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Facial rejuvenation treatment arsenal continues to expand

A better understanding of the aging face has given clinicians more options for addressing the periorbital region of the face.

Aging changes around the periorbital region are often more noticeable because the eyes play a central role in our appearance. As a result, patients tend to seek treatment consultation for aging changes related to their periorbital region more proactively.

With advanced imaging, we have better knowledge of the pathophysiology of the aging face and can now offer a variety of treatment options to deal with these multifactorial challenges, specifically in the periorbital region.

The periorbital region is defined as the soft tissue structures that surround the orbit, which includes the eyelids, the eyebrows and the glabellar region. Aging changes that result in this region are dynamically related to the cheek and forehead, as well. The aging changes that occur in this region are resultant of skin and soft tissue changes as well as bony changes and globe position. All the aforementioned factors contribute to the various patient concerns.

Youthful dynamic eyelids are full and devoid of skin laxity and excessive rhytids. They transition well into the adjacent structures, such as the brows above and the midface below. The changes that occur in this region are multidimensional with aging. Bony expansion, loss of soft tissue support from ligamentous and septal structures, and attenuation of the skin and muscle all lead to hollowing and/or bulging of the orbital fat.

Jenny Y. Yu, MD

Jenny Y. Yu

Recent advances have supported the concept of restoring youthfulness by improving volume and contour rather than the traditional approach of skeletonizing the excess. More than just offering traditional surgical approaches, mild-to-moderate changes can now be effectively addressed using in-office laser and/or minimally invasive techniques.

The consultation

The initial office consultation is crucial to the success of any treatment plan. Often, patients are seeking a quick, simple, one-procedure solution to address the various issues that affect their appearance. However, usually more than one procedure is needed to treat these issues.

Communication in addressing patient expectations is crucial to ensuring patient satisfaction. A detailed history and exam along with photo analysis are needed to address all of the patient’s concerns before making treatment options. The correct patient selection also plays an important role in treatment decision-making. A motivated patient with realistic expectations is more accepting of step-wise treatments.

In-office procedures

Periorbital skin changes, such as pigmentation, rhytids and crepiness, can be addressed using a combination of lasers and chemical peels in the office. Neurotoxins are still a mainstay in the treatment of crow’s feet and rhytids in the glabellar region. Mild volumetric changes that result in tear trough hollowing, superior sulcus hollowing and/or fat pseudoherniation can be treated with fillers.

The key to successful resolution of the hollowing in the periorbital region is the use of appropriate filler placed in the correct tissue plane. Literature suggests the prevalent use of hyaluronic acid fillers, such as Juvéderm (Allergan) or Restylane (Medicis), around the periorbital region. Our preference is to use Restylane in the periorbital region, given our experience of having less post-injection edema with Restylane compared to Juvéderm. Both tend to contour and smooth well, which is especially important while treating the tear trough region.

Thicker and bigger-particle hyaluronic acid fillers, such as Perlane (Medicis), or gel matrix collagen, such as Radiesse (Merz), should be avoided in the periorbital region, given that they can produce a bumpy appearance. More importantly, the complication of retrograde intravascular embolization leading to permanent visual loss cannot be reversed with hyaluronidase with Radiesse, unlike the hyaluronic products.

Upper lid hollowing and brow descent can also be treated with the aforementioned hyaluronic acid products so that the harsh lines of the lid and brow junction can be softened. In cases where skin redundancy of the upper lids are a result of brow descent and/or fat loss temporally, a combination of filler and neurotoxin injections can improve the appearance without the need for surgical correction.

Surgical approaches

Upper eyelid blepharoplasty remains the most common surgical procedure in restoring youthfulness in the periorbital region. The success of an upper lid blepharoplasty must be considered in the context of the adjacent areas that may need rejuvenation, particularly the brow. Careful evaluation of true ptosis during the consultation is also paramount in the success of the surgery.

Upper eyelid blepharoplasty was traditionally done by removing the excess skin along with extirpation of orbicularis muscle and removal of fat. However, with the focus on volume restoration, preservation of orbicularis muscle and fat reposition improves the contour without worsening superior hollowing that can occur with aggressive upper lid blepharoplasty. With only skin removal in upper lid blepharoplasty, the transition of the lid brow unit is much smoother and avoids creating the A-frame effect.

Festoons and pseudoherniation of lower lid fat were traditionally corrected with excision of fat. Lower lid transconjunctival blepharoplasty with fat removal is rarely the recommended treatment, as repositioning of fat achieves a much smoother transition of the lower eyelid and mid-face.

