Elsevier

Clinics in Dermatology

Volume 33, Issue 2, March–April 2015, Pages 207-216
Clinics in Dermatology

Minimally invasive eyelid care in dermatology: Medical, laser, and cosmetic therapies

https://doi.org/10.1016/j.clindermatol.2014.10.012Get rights and content

Abstract

There is a high demand for facial aesthetic enhancement, and the periorbital region is one of the first areas to show signs of aging. Many nonsurgical therapies exist to tackle these problems. These therapies are becoming more efficacious while reducing postprocedural recovery time. The goal is to restore the natural youthful appearance rather than to create an effect that differs from the patient’s appearance earlier in life. Eyelid care, and cosmetic dermatology in general, intends to restore balance and symmetry. We discuss the initial consultation, relevant anatomy for the dermatologist, and medical, laser and cosmetic therapies.

Introduction

The periorbital region is one of the first areas of the human body to show signs of aging, often beginning in the early 20s. The eyelid skin itself is the thinnest in the body, sometimes as thin as 0.2 mm. Anatomic location even as a single factor increases remarkably the susceptibility to UV damage. Additional extrinsic and intrinsic factors, including smoking, chronic inflammatory conditions or irritation, external rubbing, or genetic predisposition, may lead to long-term changes.1 These changes are clinically characterized by dyschromias, textural anomalies with decreased tissue quality manifested as loss of elasticity and skin tone that gradually result in more evident and permanent rhytides of the skin. As aging progresses, the brow may descend and potentially contribute to lateral eyelid hooding and occasionally to visual field deficits. The effects of eyelid aging may be misconstrued as fatigue, tiredness, and lethargy even in the setting of good rest, energy, and health. In some cases, brow changes may also communicate unintended emotional feelings such as sadness or anger.2

With a high demand for facial aesthetic enhancement without extended recovery time, research has led to the discovery of many nonsurgical therapeutic modalities ranging from botulinum toxin injections and volume enhancers to chemical peeling agents as well as light and laser therapies. Many of these therapies can be used additively or synergistically to enhance and rejuvenate the periorbital area with the added benefit of reducing individual treatment side effects and risks. In recent years, we are seeing a paradigm shift towards minimally invasive treatments and procedures that compile high safety and efficacy, the shortest possible recovery time, and highest cost effectiveness, interestingly, for patients and medical providers. In 2007, $4.7 billion was spent on nonsurgical aesthetic procedures, while botulinum toxin alone accounted for 2,775,176 procedures at a cost of more than $1 billion.3

Noninvasive techniques in aesthetic rejuvenation is growing at a remarkable rate. These approaches should be based on dynamic patient doctor rapport and further aim at the restoration and accentuation of a natural youthful appearance, instead of creating an effect that differs from the patient’s appearance earlier in life. Eyelid care, and cosmetic dermatology in general, is intended to restore balance and symmetry. The present contribution reviews minimally invasive eyelid care in dermatology with focus on initial consultation, relevant anatomy for the dermatologist, medical treatments, laser therapies, cosmetic devices, and minimally invasive surgical techniques. Many, if not all, of these topics can be implemented into a state of the art dermatologist’s practice.

Section snippets

Initial consultation

The initial encounter is crucial in gaining the trust of the patient and ensuring state of the art services that will gain patient respect, confidence, and satisfaction. Preparation of a comfortable office setting where uninterrupted discussion can take place is important for the establishment of this patient-doctor relationship. First fundamental step is to define the patient’s goals as specifically as possible. A handheld mirror can allow the patient to show rather than tell what concerns

Anatomy

In depth knowledge of the complex anatomy of the eyelid and surrounding structures is essential before the use of medical therapies, even minimally invasive, to the area. The eyelid skin is some of the thinnest in the body. In the upper eyelid, skin is thinnest near the ciliary margin and thickens as it approaches the brow.5 Classically, the eyelids are divided into seven layers, not all of which are present in every horizontal plane: Skin and subcutaneous tissue, muscular lid protractors

