The physician and surgeon will find here a detailed and comprehensive discussion of nonsurgical rejuvenation tools and techniques, along with thoughtful insights into evaluating and treating the aging upper face, such as the concept of visualizing a “periorbital frame” that is bordered by the eyebrows, glabella, temporal fossa, and superior mid face. Further, the authors emphasize combined treatments and how they work together for optimal rejuvenative outcomes. Presented are clinical approaches to pretreatment evaluation, use of neuromodulators, fillers, radiofrequency, and ultrasound. Complication avoidance and correction are discussed for these treatments.
Key points
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Nonsurgical rejuvenation of the upper eyelid and brow regions can produce profound improvement in overall facial appearance.
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A comprehensive understanding of structural and functional facial anatomy and ideal facial proportions is essential to evaluate each patient effectively, select the appropriate treatments, and devise an optimal treatment plan.
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Nonsurgical treatments can be classified into 1 of 3 major categories based on mechanism of action: soft tissue fillers, neuromodulators, and laser and light energy–based devices. Adjunctive treatments include chemical peels and topical therapies.
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Facial aging is characterized by volume loss from multiple tissue planes (bone, muscle, subcutaneous fat, and skin). Identification and correction of volume loss from the upper eyelid and brow is a prerequisite for effective rejuvenation of these regions.
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Combination of soft tissue fillers with neuromodulators may be appropriate for many patients and yield enhanced results. Hyaluronic acid fillers may be considered the best option for volume restoration to the upper eyelid and brow.
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Since volume loss is a cardinal feature of facial aging, adoption of a predominantly volumetric rather than ablative approach to the upper eyelid and brow may yield the best results.
Background on nonsurgical treatment of the aging face
Facial aging is also characterized by decreased tissue quality, which has manifestations including loss of elasticity, dyschromia, and textural anomalies. An integrative approach to nonsurgical rejuvenation incorporates improvement in skin quality and reflectance as a valuable adjunct to volume replacement and neuromodulation.
Age-related changes in the eyebrows can be corrected via brow repositioning and shaping with various nonsurgical rejuvenation treatments, including neuromodulators, soft tissue fillers, and radiofrequency. This can produce a beneficial, secondary improvement in upper eyelid hooding.
The ideal approach to nonsurgical rejuvenation of the upper eyelid and brow involves familiarity with the multiple treatment modalities that are currently available. An appropriate combination of treatments, tailored specifically for each patient to address individual aging patterns, may be synergistic and more efficacious than any one treatment alone.
When evaluating and treating the upper lid and brow, it is useful to visualize a “periorbital frame” that is bordered by the eyebrows, glabella, temporal fossa, and superior mid face. Nonsurgical treatments can be directed within the periorbital frame with the aim of replacing volume, regenerating tissue quality, rebalancing facial vectors and proportions, and improving skin reflectance. Treatments directed outside the periorbital frame can produce a secondary vectoring effect on the upper eyelid and brow, and include light energy-based modalities, such as fractionated radiofrequency (RF), microfocused ultrasound (MFU), and lasers, as well as soft tissue fillers and neuromodulators.
Background on nonsurgical treatment of the aging face
Facial aging is also characterized by decreased tissue quality, which has manifestations including loss of elasticity, dyschromia, and textural anomalies. An integrative approach to nonsurgical rejuvenation incorporates improvement in skin quality and reflectance as a valuable adjunct to volume replacement and neuromodulation.
Age-related changes in the eyebrows can be corrected via brow repositioning and shaping with various nonsurgical rejuvenation treatments, including neuromodulators, soft tissue fillers, and radiofrequency. This can produce a beneficial, secondary improvement in upper eyelid hooding.
The ideal approach to nonsurgical rejuvenation of the upper eyelid and brow involves familiarity with the multiple treatment modalities that are currently available. An appropriate combination of treatments, tailored specifically for each patient to address individual aging patterns, may be synergistic and more efficacious than any one treatment alone.
When evaluating and treating the upper lid and brow, it is useful to visualize a “periorbital frame” that is bordered by the eyebrows, glabella, temporal fossa, and superior mid face. Nonsurgical treatments can be directed within the periorbital frame with the aim of replacing volume, regenerating tissue quality, rebalancing facial vectors and proportions, and improving skin reflectance. Treatments directed outside the periorbital frame can produce a secondary vectoring effect on the upper eyelid and brow, and include light energy-based modalities, such as fractionated radiofrequency (RF), microfocused ultrasound (MFU), and lasers, as well as soft tissue fillers and neuromodulators.