Moderate-to-severe brow descent can be corrected with a brow lift or a browpexy through an upper eyelid blepharoplasty incision. However, as previously mentioned, with advanced techniques of combining neurotoxin and filler injections along the brow unit, most issues can be corrected without surgical correction.

Lower lid rejuvenation cannot be addressed adequately without the consideration of the mid-face. A mid-face lift is sometimes needed to restore the function and appearance of the lower lids.

Fat grafting has gained some popularity for the periorbital region in recent years. Severe volumetric loss, uncorrected with the use of fillers, can be corrected with fat grafting. However, the safety concerns in the periorbital region are real. Even in the hands of a skilled, experienced surgeon, retrograde microvascular embolism leading to blindness can occur. The complex network of vasculature in the periorbital region makes such a complication more likely. Typically, if fat grafting is done in the periorbital region, ultrasound guidance and exquisite care and knowledge of the anatomy minimize such complications.

Summary

It is an exciting time for clinicians and practitioners who enjoy the treatment challenges of the aging face, and the arsenal of treatment options continues to expand. Minimally invasive procedures in the office, such as lasers, chemical peels and cosmeticeuticals, provide great results with minimal recovery time. The changing concepts of beauty fuel the need for innovation in this field. Although surgery remains integral to periorbital rejuvenation, restoration of youthfulness can be safely done with a combination of both in-office and operating room-based procedures.

Visit UPMCPhysicianResources.com/Ocular to learn more about treatment options for facial rejuvenation. You can also submit clinical questions or read the most recent questions asked of the UPMC Eye Center’s ophthalmology experts.

References:
Lazzeri D, et al. Plast Reconstr Surg. 2012;
doi:10.1097/PRS.0b013e3182442363.
Massry GG, et al. Facial Plast Surg. 2013;doi:10.1055/s-0033-1333842.
Ogden S, et al. Br J Dermatol. 2008;doi:10.1111/j.1365-2133.2008.08845.x.
Terella AM, et al. Facial Plast Surg. 2013;doi:10.1055/s-0033-1333838.
For more information:
Jenny Y. Yu, MD, is an assistant professor of Ophthalmology at UPMC and the University of Pittsburgh and can be reached at 203 Lothrop Street, Pittsburgh, PA, 15213; 412-605-1451; email: yuj3@upmc.edu.
Disclosure: Yu has no relevant financial disclosures.

Aging changes around the periorbital region are often more noticeable because the eyes play a central role in our appearance. As a result, patients tend to seek treatment consultation for aging changes related to their periorbital region more proactively.

With advanced imaging, we have better knowledge of the pathophysiology of the aging face and can now offer a variety of treatment options to deal with these multifactorial challenges, specifically in the periorbital region.

The periorbital region is defined as the soft tissue structures that surround the orbit, which includes the eyelids, the eyebrows and the glabellar region. Aging changes that result in this region are dynamically related to the cheek and forehead, as well. The aging changes that occur in this region are resultant of skin and soft tissue changes as well as bony changes and globe position. All the aforementioned factors contribute to the various patient concerns.

Youthful dynamic eyelids are full and devoid of skin laxity and excessive rhytids. They transition well into the adjacent structures, such as the brows above and the midface below. The changes that occur in this region are multidimensional with aging. Bony expansion, loss of soft tissue support from ligamentous and septal structures, and attenuation of the skin and muscle all lead to hollowing and/or bulging of the orbital fat.

Jenny Y. Yu, MD

Jenny Y. Yu

Recent advances have supported the concept of restoring youthfulness by improving volume and contour rather than the traditional approach of skeletonizing the excess. More than just offering traditional surgical approaches, mild-to-moderate changes can now be effectively addressed using in-office laser and/or minimally invasive techniques.

The consultation

The initial office consultation is crucial to the success of any treatment plan. Often, patients are seeking a quick, simple, one-procedure solution to address the various issues that affect their appearance. However, usually more than one procedure is needed to treat these issues.

Communication in addressing patient expectations is crucial to ensuring patient satisfaction. A detailed history and exam along with photo analysis are needed to address all of the patient’s concerns before making treatment options. The correct patient selection also plays an important role in treatment decision-making. A motivated patient with realistic expectations is more accepting of step-wise treatments.

In-office procedures

Periorbital skin changes, such as pigmentation, rhytids and crepiness, can be addressed using a combination of lasers and chemical peels in the office. Neurotoxins are still a mainstay in the treatment of crow’s feet and rhytids in the glabellar region. Mild volumetric changes that result in tear trough hollowing, superior sulcus hollowing and/or fat pseudoherniation can be treated with fillers.

