipped applicator to evenly apply the acid to the periorbital area, feathering to the orbital rim. An even frosting of the skin typically occurs in a short time and marks the completion of the peel. The white frost will evolve to erythema in a matter of hours and typically turn to a brown as the epidermis is shed in the days to follow. A heavy petrolatum ointment should be applied frequently for the post-operative period. Good reviews of various peeling formulations and techniques are available.1 Caution must be taken with the higher concentration TCA to avoid peeling the skin too deeply. It’s also imperative to guard against the wicking effect of the TCA to make sure it isn’t drawn into the conjunctiva. While peeling agents have been used therapeutically for more than a century, our experience is that newer laser technology has relegated chemical peeling to a second-line option. • Laser Resurfacing. The Er:YAG may be used if only very mild changes are evident. However, our preferred approach is the ultrapulsed CO2 laser at settings of 200 mJ to 300 mJ, 50 Watts, and a density of 5 with a computer generator pattern. You’ll need to treat patients with some form of sedation, either in the form of oral or conscious sedation. Use protective eyewear, and provide eye shields for the patient. Perform resurfacing from the eyelid margins to the eyebrows superiorly, the orbital rim inferiorly and laterally, and to the nasal sidewall medially. The peripheral margins should be feathered at a lower setting of 200 mJ to 250 mJ to blend into the surrounding skin and prevent a prominent line of demarcation between treated and non-treated skin. Post-operative care is similar to that described for chemical peeling. Lasers provide more control and reproducibility for resurfacing. The contractile effect2 produced with the CO2 laser makes it useful for greater amounts of excess skin or fullness and can even delay the need for an upper-lid blepharoplasty in many patients. Also, it has the added benefit of coagulating superficial capillaries at the time of vaporization, whereas the Er:YAG usually causes pinpoint bleeding. While the risk of scarring is less with the ultrapulsed CO2 laser compared to older modalities, there are still potential complications. The spectrum of adverse sequelae range from mild (prolonged erythema, milia) to moderate (transient to permanent dyspigmentation, local infection) to severe (hypertrophic scarring, ectropion, systemic infection).3 Resurfacing Maintenance Once successful resurfacing has been accomplished and recuperation is complete, a variety of maintenance options are available. Sun precautions are of paramount importance in the prevention of the signs of aging. Microdermabrasion performed at periodic intervals is a good means of minimizing rhytids and providing the skin with improved texture and tautness. Routine use of a topical retinoid combined with a choice from many cosmeceuticals (including rejuvenators with vitamins A, C, and/or E, plant growth factors including N6-furfuryladenine (Kinerase), alpha and/or beta hydroxy acids, coenzymes, etc.) are often useful and pleasing to patients. Treating Blepharochalasis If a patient has significant blepharochalasis, blepharoplasty of the upper lids may be indicated. Prior to blepharoplasty, evaluation and approval from an ophthalmologist is imperative. Once you have a thorough understanding of this area, with the patient in an upright sitting position, mark a point in the mid pupillary line in the supratarsal fold, typically 8 mm to 10 mm above the lid margin. Place similar markings along the supratarsal fold above the upper eyelid punctum and the lateral canthus. Next, draw a line curving along the reference marks. The line should then be extended laterally into a rhytid at an approximate 45-degree angle. Prep and drape the patient in a sterile surgical fashion, and anesthetize the area to be treated with local anesthetic. Use a scalpel to score the marked line and blepharoplasty scissors to dissect along the line to the level of the orbicularis muscle. The blepharoplasty scissors are used to dissect the orbicularis muscle free from the underside of the skin flap. We find it useful to pull the redundant skin of the upper lid down and then bifurcate in multiple points in order to determine the correct amount of excess skin to excise. The correct amount is that which will still allow the lids to close without scleral showing. The bifurcations may then be connected to complete the excision. If excess orbicularis muscle is present, excise a 1-mm to 3-mm strip just below the previously made wound