Introduction and rationale for combined treatments
If, as the poets say, the eyes are the window to the soul, then the eyebrows and the eyelids may be considered the all-important frame to that window. Studies of how we view others’ faces show that an observer’s gaze consistently falls first on the eyes and the area surrounding them, before tracking to other parts of the face with repeated returns to the eyes and periorbital region. Given this focus, it is hardly surprising that rejuvenation of the brow and upper eyelid region, with consequent improvement in appearance of the eyes, can have a dramatic impact on how the whole face is perceived.
Although there is significant individual variation in patterns of facial aging, the early manifestations may often be seen in the eyebrows and eyelids ( Fig. 1 ).
Eyebrow and Lid Ptosis
Conventionally, eyebrow ptosis and/or upper eyelid ptosis (blepharoptosis) have been described. Both may be considered to be due to volume loss from multiple tissue planes, including the underlying fat compartments and bony structures, as well as an increase in skin laxity and some degree of muscular imbalance. Over time, the eyebrow tends to lose its lateral arch, and it appears somewhat flattened in older patients. It is essential to differentiate true, primary eyelid ptosis affecting the (tarso) levator muscle from eyelid ptosis that is unveiled as a secondary consequence of eyebrow ptosis. Each can present as excess folding of upper eyelid skin, but the appropriate treatment strategy for one differs from that of the other. In some patients, preexisting congenital eyelid ptosis, mechanical factors, such as repeated insertion and removal of contact lenses, or neurogenic factors may also be contributory. Based on this model, rejuvenation strategies have focused on mechanical elevation of either the eyebrows or the upper eyelids, or both.
With the understanding that these are the age-related changes that are conventionally described, careful inspection of older faces and comparison with photographs taken in youth reveal that some actually display an elevation in the eyebrows with age. The most obvious example is when upper eyelid ptosis that is more apparent on one side is secondarily offset to some extent by contraction of the frontalis muscle, resulting in one eyebrow that lies higher than the other. It is our observation that most patients exhibit some degree of partially compensated eyelid ptosis when examined closely enough both in repose and in animation. This can be obscured when the compensatory contraction by frontalis is relatively symmetric on both sides of the forehead, and also to some extent in women by differential tweezing of each eyebrow ( Fig. 2 ).
Variance in Ideal Eyebrow Position
Ideal, youthful eyebrow position and shape vary from individual to individual, and even on the basis of hereditary and ethnic factors. However, it is instructive to study the faces of children and young adults. Their eyebrows are frequently less arched and less elevated than those of older individuals who have undergone cosmetic procedures with the aim of rejuvenation. As with many aspects of our field, we still have much to learn. In the quest to correct age-related changes to the upper face, it is important not to lose sight of what looks most natural and to hoist the eyebrows high in an esthetically unappealing attempt to offset redundant upper eyelid folds. As we continue to advance our knowledge of how facial architecture changes with age, we must also strive for a better understanding of the functional changes, and incorporate both structural and functional considerations into treatment planning.
The 4 Pillars of Rejuvenation: 4 R’s Method-Based Classification
An integrative approach to facial rejuvenation has been described as being composed of 4 main pillars or 4 R’s:
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Relaxation of muscles with neuromodulators
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Refilling with injectable fillers
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Resurfacing of skin, e.g. with lasers or light energy-based devices, chemical peels
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Redraping of tissue with surgery, lasers or light energy-based devices
This classification is method-based, in that it is founded on the procedures that may be used to achieve improvement.
For many patients, a combination of procedures represents the best, multimodal approach to nonsurgical rejuvenation of the eyebrow and upper eyelid. For example, an injectable botulinum toxin neuromodulator can be administered to the superolateral aspect of the orbicularis oculi muscle to raise the lateral aspect of the brow (Relaxation). The same patient may also benefit from strategic placement of a hyaluronic acid filler above and under the eyebrow and to the upper eyelid (Refilling), and also from fractional bipolar RF to the upper face, including the region just above the eyebrows (Redraping and Resurfacing).
