The Eyes Have It

Eyes have always been a primary facial feature, referred to as “the window to the soul”, but now more than ever, they are today’s aesthetic focal point. With masks covering the lower face, the eyes are left to do all the talking. Video conferencing platforms showcase the face, especially the eyes in motion.

But eye rejuvenation is not easy. The eye is an unforgiving structure and feature. Using the wrong treatment for an aesthetic problem or failing to comprehensively treat aesthetic eye concerns can lead to unnatural and unsatisfactory results.

“The character of our facial identity comes first through our eyes. Our emotion comes first through our eyes. The eyes are the first thing that we notice when we look in the mirror and people notice when they look at us,” said Jeffrey Joseph, MD, an ophthalmic plastic and reconstructive surgeon in Newport Beach, Calif.

Dr. Joseph has been in practice for eight years and during that time he has seen big changes in the options available to aesthetic providers and patients. The options for eye rejuvenation went from basic surgical treatments and some injections to much more, including energy-based devices that address skin tone and texture.

Proven Nonsurgical Remedies

Dr. Joseph’s go-to nonsurgical option for eye area rejuvenation has been and still is neurotoxin.

“It is definitely powerful around the eyes, in the crow’s feet and for the glabellar lines,” Dr. Joseph emphasized. “All that muscle contraction really brings a harshness to the eyes that develops over time. Neurotoxin injections are still the most popular, most reliable nonsurgical treatment I do.”

Dr. Joseph is doing more with hyaluronic acid fillers around the eyes to build volume and create a smoother contour. And treating the skin texture has become more popular in his practice. He uses modalities from peels to energy- based devices, including radiofrequency (RF), to improve skin and tissue quality around the eyes.

Each nonsurgical modality plays a role in eye rejuvenation, and often a combina- tion of treatments is best. For example, according to Dr. Joseph, RF can help reduce periocular edema, as well as improve skin tone. Laser resurfacing and chemical peels improve superficial skin texture and build collagen.

Oftentimes, he uses neurotoxin, a filler and RF treatment in combination, as part of a nonsurgical eye rejuvenation plan.

According to Christopher Surek, DO, a plastic surgeon in Overland Park, Kan. being familiar with the anatomy is a must for treating patients’ aesthetic eye con- cerns, whether the provider addresses concerns surgically or nonsurgically.

Nonsurgical correction of the tear trough and cheek, for example, is primarily focused on volume, which means adding volume in the correct places to soften the harsh shadows related to fat compartment and ligamentous anatomy changes of the aging face.

One must separate lower eyelid anatomy from cheek anatomy. The division line is the lid-cheek junction, which is formed by a ligament that runs from the bone of the orbit to the skin.
“Really that is the division line between what is going on in the lower eyelid, versus what is happening in the cheek leading to mid face deflation and surface changes secondary to facial aging,” Dr. Surek explained.

Treatment can be done nonsurgically with filler products or in some cases autologous fat. Providers need to know the ligamentous anatomy as well as three-dimensional (3D) layering anatomy of the face before tackling facial injectables of any kind, Dr. Surek emphasized.

“In my opinion, the lower eyelid nasojugal groove is what separates surgical from nonsurgical candidates,” Dr. Surek noted. “[The provider has to decide] whether there is a lack of volume that can be replenished with a nonsurgical option or if there is excess volume of lower eyelid fat or tissue texture changes of the lower eyelid skin that require a surgical procedure potentially combined with resurfacing.”

Faisal Darwiche, NP, CEO of Panacea Aesthetics & Wellness Center in Newport Beach, Calif., believes the best nonsurgical way to rejuvenate eyes is with threads.
Many patients complain that their eyelids are hooded and foreheads are drooping. While providers using neurotoxin to treat those complaints can accurately paralyze the muscles, they cannot accurately lift areas to create a look for the eyes, Mr. Darwiche expressed.

“The beauty of threads for eyelifts and eyebrow lifts is that we can really customize treatment based on each patient’s face and look, and what they want to achieve,” he said. “Threads provide that control, but the provider must use the right approach. And that approach needs to be individualized for the patient.

“We have to individualize the vector, the angle of how we are lifting the brow. It can be anywhere from inside the middle of the brow, all the way to the outside, all the way to the extreme fox eyes, which is a trend that I think will fade away,” Mr. Darwiche continued.

There are two proven approaches for using threads to rejuvenate the eyes. Either providers enter through the scalp on the top of the head or from the eyebrow and move up. “Both yield really good results. Inserting the thread from the scalp and moving down toward the eyelid gives you a more subtle lift,” Mr. Darwiche began, “inserting the thread from under the eyebrow and moving up toward the scalp will give you a stronger lift.”

Mr. Darwiche uses a thread that has anchoring and lifting portions. The anchoring portion has more area than the lifting, which allows him to reverse insert it from the brow moving up. “Instead of cutting some of the anchoring portion, I can use the full 5 cm as lifting,” he shared. “The challenge with that comes with the size of the forehead. If the forehead is too small or skinny it is better not to insert from the eyebrow, going up toward the hairline.”

Mr. Darwiche says he never does a thread lift on the brows through the forehead unless the patient is first treated with neurotoxin to paralyze the forehead, which prevents forehead mus- cles from moving against the threads. Patients get more longevity from treat- ment when the forehead muscles do not move much. “I inject a heavy dose of neurotoxin, then a week or two later, when it kicks in, I insert the threads.”

He also recommends that patients main- tain neurotoxin treatment for as long as they can while the threads remain under their skin, to avoid breaking the threads. “These threads are very thin. Because the area is bony, you cannot use very thick threads. That makes them more vul- nerable to breaking and our muscles are stronger than we think.”