margin exposing the orbital septum and levator aponeurosis. The excess adipose deposits may then either be resected or desiccated. Take exact measurements of the excised skin ellipse as well as the position of the surgical margins relative to the eyelid margin. These must be reproduced exactly on the opposite side to produce symmetry. Intraoperatively, two fat pads are identified and removed in the upper lid, a small medial and larger central fat pad. Give special care to protect the lacrimal gland, normally located in the lateral upper canthus. Medial relocation of this gland may occur due to adipose deposition. Hemostasis must be achieved prior to closure with a few interrupted tacking sutures and steristrips. Post-operatively, apply ice packs. We’ve recently published an overview of various approaches for the upper lid blepharoplasty.4 Post-operative complications may range from minor (corneal irritation, milia, contact dermatitis, chemosis, loss of eyelashes, hematoma, etc.) to severe (penetration of the globe, lacrimal gland injury, lagophthalmos, overresection of fat, ptosis, etc.). Permanent Make-Up We get many requests from younger patients for permanent eyeliner, a purely cosmetic procedure. We recommended that you have patients come for pre-operative consultation with eyeliner in the desired position and that you take photos for documentation. To give a patient permanent eyeliner, prep and drape the eyelid margins in a sterile fashion and use a 0.25% dilute lidocaine to thoroughly tumesce the lid margins. Using a handheld tattooing needle, dip the wand into the pigment and cautiously move along the area to be accented in small increments. Adequate skin turgor is imperative for successful penetration of the skin by the tattooing needle. The rapid repeated penetration of the tattooing needle into the tumesced skin is apparent. Perform several overlapping passes along the planned path until the desired density is achieved. For the upper lid, start near the medial limbus and extend the line to be even with the lateral canthus. Often, patients desire a small lateral flare. For the lower lid, begin in the same position medially but do not extend to connect with the upper lid line. Joining these two lines tends to produce an undesirable tapered or narrowed look to the lateral eye. It’s much easier to place additional pigment for a longer or thicker line than it is to remove the pigment once placed. Use dark tattoo inks such as black or dark brown. Lighter, blended colors have a tendency to fade over time. Post-operatively, use ice packs and topical ophthalmic antibiotic ointment. Enhancing Aesthetic Appeal Periorbital rejuvenation is an important aspect for enhancing aesthetic appeal. Early changes of aging often first manifest in this area, making intervention desirable to patients in their thirties and forties. Fortunately, we have a number of safe and effective treatment options to offer our patients.
Periorbital Rejuvenation for Early Signs of Aging:Exploring Aesthetic Interventions, Part 2
T he eyes have been described as a window to the soul, and we use them to convey a wide range of emotions. Often, a person’s eyes are the first feature you notice when meeting someone new. Since our eyes are so essential to our overall appearance, it’s not surprising that rejuvenation of the periorbital area is so often requested. Here, we’ll detail strategies for changes of the periorbital area early in the aging process — for patients in their third and fourth decades of life. Aging of the Periorbital Area Redundancy of the skin of the upper eyelids often starts to manifest in the third decade. Early changes are characterized by loss of crisp definition of the palpebral lines. In time, the skin progressively sags and comes to rest on the eyelashes by the time patients reach their 60s and 70s. By the fourth decade, lateral canthal rhytids and accentuation of the lower eyelid folds are apparent at rest. These changes usually develop earlier and progress more rapidly than herniation of fat pads noted in the lower eyelids. The cumulative effect is a very tired, hooded appearance. Typically, only mild periorbital fullness, redundancy of the upper eyelids, and rhytids are apparent in patients in their third and fourth decades. Fortunately, we have a variety of treatment options for rejuvenation of the periorbital area for patients in this group, such as resurfacing, blepharoplasty and permanent eyeliner. With the recent FDA-approval of botulinum A toxin (Botox) for glabellar lines, popularity of this procedure has escalated. While Botox certainly has its place