AROUND THE EYES

The periorbital region is one of the first facial regions to show signs of aging. It is critically important to understand precisely what feature of the periocular area is of the most concern to the patient before making therapeutic recommendations. Aging skin is characterized by the appearance of fine and coarse rhytids (wrinkles), rough and uneven texture, dryness, and changes in pigmentation. Fat atrophy occurs in the upper and lower periorbital region leading to progressive skeletonization of the orbit. Fat atrophy in the lower periorbital complex leads to a more prominent infraorbital rim, increasing the height of the lower eyelid and the overall soft tissue vertical dimension of the orbit. Typically, the nasojugal crease is more evident with aging. The malar fat pad has atrophied, the temples have hollowed, and the brow and upper lid have lost volume. In general, changes in skin texture, tone, laxity, or pigmentation are treated with physician skincare cosmeceuticals, chemical peels, lasers, or energy-based solutions. I can augment volume loss with the use of fillers, Autologous fat injection, and BOTOX A. Hyaluronic acid (HA) is the workhorse for the periorbital area because of its good efficacy and predictability and an excellent choice for correcting static rhytids that cannot be treated with BoNT alone and to recontour. Milli fat, micro fat, and nano fat with the addition of SVF and PRP for more massive volume deficits around the eyes may also be beneficial.

It is critically important to understand what features around the eyes are of the most concern to the patient before making treatment. Patients can complain of “looking tired” when concerned about losing skin tone, excessive eyelid skin, eyebrow ptosis, dark circles under the eyes, hollowness in the tear trough area, bulging orbital fat pads, or deep lateral canthal rhytides. The best candidates for around-the-eyes BTX injections are those with mild to moderately deep lateral canthal rhytides (smile lines) or crow’s feet wrinkles and those who develop a “roll” as they smile. Botox should be used with caution in patients with dry eyes, weak muscle function, and patients whose eyes do not close well due to earlier nerve palsy, thyroid eye disease, or previous surgery.

Around the eyes, (periorbital) fat injection demands a thorough understanding of the complex anatomy. Complex periorbital consists of the upper brow, upper eyelid, lateral canthus, lower eyelid, and infraorbital rim—begins to show signs of aging in the mid to late 30s. Aging skin is characterized by the appearance of fine and coarse rhytides (wrinkles), rough and uneven texture, dryness, and changes in pigmentation. Fat atrophy occurs in the upper and lower periorbital region leading to progressive skeletonization of the orbit. Fat atrophy in the lower periorbital complex leads to a more prominent infraorbital rim, increasing the height of the lower eyelid and the overall soft tissue vertical dimension of the orbit. With new advancements in cosmetic medicine, nonsurgical and minimally invasive procedures have become first-line treatment options. Treatments commonly used today include topical therapies, mechanical and chemical skin resurfacing techniques, lasers and radiofrequency devices, fillers, and neuromodulation by use of botulinum toxin (Botox). A conservative trans-conjunctival blepharoplasty or skin-only upper blepharoplasty combined with fat grafting can provide reliable rejuvenation and limit morbidity associated with higher volumes of fat grafting that would otherwise be necessary without concomitant excisional-based surgery.