Natural, more youthful, more open eyes from threads last for six to eight months. And most patients are good candidates for the treatment, according to Mr. Darwiche.

“I think the people who see the best outcomes are people whose saggy skin is more to the sides – to the lateral outside portion where the crow’s feet are. There, I can do a lot more in terms of opening the entire eye, not just lifting the brow. We can pull the skin on the sides of the eye, moving back and up toward the hairline, then we would finish it up by lifting the brows from the top. Those patients see a much bigger wow! factor,” he stated.

Aesthetic providers are also using devices to treat the eyes. Nuttapol Larpcharoenkij, MD, an aesthetic dermatologist who practices in Bangkok, Thailand, uses Medixysteme’s 3D Trifocal SygmaLift, to treat the wrinkled, puffy and dyschromic under-eye skin.

The SygmaLift combines stabilized high-intensity focused ultrasound (HIFU) with a diode laser. Providers use the 3D Trifocal probe to treat skin around the eyes in direct contact and circular patterns at a proper energy level for about 20 minutes per eye, followed by the low-level laser. The laser provides oxygen and drains out aged cells, according to Dr. Larpcharoenkij.

Optimal interval for treatments should be one month, he advised. “With emis- sion of ultrasonic waves in a 3D Helix pattern, the specific eye handpiece of 3D Trifocal induces neocollagenesis at the right tissue depth contributing to smoother, tighter, less saggy and brighter under-eye skin. Many clinical experiences show significant improve- ment [one week] after the treatment,” Dr. Larpcharoenkij reported.

Recognizing the true pathology of each patient’s aging eyes is key for successful treatment. This allows providers to choose the optimal energy and correct depth of treatment. “I also encourage use of the device’s diode laser after that in order to facilitate the more brilliant outcome without downtime,” Dr. Larpcharoenkij added.

Dr. Larpcharoenkij often combines therapies for additional aesthetic improve- ment. To customize treatment around the eyes, for example, he might also use laser resurfacing and injectable hyal- uronic acid fillers.

“For those who have severe wrinkles and static lines, I do fractional laser and RF to achieve the best patient satisfaction,” he stated. “For sunken eyes, I use the hyaluronic acid filler to replace the bone or fat loss in conjunction with the 3D Trifocal treatment.”

Surgery Remains a Mainstay

Despite increasing demand for non- surgical options, upper and lower lid blepharoplasty remain the most popular treatments for addressing aesthetic eye concerns at Dr. Joseph’s practice. He said focused temporal brow lifting also helps reframe and balance the relation- ship between the brow and upper lid.
The reality is there are some things that only surgery can accomplish, such as long-term elevation of a structure like the brow or removal of excess skin, according to Dr. Joseph.

“I like to break up periocular treatments into above the eye and below the eye. Above the eye is the brow and upper lid. The biggest pearl I have for that area is do not forget the brow. There are a lot of surgeons who see the heaviness of the upper lid skin and do an upper lid blepharoplasty, but the patient is disap- pointed because they still have bunching at the lateral brow area. Elevating the lateral brow, whether it is surgically or even with a little bit of neurotoxin, can be really powerful to enhance the overall result with an upper lid blepharoplasty,” Dr. Joseph explained.

Upper eyelid surgery has changed in recent years, according to Dr. Surek.

“We’ve transitioned away from volume reduction surgery to volume retention,” Dr. Surek pointed out. “We do a very conservative skin excision of the upper eyelid and sometimes even fat graft the infa-brow to create volume. We have really come to find out that the youthful brow is often a full brow, as opposed to a skeletonized brow and upper lid.”

In Dr. Surek’s opinion, providers often underestimate the lower eyelid. “That is a surgery that should be taken very seriously and performed with the appropriate amount of caution and detail,” he stated.

There are two ways to surgically access lower eyelid fat, Dr. Surek advised. “One way is from the inside of the eye, through what is called a transconjunctival approach. With this approach you make an incision in the conjunctiva and then dissect down to the fat pads of the intraorbital fat pad,” Dr. Surek explained. “The other option is to make a subciliary incision, which is an incision on the front of the eyelid in the skin right below the eyelashes.”

With access to the intraorbital fat, surgeons can resect it and if needed release the tear trough ligament. “You can release that ligament and sometimes even transpose that lower eyelid fat down underneath the tear trough ligament to help prevent reinsertion of the ligament post-operatively,” Dr. Surek shared.

Assessing for Optimal Outcomes

Assessing individual patient’s needs is the key to achieving optimal outcomes from eye rejuvenation.

“From a nonsurgical perspective, you need to determine are they really a can- didate for volume correction or do they need surgery?” Dr. Surek stated.
For surgical patients, the assessment includes looking at the position of the globe relative to the cheekbone, and whether there is a negative or positive vector. The surgeon needs to assess for the position of the lateral canthus and determine if a patient has laxity of the lower eyelid that might affect a proce- dure. Surgeons must also assess for pre- existing conditions, like dry eyes.

Forming a complete treatment plan requires that the provider study the relationships among the periocular structures, including the brow, upper lid, lower lid, cheek, as well as tissue quality, according to Dr. Joseph.

“It is important to have a balanced approach to the patient’s problems,” Dr. Joseph began, “I very rarely do just one treatment for this area because the eyes are so complex and there are so many factors that contribute to the way our eyes age. When formulating a plan for eye rejuvenation, I always make sure my plan is comprehensive and incor- porates as many of those factors as possible.”