in periorbital rhytids as well, we’ll discuss this treatment option in a future article. Here, we’ll discuss treatment options and post-operative maintenance. Resurfacing Options Resurfacing of the periorbital area is often the first intervention of choice. Options for resurfacing include a superficial- to medium-depth chemical peel, erbium:yttrium-aluminum-garnet (Er:YAG) laser, or the carbon dioxide (CO2) laser. Resurfacing may improve fine- to medium-depth rhytids, as well as improve the photodamage that’s commonly present. • Chemical Peels. A common regimen for chemical peeling is trichloroacetic acid (TCA) 35% to 50% for the periorbital areas, depending on the extent of photodamage and depth of rhytids. When opting for this treatment, first thoroughly degrease and dry the area you’ll treat and have a rinsing agent readily available for the procedure. Use a cotton-tipped applicator to evenly apply the acid to the periorbital area, feathering to the orbital rim. An even frosting of the skin typically occurs in a short time and marks the completion of the peel. The white frost will evolve to erythema in a matter of hours and typically turn to a brown as the epidermis is shed in the days to follow. A heavy petrolatum ointment should be applied frequently for the post-operative period. Good reviews of various peeling formulations and techniques are available.1 Caution must be taken with the higher concentration TCA to avoid peeling the skin too deeply. It’s also imperative to guard against the wicking effect of the TCA to make sure it isn’t drawn into the conjunctiva. While peeling agents have been used therapeutically for more than a century, our experience is that newer laser technology has relegated chemical peeling to a second-line option. • Laser Resurfacing. The Er:YAG may be used if only very mild changes are evident. However, our preferred approach is the ultrapulsed CO2 laser at settings of 200 mJ to 300 mJ, 50 Watts, and a density of 5 with a computer generator pattern. You’ll need to treat patients with some form of sedation, either in the form of oral or conscious sedation. Use protective eyewear, and provide eye shields for the patient. Perform resurfacing from the eyelid margins to the eyebrows superiorly, the orbital rim inferiorly and laterally, and to the nasal sidewall medially. The peripheral margins should be feathered at a lower setting of 200 mJ to 250 mJ to blend into the surrounding skin and prevent a prominent line of demarcation between treated and non-treated skin. Post-operative care is similar to that described for chemical peeling. Lasers provide more control and reproducibility for resurfacing. The contractile effect2 produced with the CO2 laser makes it useful for greater amounts of excess skin or fullness and can even delay the need for an upper-lid blepharoplasty in many patients. Also, it has the added benefit of coagulating superficial capillaries at the time of vaporization, whereas the Er:YAG usually causes pinpoint bleeding. While the risk of scarring is less with the ultrapulsed CO2 laser compared to older modalities, there are still potential complications. The spectrum of adverse sequelae range from mild (prolonged erythema, milia) to moderate (transient to permanent dyspigmentation, local infection) to severe (hypertrophic scarring, ectropion, systemic infection).3 Resurfacing Maintenance Once successful resurfacing has been accomplished and recuperation is complete, a variety of maintenance options are available. Sun precautions are of paramount importance in the prevention of the signs of aging. Microdermabrasion performed at periodic intervals is a good means of minimizing rhytids and providing the skin with improved texture and tautness. Routine use of a topical retinoid combined with a choice from many cosmeceuticals (including rejuvenators with vitamins A, C, and/or E, plant growth factors including N6-furfuryladenine (Kinerase), alpha and/or beta hydroxy acids, coenzymes, etc.) are often useful and pleasing to patients. Treating Blepharochalasis If a patient has significant blepharochalasis, blepharoplasty of the upper lids may be indicated. Prior to blepharoplasty, evaluation and approval from an ophthalmologist is imperative. Once you have a thorough understanding of this area, with the patient in an upright sitting position, mark a point in the mid pupillary line in the supratarsal fold, typically 8 mm to 10 mm above the lid margin. Place similar markings along the supratarsal fold above the upper eyelid punctum and the lateral canthus. Next, draw a line curving along the reference marks. The line