Nonsurgical Brow and Eyelid Rejuvenation

Introduction

The shift towards less nonsurgical techniques to rejuvenate the periorbital area continues, and patient requests for procedures involving minimal downtime with less “surgical” results increase each year. The American Society of Aesthetic Plastic Surgeons reported that patients received a total of 8.9 million cosmetic nonsurgical procedures, including 5.5 million injectable treatments and 2.1 million skin rejuvenation treatments . Understanding the underlying anatomy and aging changes represents a critical component to successful nonsurgical treatment of the periorbital region.

The aging face changes in all layers including the skin, muscle, fat, and bone; addressing these changes will allow for optimal facial rejuvenation . The three-dimensional contours of the face should also be kept in mind when addressing facial aging. Deflation of the brow and unveiling of periorbital hollows is a major concern for patients seeking periorbital rejuvenation. Because of this, soft tissue filling with hyaluronic acid gel (HAG) fillers has reached an all-time high of 1.7 million procedures. In line with this, botulinum toxin (BT) treatments have increased to 3.6 million procedures and skin rejuvenation to 2.1 million procedures in the United States alone .

Surgical and nonsurgical procedures can be complementary and can often be used in conjunction for periorbital rejuvenation. Surgical treatments will be covered elsewhere, and this chapter will focus on nonsurgical rejuvenation of the brow and periorbital complex.

Anatomy

When performing facial rejuvenation, it is important to understand the anatomy of the area. A detailed description of the anatomy is beyond the scope of this chapter but a general overview of the layers will be described.

The skin in the periorbital area has different thicknesses and elasticity, with the brow and forehead having thicker skin and the eyelid having thinner skin. The elasticity of the skin decreases with age. This, with subcutaneous volume loss, can also affect the apparent skin quality and wrinkling.

The muscles of the periorbital area include the frontalis, corrugator, procerus, and orbicularis oculi. Manipulation of the action of these various muscles can be used to change the position of both the eyebrows and eyelids. The frontalis is the main elevator of the eyebrow, and interdigitates with the main depressors of the eyebrow: the procerus, corrugator supercilii, depressor supercilii, and orbicularis oculi . Furthermore, laterally, the frontalis may change slightly during aging, accounting for some of the lateral brow descent, in addition to brow volume deflation, found in older patients .

Volume deflation also unveils the underlying structures including the periorbital ligaments. The orbicularis retaining ligament (ORL) encircles the entire bony orbit and inserts into the dermis of the skin . The ORL contributes to hollows in both the upper and lower eyelid depending on the adjacent volume loss or fat herniation. In the upper eyelid superior volume loss can unveil the ORL especially in Asian patients. In the lower eyelid, other periorbital hollows include the septal confluence and the zygomaticomalar ligament . Deflation in the adjacent areas, such as the midface and temple, can also affect the appearance of the periorbital area. Therefore the periorbital area should not be treated in isolation but rather in conjunction with these areas of the face.

Skin Rejuvenation

Skin ages via both intrinsic and extrinsic factors, which result in changes including skin wrinkling, loss of elasticity, the appearance of excess skin, and pigmentation changes . To address these changes, various procedures can be performed including surgical or nonsurgical procedures. Surgery alone, however, cannot change the quality, texture, or elastic properties of the skin, which is where chemical peeling and laser resurfacing can help .

Nonsurgical skin rejuvenation procedures essentially remove different layers of the skin and thus induce the genesis of new collagen and elastin. Treatments can be aimed at either superficial or deep treatments. The most superficial layer of the skin can be addressed with various exfoliants, retinoids, mild α-hydroxy acids, or abrasives. Treating the deeper skin layers is usually accomplished with chemical peeling or laser resurfacing.

In the periorbital area, 20% trichloroacetic acid peel is commonly used. When used carefully with a frost and feathering technique, light acid peels have minimal complications. Other deeper chemical peels such as phenol present a higher risk for complications in the periorbital area and are therefore not used as frequently .

Laser treatments can also be used in the periorbital area but with care. Laser treatments have been classified into superficial and deep. Superficial lasers produce injury of the epidermis and dermis less than 750 µm, and deep lasers produce injury greater than 750 µm . The eyelid skin is very thin and more superficial treatments are generally favored to prevent full-thickness dermal injury, which could lead to eyelid malposition. Near-infrared, intense pulsed light devices, and nonablative lasers have a very low complication rate, but unfortunately they have minimal effects on wrinkle reduction and collagen formation. Fully ablative lasers such as carbon dioxide (CO ₂ ) and erbium:yttrium-aluminum-garnet have been successfully used in periorbital rejuvenation, but they carry a higher complication rate (prolonged healing, erythema, and pigmentary changes). Fractional CO ₂ lasers are intermediate in risk and reward, and may have more of a role in the periorbital area. They produce small columns of thermal injury with sparing of adjacent untreated skin, allowing for a more rapid healing process .