The 4 Pillars of Rejuvenation: 4 R’s Outcome-Based Classification
Although a method-based classification is certainly helpful, an outcome-based classification that relates to desired objectives is also of value because it facilitates the formulation of effective, patient-centric treatment plans. Using the 4 R’s formula, we might consider the pillars of an outcome-based classification to be the following:
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Replacement of tissue volume
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Regeneration of tissue quality
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Rebalancing of facial vectors and proportions
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Improvement of skin Reflectance
The synergistic potential of combining multitasking nonsurgical procedures is apparent if we now examine the treatment plan listed previously through the prism of this classification. The injected neuromodulator effects a rebalancing of facial vectors and proportions. The filler also rebalances facial vectors and proportions by lifting and contouring. In addition, fillers replace tissue volume, regenerate tissue quality via stimulation of collagenesis, and can improve skin reflectance, especially if a multiplane “sandwich” implantation technique is used. RF can rebalance facial vectors and proportions, improve skin reflectance, and also contribute to regeneration of tissue quality and replacement of tissue volume.
Brief anatomic overview
Anatomic considerations for the upper eyelid and brow are addressed in detail elsewhere in this issue; therefore, a brief overview is provided here.
Like the rest of the face, the upper periorbital region (upper eyelid, orbital sulcus, and eyebrow) is best viewed as a 3-dimensional structure. The upper eyelid should have a well-defined supratarsal crease. Age-related loss of bone contributes significantly to an inward caving of the supraorbital fossa, and supraorbital hollowing, which is a principal feature of facial aging. Supraorbital hollowing has been described as occurring in 4 main zones, as a result of varying degrees and patterns of volume loss. From medial to lateral, these zones are the medial fat pad, the hollow overlying the supraorbital foramen, the middle fat pad, and the lateral fat pad. (See the articles by Lam and colleagues, and Terella and Wang, elsewhere in this issue, for detailed anatomic description and graphics.)
The tissue planes underlying the brow from most superficial to most deep are the epidermis, dermis, subcutaneous fat, superficial fascia and musculature, subgaleal loose areolar tissue, periosteum (deep fascia), and bone. Eyelids also have several layers. The middle layer, known as the orbital septum, is a connective tissue sheet that thickens as it extends toward the bony orbit and is ultimately referred to as the arcus marginalis where it inserts into the orbital rim. Fat at the roof of the orbit lies beneath the arcus marginalis.
Key musculature of the upper eyelid and brow includes the procerus (which pulls the medial aspect of the brow downward); the corrugator supercilli and depressor supercilii bilaterally (which pull the medial brow downward and medially); and the orbicularis oculi, the sphincteric ring around the bony orbit that approximates the upper and lower eyelids when contracted and whose medial portion serves as a medial brow depressor. The eyebrows are elevated by contraction of the frontalis muscle, which is in the form of bifid muscle bellies or a continuous sheet that extends over the forehead to join with the occipitalis muscle on the scalp ( Fig. 3 ).
Pretreatment evaluation
The ideal eyebrow shape for a woman is quite different from the ideal for a man. In both, the medial brow should transition smoothly into the skin at the root of the nose, creating a continuous, gently curved line from the nose to the orbit. Youthful female eyebrows arch gracefully, with the arch positioned such that it directly overlies the superciliary groove of the orbital foramen. The peak of the arch should be positioned above the lateral limbus of the iris, and the eyebrow should then slope downward as it passes toward the lateral canthus. Ideally, the most lateral portion of the female eyebrow (the “tail”) lies on a horizontal plane that is 1 to 2 mm above the lowest portion of the medial eyebrow. The ideal female eyebrow has been described as resembling the wing of a gull. In contrast, the male eyebrow should have less of an arch, and be positioned at approximately the level of the superior bony orbital margin, ie, lower on the superciliary arch than in females ( Fig. 4 ).
Symmetry and Height Measurements
Before treatment, the patient’s eyebrows should be evaluated for symmetry of height as well as for degree and position of the arch. Eyebrow ptosis can be determined by measuring the distance from the central inferior edge of the brow to the central upper lid margin. If this distance is much less than 10 mm, the diagnosis of eyebrow ptosis should be considered. This measurement can also be performed for the medial and lateral aspects of the eyebrow. Comparison of these 3 measurements for each eyebrow and comparison between the eyebrows can help to determine whether or not there is eyebrow ptosis or asymmetry of the eyebrows.