Sunscreens

Prevention of aging should be a mainstay of any therapeutic regimen targeting skin care of the eyelids and periorbital region. Sunscreens are the mainstay of preventive therapy, and the ideal sunscreen offers ultraviolet (UV) A and UVB protection. Two general classes of sunscreens exist: Chemical and physical. Chemical sunscreens act by converting UVB radiation into heat whereas physical sunscreens such as zinc oxide scatter, reflect, and absorb solar radiation. Physical sunscreens are

Laser and light energy-based therapies

Several laser and light-emitting devices are used currently to tighten the skin of the upper eyelid and brow to improve position and shape. They include nonablative erbium-doped mid-infrared (IR), IR, near-IR lasers, sublative fractionated radiofrequency (RF) devices, ablative fractionated carbon dioxide and fractionated erbium:YAG lasers, and devices that emit microfocused ultrasound (MFU). Transient postprocedural edema can produce upward vectoring and mimic a lifting effect so this should be

Cosmetic

Nonsurgical rejuvenation of the eyelids and brows consists of fillers aimed at increasing volume of atrophied tissues, dermabrasion and chemical peels aimed at resurfacing aged skin, and neuromodulators aimed at relaxing the periocular musculature. Achievement of optimum cosmetic results and patient satisfaction necessitates a systemic approach not only to the eyelids and brows but also to the surrounding superior and inferior orbital rims, temporal fossa, forehead, glabella, and upper cheek

Conclusions

There are many minimally invasive options for rejuvenation of the periorbital region. Patients can look younger and have a higher quality of life without sacrificing extended periods for recovery. It is prudent that the provider and the patient are clear on the goals of treatment and the risks of each of the above described modalities. Many of these above strategies can be used synergistically to optimize results and minimize adverse effects. Comfort with use of each of the above can provide

References (56)

  • E.K. Kim et al.

    Dermabrasion

    Clin Plast Surg

    (2011)
  • B.C. Mendelson et al.

    Age-related changes of the orbit and midcheek and the implications for facial rejuvenation

    Aesthetic Plast Surg

    (2007)
  • M. Cantisano-Zilkha et al.

    Overview of the aesthetic approach

  • M. Cantisano-Zilkha et al.

    Aesthetic Oculofacial Rejuvenation

    (2010)
  • K. Hwang

    Surgical anatomy of the upper eyelid relating to upper blepharoplasty or blepharoptosis surgery

    Anat Cell Biol

    (2013)
  • Sunscreen drug products for over-the-counter use; final monograph. Food and Drug Administration, HHS. Final rule

    Fed Regist

    (1999)
  • P.B. McCay

    Vitamin E: Interactions with free radicals and ascorbate

    Annu Rev Nutr

    (1985)
  • A.C. Chan

    Partners in defense, vitamin E and vitamin C

    Can J Physiol Pharmacol

    (1993)
  • S.K. Katiyar et al.

    Green tea and skin

    Arch Dermatol

    (2000)
  • W. Gehring

    Nicotinic acid/niacinamide and the skin

    J Cosmet Dermatol

    (2004)
  • C.E. Griffiths et al.

    Restoration of collagen formation in photodamaged human skin by tretinoin (retinoic acid)

    N Engl J Med

    (1993)
  • L. Pickart et al.

    Growth-modulating plasma tripeptide may function by facilitating copper uptake into cells

    Nature

    (1980)
  • C. Blanes-Mira et al.

    A synthetic hexapeptide (Argireline) with antiwrinkle activity

    Int J Cosmet Sci

    (2002)
  • H. Sundaram

    Role of physiologically balanced growth factors in skin rejuvenation

    J Drugs Dermatol

    (2009)
  • A. Brieva et al.

    Molecular basis for the regenerative properties of a secretion of the mollusk Cryptomphalus aspersa

    Skin Pharmacol Physiol

    (2008)
  • S. Brychtova et al.

    The role of vascular endothelial growth factors and their receptors in malignant melanomas

    Neoplasma

    (2008)
  • D. Yarosh et al.

    Pyrimidine dimer removal enhanced by DNA repair liposomes reduces the incidence of UV skin cancer in mice

    Cancer Res

    (1992)
  • W. Dong et al.

    IKKalpha contributes to UVB-induced VEGF expression by regulating AP-1 transactivation

    Nucleic Acids Res

    (2012)
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