Nonsurgical Rejuvenation of the Periorbital Area

The Clinical Problem

A variety of differing aesthetic treatments and procedures are presently available for nonsurgical periorbital rejuvenation. Although less invasive treatments will not replace surgery, a growing patient population is seeking results through low-risk procedures with associated minimal downtime. These techniques are largely based on wound healing and collagen generation and continue to improve as new technologies become available. Many devices target the injury deep in the underlying tissue, leaving no visible external signs of trauma and an increased ability to deliver energy safely to deeper tissue planes. Each of these techniques has its own relative benefits and risks, and a combination of treatments is steadily gaining a foothold.

Synopsis

Nonsurgical periorbital rejuvenation techniques include the following:

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Botulinum toxin injections
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Hyaluronic acid and/or other type of dermal fillers
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Monopolar, bipolar radiofrequency (RF) energy
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Microneedling collagen induction therapy
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Microfocused high-intensity ultrasound
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Platelet-rich plasma (PRP, or plasma therapy)
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Bidirectional suspension sutures
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Chemical peels
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Nonablative and ablative lasers
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Combination nonsurgical techniques, DUBLiN lift

The Aesthetic Problem ( Fig. 10.1 )

The periorbital area consists of the eyelids and surrounding areas, including the eyebrows, bony eye socket and rims, cheeks, and forehead. It is often the first area to show signs of aging because of multidimensional and multifactorial reasons. The demand for minimally invasive skin-tightening procedures has been rising as patients seek effective alternatives to aesthetic surgical procedures of the area.

The face, and more especially the eyes, is the area for which most patients seek cosmetic rejuvenation. The periorbital area is very important in contact between humans because it provides a window to the rest of society regarding a patient's level of health, tiredness, emotional status, and interest in others.

The eyes and eyelids are very complex and delicate areas and, as such, need to be approached and treated with care. Recent studies have shown that changes occur in the bony structure surrounding the eye and have a substantial impact on the aging process, especially with respect to volumetric changes. The periorbital aging process is complex; it is a three-dimensional process that affects not only the skin, but also constantly interacts with the underlying layers— adipose tissue, muscles, and bones. The aesthetically attractive lower eyelid should display a relatively smooth transition between the preseptal and orbital portions of the orbicularis oculi muscle and continue into the upper malar region without a definable transition point.

Periorbital aging can hence be attributed to the following:

Gravity and its effect
Decrease in collagen and elastin
Laxity and ptosis of subcutaneous tissues
Atrophy and hypertrophy of adipose tissues
Bone reabsorption

Surgical Preparation and Technique

Neuromodulators

The periorbital anatomy is particularly well suited for botulinum toxin A (Botox) treatments and is the most frequent site to benefit from the cosmetic application of the toxin. Therapy is aimed at paralyzing specific muscles to reverse their effects on the overlying skin. Dermatologic use of Botox has traditionally been applied to the treatment of glabellar furrows and forehead and periorbital rhytids. Cosmetic benefits of Botox treatment include smoother, line-free skin, improved brow contour, and optimal postsurgical healing in certain circumstances. Botox therapy is simple, effective, and forgiving, making it very popular among physicians and patients alike.

Case 1 ( Fig. 10.2 )

A 33-year-old patient wished to have a smoother forehead, improved brow contour, and reduction in the periorbital rhytids, which resulted from both photoaging and contraction of the orbicularis oculi muscles.

FIGURE 10.2, A 33-year-old patient before (A,B) and after (C) treatment with botulinum toxin 2 weeks later.

Case 2 ( Fig. 10.3 )

A 42-year-old patient wished to have improved brow contour and reduction in periorbital rhytids. Botox can be used in the following areas:

Forehead (horizontal lines)
Frown lines (vertical)
Crow's feet (periorbital)
Eyebrows (arched, horizontal, gullwing). It also permits the lifting of the eyebrow

FIGURE 10.3, A 42-year-old patient showing evidence of brow elevation after injecting the orbicularis oculi muscle in three areas, before (A) and after (B,C) treatment 2 weeks later.

Botox was used to weaken the orbicularis oculi muscle and allow the frontalis to cause a minimal elevation and open up the eye area. This technique can also become useful before or after periorbital laser resurfacing augments the effects of the laser and helps maintain the improved appearance of wrinkles, as can be seen in the next case.

Chemical Peels

Chemical peels are one of the most common procedures used for skin rejuvenation. The process involves applying a caustic substance to the skin to produce a controlled, partial-thickness injury. Peels are categorized as affecting the superficial, medium, and deep levels. Superficial peels penetrate the epidermis down to the dermal-epidermal junction. These peels include Jessner's solution, which is a combination of resorcinol, salicylic acid, and lactic acid in an alcohol solution. Glycolic acid at concentrations of 20% to 70% is a more popular agent used for superficial chemical peeling. Trichloroacetic acid is a versatile peeling agent because the concentration may be adjusted to achieve the desired depth of peel. Deep chemical peeling entails longer healing times and increased potential for complications. Baker's formula is the most commonly used deep chemical peel.

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