Periocular aging targetable with a host of minimally invasive devices

Atlanta - Multiple changes in the skin and underlying tissues contribute to the appearance of periocular aging, and several options rejuvenate the eyes without performing incisional surgery. Often, the best outcome depends on a combination approach, but the plan should be individualized based on findings from the physical exam and factoring in any budget limitations the patient may have, says Rhoda S. Narins, M.D.

“Injections with a neurotoxin or filler, resurfacing procedures, and technologies for tightening lax skin can all be used to create a more youthful and refreshed appearance around the eyes. Depending on the situation, using more than one of these techniques and addressing other areas of the face may enhance the patient’s appearance even more,” says Dr. Narins, private practice, Manhattan and Westchester, N.Y.

“Careful preoperative evaluation is needed to pick the right tools for the right patient, and then (clinicians) should take into account monetary concerns to guide them toward selecting an intervention that will give the patient the biggest bang for the buck.”

The exam is performed with the face at rest and while having the patient make different motions using various muscles. The aims are to identify symmetry in brow position and eye size, ability to raise the brows, and the presence of lines and wrinkles, skin laxity, volume loss, or any unsightly lesions.

Customized solutions

An injectable filler can be used for addressing hollowing below the eyes, filling out the skin over the cheekbones and in the temples and for minimizing the appearance of fine lines. Any of several hyaluronic acid products (Belotero Balance, Merz Aesthetics; diluted Restylane, Medicis, diluted Juvéderm XC, Allergan) are most appropriate for filling fine lines.

When volumizing below the eyes, Dr. Narins says she prefers Restylane, which is a particle filler, although fat can also be used. One of the more permanent fillers (Radiesse, Merz Aesthetics; Sculptra, Valeant Aesthetics; Artefill, Suneva Medical) can be used in the midface area, over the cheekbones and in the temple, but they cannot be used in the thin skin just under the eye.

Dr. Narins’ technique for delivering filler below the eyes is to use a cannula instead of a needle to criss-cross the area and a two-stage approach.

“A cannula enables finer sculpting in this area, and if I feel that two syringes is the appropriate amount of filler needed, I will inject just half the volume at the first visit and then allow the filler to settle into the skin for one or two weeks before injecting the rest,” she explains.

Botulinum toxin type A injections can be used in various ways to rejuvenate the eyes. A small dose of neurotoxin injected below the eyes, one to two units in the orbicularis muscle, will open up the eyes and make them look bigger. The same technique applied only to the smaller eye can create symmetry in patients whose eyes appear uneven in size. However, botulinum toxin injection below the eyes should not be performed in older patients with excessive laxity of under eye skin.

“In an older patient whose skin and lymphatics are already compromised, injecting botulinum toxin under the eye can create festoons, cause fluid collection or give a very flat look,” Dr. Narins says.

Botulinum toxin injection can also be used to alter eyebrow position. Injecting into the lateral orbicularis oculi depressor muscle over the eyebrow will raise the brow on that side. Injecting a small dose of toxin in the side of the forehead with the higher brow will even out asymmetric brow position. The neurotoxin can also be used to minimize the appearance of crow’s feet and severe glabellar lines, but resurfacing may be required.

If resurfacing is indicated, there are multiple options from which to choose. Noting that she no longer uses dermabrasion, Dr. Narins says her preference is for a fractional CO₂ ablative laser that also tightens the skin. However, nonablative laser resurfacing is another option that doesn’t work nearly as well while a chemical peel is a less expensive alternative for patients with a tighter budget.

Skin tightening procedures may be appropriate to address laxity under and around the eye or to tighten the forehead as a means to raise the brows. There are also several different platforms that can be used to achieve this goal based on radiofrequency (Thermage, Solta Medical; Exilis, BTL Industries) or ultrasound (Ultherapy, Ulthera).

An intense pulsed light device, Nd:YAG laser, or vascular-specific laser may also be helpful for treating pigmented and vascular lesions, and to enhance the patient’s cosmetic appearance, clinicians should not overlook the value of removing syringomas, seborrheic keratoses, skin tags, xanthelasma, or milia that occur around the eyes. DT

Disclosures: Dr. Narins has been an investigator and advisor to Medicis, Allergan, Merz, Dermik and Suneva.