should then be extended laterally into a rhytid at an approximate 45-degree angle. Prep and drape the patient in a sterile surgical fashion, and anesthetize the area to be treated with local anesthetic. Use a scalpel to score the marked line and blepharoplasty scissors to dissect along the line to the level of the orbicularis muscle. The blepharoplasty scissors are used to dissect the orbicularis muscle free from the underside of the skin flap. We find it useful to pull the redundant skin of the upper lid down and then bifurcate in multiple points in order to determine the correct amount of excess skin to excise. The correct amount is that which will still allow the lids to close without scleral showing. The bifurcations may then be connected to complete the excision. If excess orbicularis muscle is present, excise a 1-mm to 3-mm strip just below the previously made wound margin exposing the orbital septum and levator aponeurosis. The excess adipose deposits may then either be resected or desiccated. Take exact measurements of the excised skin ellipse as well as the position of the surgical margins relative to the eyelid margin. These must be reproduced exactly on the opposite side to produce symmetry. Intraoperatively, two fat pads are identified and removed in the upper lid, a small medial and larger central fat pad. Give special care to protect the lacrimal gland, normally located in the lateral upper canthus. Medial relocation of this gland may occur due to adipose deposition. Hemostasis must be achieved prior to closure with a few interrupted tacking sutures and steristrips. Post-operatively, apply ice packs. We’ve recently published an overview of various approaches for the upper lid blepharoplasty.4 Post-operative complications may range from minor (corneal irritation, milia, contact dermatitis, chemosis, loss of eyelashes, hematoma, etc.) to severe (penetration of the globe, lacrimal gland injury, lagophthalmos, overresection of fat, ptosis, etc.). Permanent Make-Up We get many requests from younger patients for permanent eyeliner, a purely cosmetic procedure. We recommended that you have patients come for pre-operative consultation with eyeliner in the desired position and that you take photos for documentation. To give a patient permanent eyeliner, prep and drape the eyelid margins in a sterile fashion and use a 0.25% dilute lidocaine to thoroughly tumesce the lid margins. Using a handheld tattooing needle, dip the wand into the pigment and cautiously move along the area to be accented in small increments. Adequate skin turgor is imperative for successful penetration of the skin by the tattooing needle. The rapid repeated penetration of the tattooing needle into the tumesced skin is apparent. Perform several overlapping passes along the planned path until the desired density is achieved. For the upper lid, start near the medial limbus and extend the line to be even with the lateral canthus. Often, patients desire a small lateral flare. For the lower lid, begin in the same position medially but do not extend to connect with the upper lid line. Joining these two lines tends to produce an undesirable tapered or narrowed look to the lateral eye. It’s much easier to place additional pigment for a longer or thicker line than it is to remove the pigment once placed. Use dark tattoo inks such as black or dark brown. Lighter, blended colors have a tendency to fade over time. Post-operatively, use ice packs and topical ophthalmic antibiotic ointment. Enhancing Aesthetic Appeal Periorbital rejuvenation is an important aspect for enhancing aesthetic appeal. Early changes of aging often first manifest in this area, making intervention desirable to patients in their thirties and forties. Fortunately, we have a number of safe and effective treatment options to offer our patients.
T he eyes have been described as a window to the soul, and we use them to convey a wide range of emotions. Often, a person’s eyes are the first feature you notice when meeting someone new. Since our eyes are so essential to our overall appearance, it’s not surprising that rejuvenation of the periorbital area is so often requested. Here, we’ll detail strategies for changes of the periorbital area early in the aging process — for patients in their third and fourth decades of life. Aging of the Periorbital Area Redundancy of the skin of the upper eyelids often starts to manifest in the third decade. Early changes are characterized by loss of crisp definition of the palpebral lines. In time, the skin progressively sags and comes to rest on the eyelashes by the time patients reach their 