Different Approaches to Treatng the Periorbita
Dr Nikola Milojević explains how dermal fillers, botulinum toxin and plasma can be used to address the signs of ageing in the upper and lower eye.
History and overview
The history of eyelid procedures dates back to 25 A.D. when Aulus Cornelius Celsus, a Roman philosopher, described the excision of excess skin of the upper eyelid. Coming forward to the 1970s, Dr Bob Flowers from Hawaii introduced the supratarsal fixation foe the upper eyelid crease, which is where a low eyelid is re-established by fixating a fold higher up; a procedure very popular among Asian patients to this day. Dr Flowers was a close friend and colleague of my late father Professor Bosko Milojevic, and they worked on this procedure together, hence my fascination with the periorbital area feom a very early age.
More pertinent to this article was the accidental discovery of botulinum toxin for wrinkles. In 1987, a Canadian ophthalmologist, Dr Jean Carruthers was treating blepharospasm in her patients with botulinum toxinum, and, to her surprise, noticed a side effect of wrinkles reduction around the eyes.
Then, in 2007, ophthalmologist and oculoplastic surgeon Dr Raman Malhotra first described the non-surgical 'eye bag' removal procedure using hyaluronic acid(HA) dermal fillers, and my practice has been enriched by this procedure ever since. With these new advances, we are able to apply a more holistic approach to treatment and, increasingly, we're able to perform procedures effectively, with fewer risks and downtime than surgical procedures.
Anatomy and physiology
The anatomy and physiology of the ageing upper face is well known and documented. In the lower eye area, there is often tear trough depression due to a genetic predisposition associated with the tear trough ligament. In most cases, however, the hollow or dark circle appearace is due to mid-cheek malar fat pad atrophy and the subsequent parting between the lower eye bag fat pad and the malar fat pad, which slides lower with gravity. The decreased elasticity of the overlying ageing skin also contributes to this hollow, as well as skeletal ageing. In the upper eyelid, the skin increasingly sags and droops due to a loss of elasticity in individuals with a genetic predisposition or due to extrinsic factors.
Indications and patient presentation
Upper and lower eyelid ageing is a problem for many patients- according to the British Association of Aesthetic Plastic Surgeons (BAAPS), blepharosplasty was the second most common surgical procedure in 2016 in the UK, with the first being breast augmentation. Patients usually present with the complaint of energy and lead healthy lives.
Common presentations in my clinc for eye concerns include:
Younger patients, aged 20 to 30 years of age, who present with an inherited tear trough indentation under the eye, giving them a tired look at an early age; these patients look older for their age because of it. Often these patients also have dark circles.
A later onset tear trough under the eye, most commonly in patients in their mid 30s, due mainly to malar fat pad atrophy. this indentation often extends onto the upper cheek.
Augmented eye bags, caused by the growing size of the infraorbital fat pad, which bulges and does not slide down, due to the presence of a ligament. There may also be excess skin below the eye and into the lateral canthal line areas, as well as rhytides below and around the eyes.
'Lowered' upper eyelids, due to execess skin and lack of elasticity, which often results in a presentation of a reduced filed of vision, providing and indication for which patients can usually have a surgical blepharoplasty on the NHS.
Treatments
Below, i will detail some of the common treatments i perform in my clinic related to the above concrens.
Tear trough with dermal fillers
This is a complex procedure, only to be performed by those with extensive experience in the administration of dermal fillers and a thorough knowledge of facial anatomy. The choice of material is key, and more permanent options, such as permanent fillers, which patients may seek, are simply contraindicated here due to the longterm risk of side effects. In my opinion, the only option for treatment of the tear trough is a cross-linked HA dermal fillers, as it is reversible using hyaluronidase, which gives patients and practitioners reassurance. Also, the cross-linking ensures that results last, and with the right choice of filler, from my experience, these results can last as long as 12.24 months. In some cases, i have even seen results last longer than 24 months.It is important that the thickness of the filler has been chosen correctly; practitioners must note that they are unlikely to use the same type of fillers for different patients. In patients with shallow dark circles and thin skin, a filler with a low G-prime, designed for rejuvenation may be used. However, in patients with large eye bags and significant volume loss, it is more appropriate to use a filler with a high G-prime and volumise the upper cheek to help fill the tear troughs. On average, i use 1ml filler per eye.
Iprefer to use a needle as i fell that it offers a much more precise way to achieve good results without side effects, as opposed to the cannula. As long as practitioners know the anatomy of the area, they can avoid side effects such as bruising and vascular compromise. Sometimes bruising is an unavoidable side effect, although if managed properly, it should not adversely impact the lifestyle of the patient. It is important to inject deep and, in most cases, just above the periosteum. I use many different techniques in most of my patients to achieve the best results, as, in my opinion, they work in synergy for results which are the most natural, with the least side effects. Of course, depending o the depth of the tear trough, or whether the skin under the eye is thin or thick, some of the techniques may or may not be necessary. With as many as 30 injections around each eye, i build the dermal filler to correct the depression and to literally hide the eye bag in what i call a 'patchwork technique', wich is not possible with a cannula.
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