Ptosis Evaluation
Upper eyelid ptosis (blepharoptosis) can be detected by measuring either the palpebral fissure width (also known as the palpebral fissure height) or the margin reflex distance-1 (MRD 1 ). The palpebral fissure width is the distance between the margins of the central upper eyelid and the central lower eyelid; ideally, this should be approximately 10 mm on each side. The MRD 1 is evaluated with the patient in a primary gaze position, by shining a light placed between the examiner’s eyes directly toward and parallel to the patient’s eyes at the same level. MRD 1 is the distance from the central upper eyelid margin to the center of the pupillary light reflex. Measurement of the MRD 1 allows more accurate assessment of upper eyelid ptosis than measurement of the palpebral fissure width, as the MRD 1 is independent of lower eyelid position. A normal MRD 1 is approximately 4.0 to 4.5 mm. Measurements smaller than the lowest limit of normal can signify upper eyelid ptosis. A difference between the MRD 1 measurements of each eye signifies upper eyelid asymmetry.
Upper Eyelid Crease Measurement
The upper eyelid crease is quantified by the marginal crease distance (MCD), which is the distance from the central portion of the upper lid margin to the central aspect of the crease in downward gaze. To measure the MCD, the patient is asked to look downward, then slightly upward, then downward again. A normal central MCD has been defined for women as 8 to 10 mm, and for men as 5 to 7 mm; however, a central MCD as high as 9 to 11 mm may be considered within normal limits. A disinsertion or dehiscence of the levator aponeurosis causing acquired upper eyelid ptosis results in an MCD that is much greater than normal. In contrast, patients with congenital ptosis often have an indistinct upper eyelid crease.
Recognition of eyebrow elevation may be more difficult unless there is asymmetrical compensated eyelid ptosis, as it requires knowledge of the patient’s own baseline: her eyebrow position in youth. Comparison of the patient’s current appearance with photographs taken before the age of 30 may be helpful in this regard.
Patient assessment and establishment of realistic expectations
The patient can be provided with a mirror and asked to point out what she specifically dislikes about the area around her eyes, and what she expects rejuvenation procedures to accomplish. Comparison with photographs from the patient’s youth may give a clearer picture of individual patterns of aging and what is realistically achievable.
Patients invariably desire treatments that are safe, effective, long-lasting, as painless as possible, and have the least possible postprocedural recovery time. Establishment of realistic expectations during pretreatment consultation is key to achieving patient satisfaction. It is important to discuss the nature of facial aging, and what can truly be defined as rejuvenation, ie, the achievement of a more youthful appearance. In our opinion, this does not include the obliteration of lines of expression or facial mobility, both of which are present even in children, the most shining examples of youthful beauty. Nor does it include the raising of the eyebrows to a level that is higher than is typically seen in children and young adults, in an attempt to offset loss of tissue volume, skin elasticity, and/or muscle tone. Patients may be best advised that well-performed procedures can help them to look their best for their age, rather than fueling an ill-advised and ultimately futile attempt to look a different age.
The practitioner can provide an approximate prediction of how much improvement in quality of upper eyelid skin might be accomplished through each laser and light energy-based device that is being considered for this purpose. Similarly, it is informative to define the extent to which eyebrows can repositioned or reshaped through the use of neuromodulators, fillers, and laser or light energy-based devices in the upper face. Finally, patients can be counseled if they probably will not achieve the outcome they desire with nonsurgical procedures alone, and if more invasive measures, such as blepharoplasty or endoscopic brow lifting, are appropriate.
Nonsurgical rejuvenation procedures
As noted previously, it is important to understand both structural anatomy and the functional interplay of eyebrows and eyelids when considering treatment strategies. Volume loss in all tissue planes ascending from the bone to the epidermis is now recognized as a cardinal feature of the aging process. In addition, skin elasticity decreases and there are changes in muscle tone, both in repose and in animation. These manifestations of aging can be addressed via nonsurgical procedures, with the caveat that the goal should always be to achieve natural-looking results, even if this entails compromising on the extent of improvement that is sought.
Treatment of the upper face with a combination of nonsurgical rejuvenation techniques can improve brow position, and correct upper eyelid hooding to some extent. These techniques can be divided into 1 of 4 categories:
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Neuromodulators
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Soft tissue fillers
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Laser and light energy-based devices
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Adjunctive treatments, including chemical peels and topical therapies
A further subdivision can be made according to the area to which the treatments are applied: within or outside the periorbital frame.
The Periorbital Frame
It may be helpful to assess the eyes within a “periorbital frame,” which we define as encompassing the eyebrow, the upper eyelid, the lower eyelid, and also the glabella and superior mid face. An individualized strategy for injection of neuromodulators within the periorbital frame can be formulated by coupling evaluation of each patient’s muscle mass and activity, and the extent and pattern of hyperdynamic and static rhytides, with a thorough understanding of facial anatomy and the patient’s treatment objectives.