60s and 70s. By the fourth decade, lateral canthal rhytids and accentuation of the lower eyelid folds are apparent at rest. These changes usually develop earlier and progress more rapidly than herniation of fat pads noted in the lower eyelids. The cumulative effect is a very tired, hooded appearance. Typically, only mild periorbital fullness, redundancy of the upper eyelids, and rhytids are apparent in patients in their third and fourth decades. Fortunately, we have a variety of treatment options for rejuvenation of the periorbital area for patients in this group, such as resurfacing, blepharoplasty and permanent eyeliner. With the recent FDA-approval of botulinum A toxin (Botox) for glabellar lines, popularity of this procedure has escalated. While Botox certainly has its place in periorbital rhytids as well, we’ll discuss this treatment option in a future article. Here, we’ll discuss treatment options and post-operative maintenance. Resurfacing Options Resurfacing of the periorbital area is often the first intervention of choice. Options for resurfacing include a superficial- to medium-depth chemical peel, erbium:yttrium-aluminum-garnet (Er:YAG) laser, or the carbon dioxide (CO2) laser. Resurfacing may improve fine- to medium-depth rhytids, as well as improve the photodamage that’s commonly present. • Chemical Peels. A common regimen for chemical peeling is trichloroacetic acid (TCA) 35% to 50% for the periorbital areas, depending on the extent of photodamage and depth of rhytids. When opting for this treatment, first thoroughly degrease and dry the area you’ll treat and have a rinsing agent readily available for the procedure. Use a cotton-tipped applicator to evenly apply the acid to the periorbital area, feathering to the orbital rim. An even frosting of the skin typically occurs in a short time and marks the completion of the peel. The white frost will evolve to erythema in a matter of hours and typically turn to a brown as the epidermis is shed in the days to follow. A heavy petrolatum ointment should be applied frequently for the post-operative period. Good reviews of various peeling formulations and techniques are available.1 Caution must be taken with the higher concentration TCA to avoid peeling the skin too deeply. It’s also imperative to guard against the wicking effect of the TCA to make sure it isn’t drawn into the conjunctiva. While peeling agents have been used therapeutically for more than a century, our experience is that newer laser technology has relegated chemical peeling to a second-line option. • Laser Resurfacing. The Er:YAG may be used if only very mild changes are evident. However, our preferred approach is the ultrapulsed CO2 laser at settings of 200 mJ to 300 mJ, 50 Watts, and a density of 5 with a computer generator pattern. You’ll need to treat patients with some form of sedation, either in the form of oral or conscious sedation. Use protective eyewear, and provide eye shields for the patient. Perform resurfacing from the eyelid margins to the eyebrows superiorly, the orbital rim inferiorly and laterally, and to the nasal sidewall medially. The peripheral margins should be feathered at a lower setting of 200 mJ to 250 mJ to blend into the surrounding skin and prevent a prominent line of demarcation between treated and non-treated skin. Post-operative care is similar to that described for chemical peeling. Lasers provide more control and reproducibility for resurfacing. The contractile effect2 produced with the CO2 laser makes it useful for greater amounts of excess skin or fullness and can even delay the need for an upper-lid blepharoplasty in many patients. Also, it has the added benefit of coagulating superficial capillaries at the time of vaporization, whereas the Er:YAG usually causes pinpoint bleeding. While the risk of scarring is less with the ultrapulsed CO2 laser compared to older modalities, there are still potential complications. The spectrum of adverse sequelae range from mild (prolonged erythema, milia) to moderate (transient to permanent dyspigmentation, local infection) to severe (hypertrophic scarring, ectropion, systemic infection).3 Resurfacing Maintenance Once successful resurfacing has been accomplished and recuperation is complete, a variety of maintenance options are available. Sun precautions are of paramount importance in the prevention of the signs of aging. Microdermabrasion performed at periodic intervals is a good means of minimizing rhytids and providing the skin with improved texture and tautness. Routine use of a topical retinoid combined with a choice from many cosmeceuticals (including