The key to successful resolution of the hollowing in the periorbital region is the use of appropriate filler placed in the correct tissue plane. Literature suggests the prevalent use of hyaluronic acid fillers, such as Juvéderm (Allergan) or Restylane (Medicis), around the periorbital region. Our preference is to use Restylane in the periorbital region, given our experience of having less post-injection edema with Restylane compared to Juvéderm. Both tend to contour and smooth well, which is especially important while treating the tear trough region.

Thicker and bigger-particle hyaluronic acid fillers, such as Perlane (Medicis), or gel matrix collagen, such as Radiesse (Merz), should be avoided in the periorbital region, given that they can produce a bumpy appearance. More importantly, the complication of retrograde intravascular embolization leading to permanent visual loss cannot be reversed with hyaluronidase with Radiesse, unlike the hyaluronic products.

Upper lid hollowing and brow descent can also be treated with the aforementioned hyaluronic acid products so that the harsh lines of the lid and brow junction can be softened. In cases where skin redundancy of the upper lids are a result of brow descent and/or fat loss temporally, a combination of filler and neurotoxin injections can improve the appearance without the need for surgical correction.

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Surgical approaches

Upper eyelid blepharoplasty remains the most common surgical procedure in restoring youthfulness in the periorbital region. The success of an upper lid blepharoplasty must be considered in the context of the adjacent areas that may need rejuvenation, particularly the brow. Careful evaluation of true ptosis during the consultation is also paramount in the success of the surgery.

Upper eyelid blepharoplasty was traditionally done by removing the excess skin along with extirpation of orbicularis muscle and removal of fat. However, with the focus on volume restoration, preservation of orbicularis muscle and fat reposition improves the contour without worsening superior hollowing that can occur with aggressive upper lid blepharoplasty. With only skin removal in upper lid blepharoplasty, the transition of the lid brow unit is much smoother and avoids creating the A-frame effect.

Festoons and pseudoherniation of lower lid fat were traditionally corrected with excision of fat. Lower lid transconjunctival blepharoplasty with fat removal is rarely the recommended treatment, as repositioning of fat achieves a much smoother transition of the lower eyelid and mid-face.

Moderate-to-severe brow descent can be corrected with a brow lift or a browpexy through an upper eyelid blepharoplasty incision. However, as previously mentioned, with advanced techniques of combining neurotoxin and filler injections along the brow unit, most issues can be corrected without surgical correction.

Lower lid rejuvenation cannot be addressed adequately without the consideration of the mid-face. A mid-face lift is sometimes needed to restore the function and appearance of the lower lids.

Fat grafting has gained some popularity for the periorbital region in recent years. Severe volumetric loss, uncorrected with the use of fillers, can be corrected with fat grafting. However, the safety concerns in the periorbital region are real. Even in the hands of a skilled, experienced surgeon, retrograde microvascular embolism leading to blindness can occur. The complex network of vasculature in the periorbital region makes such a complication more likely. Typically, if fat grafting is done in the periorbital region, ultrasound guidance and exquisite care and knowledge of the anatomy minimize such complications.

Summary

It is an exciting time for clinicians and practitioners who enjoy the treatment challenges of the aging face, and the arsenal of treatment options continues to expand. Minimally invasive procedures in the office, such as lasers, chemical peels and cosmeticeuticals, provide great results with minimal recovery time. The changing concepts of beauty fuel the need for innovation in this field. Although surgery remains integral to periorbital rejuvenation, restoration of youthfulness can be safely done with a combination of both in-office and operating room-based procedures.

Visit UPMCPhysicianResources.com/Ocular to learn more about treatment options for facial rejuvenation. You can also submit clinical questions or read the most recent questions asked of the UPMC Eye Center’s ophthalmology experts.

References:
Lazzeri D, et al. Plast Reconstr Surg. 2012;
doi:10.1097/PRS.0b013e3182442363.
Massry GG, et al. Facial Plast Surg. 2013;doi:10.1055/s-0033-1333842.
Ogden S, et al. Br J Dermatol. 2008;doi:10.1111/j.1365-2133.2008.08845.x.
Terella AM, et al. Facial Plast Surg. 2013;doi:10.1055/s-0033-1333838.
For more information:
Jenny Y. Yu, MD, is an assistant professor of Ophthalmology at UPMC and the University of Pittsburgh and can be reached at 203 Lothrop Street, Pittsburgh, PA, 15213; 412-605-1451; email: yuj3@upmc.edu.
Disclosure: Yu has no relevant financial disclosures.