Strategies for soft tissue fillers and lasers or light energy-based devices are determined by evaluation of periorbital volume loss, loss of skin elasticity, and dyspigmentation (most commonly, hyperpigmentation). Other treatment modalities that may be considered for integrative rejuvenation of the periorbital frame include chemical peels with glycolic acid, salicylic acid, or trichloroacetic acid; cosmetic tattooing (permanent makeup); semipermanent eyelash extensions; and eyebrow and eyelash tinting. Although some of these procedures may seem minor, and even trivial, they can produce gratifying results at a reasonable cost and with little or no recovery time ( Fig. 5 ).
Neuromodulators
The injectable neuromodulators that are currently approved by the United States Food and Drug Administration (FDA) for esthetic use are abobotulinumtoxin A (Dysport; Medicis, Scottsdale, AZ), incobotulinumtoxin A (Xeomin; Merz Aesthetics, San Mateo, CA), and onabotulinumtoxin A (Botox Cosmetic; Allergan, Irvine, CA).
Dysport and Botox are classified as complexed toxins because they are manufactured with the 150-kDa botulinum toxin A (BoNT-A) molecule bound covalently in a complex to accessory proteins, which are believed to dissociate from the toxin molecule within minutes of being exposed to physiologic pH during the reconstitution and/or injection process.
Xeomin consists of the BoNT-A molecule alone and is classified as a naked toxin.
Controlled studies of evidence level II have shown the safety and efficacy of Dysport, Xeomin, and Botox all to be excellent. Dosage units of Botox and Xeomin are clinically equivalent, whereas the dosage units for Dysport are distinct. Although there may be some variation in the equivalence of Dysport units with Botox or Xeomin units at different dosages, for practical purposes 2.5 Dysport (Speywood) units may be considered equivalent to 1 Botox or Xeomin unit.
Brow Shaping
When performed appropriately, eyebrow shaping has a profound effect on the face, both for women and men. In women, restoration of graceful arches to the eyebrows can partially relieve upper eyelid hooding and increase the emphasis of the eyes. This, in turn, increases the prominence of the upper one-third of the face relative to the lower two-thirds, which shifts facial proportions back toward the youthful ideal of the heart shape or inverted egg. Brow shaping with neuromodulators is often combined with neuromodulator treatment of the glabella, forehead, and crow’s feet to optimize patient satisfaction. In appropriately selected patients who have retained good skin elasticity and do not have a bulging pretarsal orbicularis oculi, it may also be valuable to add a small dose of neuromodulator to this zone of the orbicularis sphincter in the midpupillary line, with the aim of lowering the inferior ciliary margin by a fraction of a millimeter to produce an appealing, wide-eyed look.
Successful brow shaping with neuromodulators requires an understanding of the fascinating interplay among the following:
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Frontalis muscle, which serves as the brow elevator
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Superolateral portion of orbicularis oculi, which is the lateral brow depressor
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Procerus, corrugator supercilii, depressor supercilii, and medial portion of orbicularis oculi, which are the medial brow depressors
Technique
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To elevate the lateral portion of the eyebrows, a small dose of neuromodulator is injected subdermally at a single point into the superolateral portion of the orbicularis oculi on each side. Weakening of this lateral brow depressor allows the relatively unopposed frontalis muscle to better elevate the lateral eyebrow.
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The appropriate injection site can be identified by palpating the belly of orbicularis oculi under the lateral arch of the eyebrow in maximal contraction (frowning). The injection can then be performed with the patient in repose.
Surgical note: The eyebrows themselves cannot serve as an accurate guide to placement of this injection, as there is great individual variation in eyebrow shape and position, often amplified by tweezing in women .
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Injection of neuromodulator into the procerus and the corrugator and depressor supercilii muscles similarly weakens the medial brow depressors and allows the frontalis to elevate the medial portion of the eyebrows.
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If the frontalis is injected concurrently, its pattern of injection also influences eyebrow position and shape.
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To enhance the arch of the eyebrows, the lateral injection point on each side of the frontalis can be placed slightly higher than the medial injection point at mid-forehead level, to weaken the lateral portion of the frontalis less than the medial portion. A higher dose of neuromodulator over the medial and lateral portions of the eyebrows and a lower dose over the middle portion will magnify this effect ( Figs. 6 and 7 )