rejuvenators with vitamins A, C, and/or E, plant growth factors including N6-furfuryladenine (Kinerase), alpha and/or beta hydroxy acids, coenzymes, etc.) are often useful and pleasing to patients. Treating Blepharochalasis If a patient has significant blepharochalasis, blepharoplasty of the upper lids may be indicated. Prior to blepharoplasty, evaluation and approval from an ophthalmologist is imperative. Once you have a thorough understanding of this area, with the patient in an upright sitting position, mark a point in the mid pupillary line in the supratarsal fold, typically 8 mm to 10 mm above the lid margin. Place similar markings along the supratarsal fold above the upper eyelid punctum and the lateral canthus. Next, draw a line curving along the reference marks. The line should then be extended laterally into a rhytid at an approximate 45-degree angle. Prep and drape the patient in a sterile surgical fashion, and anesthetize the area to be treated with local anesthetic. Use a scalpel to score the marked line and blepharoplasty scissors to dissect along the line to the level of the orbicularis muscle. The blepharoplasty scissors are used to dissect the orbicularis muscle free from the underside of the skin flap. We find it useful to pull the redundant skin of the upper lid down and then bifurcate in multiple points in order to determine the correct amount of excess skin to excise. The correct amount is that which will still allow the lids to close without scleral showing. The bifurcations may then be connected to complete the excision. If excess orbicularis muscle is present, excise a 1-mm to 3-mm strip just below the previously made wound margin exposing the orbital septum and levator aponeurosis. The excess adipose deposits may then either be resected or desiccated. Take exact measurements of the excised skin ellipse as well as the position of the surgical margins relative to the eyelid margin. These must be reproduced exactly on the opposite side to produce symmetry. Intraoperatively, two fat pads are identified and removed in the upper lid, a small medial and larger central fat pad. Give special care to protect the lacrimal gland, normally located in the lateral upper canthus. Medial relocation of this gland may occur due to adipose deposition. Hemostasis must be achieved prior to closure with a few interrupted tacking sutures and steristrips. Post-operatively, apply ice packs. We’ve recently published an overview of various approaches for the upper lid blepharoplasty.4 Post-operative complications may range from minor (corneal irritation, milia, contact dermatitis, chemosis, loss of eyelashes, hematoma, etc.) to severe (penetration of the globe, lacrimal gland injury, lagophthalmos, overresection of fat, ptosis, etc.). Permanent Make-Up We get many requests from younger patients for permanent eyeliner, a purely cosmetic procedure. We recommended that you have patients come for pre-operative consultation with eyeliner in the desired position and that you take photos for documentation. To give a patient permanent eyeliner, prep and drape the eyelid margins in a sterile fashion and use a 0.25% dilute lidocaine to thoroughly tumesce the lid margins. Using a handheld tattooing needle, dip the wand into the pigment and cautiously move along the area to be accented in small increments. Adequate skin turgor is imperative for successful penetration of the skin by the tattooing needle. The rapid repeated penetration of the tattooing needle into the tumesced skin is apparent. Perform several overlapping passes along the planned path until the desired density is achieved. For the upper lid, start near the medial limbus and extend the line to be even with the lateral canthus. Often, patients desire a small lateral flare. For the lower lid, begin in the same position medially but do not extend to connect with the upper lid line. Joining these two lines tends to produce an undesirable tapered or narrowed look to the lateral eye. It’s much easier to place additional pigment for a longer or thicker line than it is to remove the pigment once placed. Use dark tattoo inks such as black or dark brown. Lighter, blended colors have a tendency to fade over time. Post-operatively, use ice packs and topical ophthalmic antibiotic ointment. Enhancing Aesthetic Appeal Periorbital rejuvenation is an important aspect for enhancing aesthetic appeal. Early changes of aging often first manifest in this area, making intervention desirable to patients in their thirties and forties. Fortunately, we have a number of safe and effective treatment options to offer our patients.
