Minimally invasive eyelid care in dermatology: 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
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