My current practice is half functional – from repairing issues caused by trauma and cancers, to aging and even correcting overaggressive surgery or injections. I see the good, the bad and the ugly! I have found that patients feel more comfortable and confident with surgeons who know the anatomy of the ocular area surgically, not just superficially. I pride myself on providing patients with natural looking results. I do not want them to look like they were “done” with 20 cc of injectables – I want them to look well rested. If you come to me, your friends will not know what you did, they will just know that you look great.
Common Mistakes
I believe that, generally speaking, using fillers periorbitally can be too aggressive. Fillers have a place around the eye but correcting this area to perfection often leads to a bad outcome. Not every flaw that we see needs to be addressed, and not every wrinkle should be ‘toxed’. We have that natural anatomy for a reason. I most commonly see patients that are overfilled around their lower eye and tear trough, causing them to appear swollen and tired, and eventually worse than when they started.
Patients’ eyes might not open in quite the manner they should, and aesthetic surgeons can struggle addressing drooping of the eye lid. There are ways of addressing the periorbital unit by balancing treatment instead of having patients look done and overdone. We even have a nonsurgical option with oxymetazoline 0.1% (Upneeq from RVL Pharmaceuticals), topical drops that can help rejuvenate the appearance of the entire area. Oxymetazoline was approved in 2020 as the first and only pharmaceutical to treat acquired blepharoptosis in adults. Ocular application of oxymetazoline is thought to stimulate the alpha-adrenergic receptors on Muller’s muscle, which results in contraction and eyelid elevation. It also helps to whiten the eye.
My Protocol
I always start by asking the patient why they came in, what are their primary needs and what are they bothered by. Then, I tell them what I see. If they just want to get the wrinkle out of their crow’s feet, I am not going to inject them with a bunch of filler and have them end up being dissatisfied or not looking like themselves. We come up with a plan together.
When approaching the periocular area, remember that it does not live alone, there are other structures around it that ultimately need to be addressed. Start at the top moving to the bottom, make sure the brow area is sufficient, evaluate the amount of fat, and determine if the brows are too high or too low. Then the cheekbones; are they descending or lacking in volume? The rest of the face around the eye should be harmonized which makes the eye area itself easier to treat. Approaching it in this way avoids the risk of overdoing the treatment.
I determine, do they look tired, are their eyelids droopy, do they want to have their eyes look more open? This is where I offer topical oxymetazoline to brighten the entire eye area. This is something they can use on demand without committing to surgery, which is always an option as well.
Using Oxymetazoline Topical Drops
In my experience with oxymetazoline, it does not matter if the lid droop is mild, moderate or severe, it works in almost all patients giving them an “extra oomph.” One of the surest ways to rejuvenate the eyelid is to add the drop to whatever else they are having done. I tell my patients they can use it as often as they want.
Many patients come in because they have a special event like a wedding coming up where they want to look their best, but they do not want the downtime associated with a procedure. The topical drop gives that extra pop, opening the eye even if the ptosis is very mild. Oxymetazoline clears and brightens the eye, giving the appearance of youthfulness in the ocular area.
Patients with drooping lids raise their brows to compensate. The worst thing that can be done for those patients is inject toxin into their forehead. Injecting botulinum toxin in those patients will create a heavy brow. We can prevent patients from having a bad outcome from forehead injections. Instead, using oxymetazoline to lift the lids and widen the eye will naturally soften that raising of the brows and forehead wrinkling. The drops make a world of difference for the mother of the bride or the moth[1]er of the groom because their eyes will look more youthful without losing the expression or feeling of having a heavy brow caused by botulinum toxin products.
Functional, Then Aesthetic
I began by using oxymetazoline for my patients who had ptosis that was impairing their visual function. It is an excellent option for those who are not surgical candidates for a variety of reasons, such as illness, radiation treatment, dry eye or other contraindications. Then I moved into using it for aesthetic reasons. I am often asked to prescribe oxymetazoline for patients working nights or long hours whose eyes get tired and they need to feel more awake. The drop gives a boost to the eyes, making them look wide open and feeling rested and less tired.
Patients with moderate or severe eyelid droop will enjoy their results so much that they naturally transition to having surgery. Oxymetazoline opens the entire aperture of the eye very nicely; however, with surgery only the upper eye lid is treated. Most oculoplastic surgeries do not open up the lower eye be[1]cause that can cause issues with dryness and irritation. For that reason, I feel that oxymetazo[1]line excels with regard to overall appearance compared with surgery.
