Key points

Introduction

The periorbital facial subunit consists of the eyebrows, upper and lower eyelids, glabellar region, and pericanthal area. It is one of the first regions to reveal signs of aging and plays an important role in overall facial appearance. The aging process is influenced by our genetic composition as well as environmental factors. Aging skin is characterized by the appearance of fine and coarse rhytides (wrinkles), rough and uneven texture, dryness, and changes in pigmentation. Animation lines in the glabella and lateral canthi, along with volume loss, add to the aging appearance. Repeated facial expressions, ultraviolet radiation exposure, and cigarette smoking all contribute to decreased skin elasticity and development of aging characteristics. With new advancements in cosmetic medicine, nonsurgical and minimally invasive procedures have become first-line treatment options. Treatments that are commonly used today include topical therapies, mechanical and chemical skin resurfacing techniques, use of lasers and radiofrequency devices, fillers, and neuromodulation by use of botulinum toxin (BoNT). Each of these treatment options provide specific benefits as well as different side-effect profiles and can be combined to maximize results.

Introduction

The periorbital facial subunit consists of the eyebrows, upper and lower eyelids, glabellar region, and pericanthal area. It is one of the first regions to reveal signs of aging and plays an important role in overall facial appearance. The aging process is influenced by our genetic composition as well as environmental factors. Aging skin is characterized by the appearance of fine and coarse rhytides (wrinkles), rough and uneven texture, dryness, and changes in pigmentation. Animation lines in the glabella and lateral canthi, along with volume loss, add to the aging appearance. Repeated facial expressions, ultraviolet radiation exposure, and cigarette smoking all contribute to decreased skin elasticity and development of aging characteristics. With new advancements in cosmetic medicine, nonsurgical and minimally invasive procedures have become first-line treatment options. Treatments that are commonly used today include topical therapies, mechanical and chemical skin resurfacing techniques, use of lasers and radiofrequency devices, fillers, and neuromodulation by use of botulinum toxin (BoNT). Each of these treatment options provide specific benefits as well as different side-effect profiles and can be combined to maximize results.

Topical therapies

Adjunctive skin care is important in the overall rejuvenation and to help maintain results with other procedures. Given that there are thousands of products available and the high acceptance by patients, it is important that physicians review which products may actually be of value for the patient ( Box 1 ). Eyelid skin is the thinnest in the body and can be sensitive to any of the topical products.

Sunscreens are indispensable to help prevent photodamage and to help reduce the development of after-procedure hyperpigmentation. To maximize their benefit, a sun protection factor of 30 or higher (for ultraviolet B [UVB] protection) and a “broad spectrum” (for ultraviolet A [UVA] protection) sunscreen should be worn on a daily basis. Many makeup lines will have UVB protection but usually lack adequate UVA protection.

Antioxidants scavenge free radicals, which are capable of damaging cellular membranes, DNA, and proteins within cells. The most commonly used in topical therapies include vitamin C and vitamin E, and combinations of the 2 have been shown to provide more potent photoprotection than either agent alone. Niacinamide has anti-inflammatory properties as well and may improve hyperpigmentation by decreasing the transfer of melanosomes to keratinocytes.

The use of topical retinoids improves wrinkles by increasing dermal collagen synthesis and inhibiting dermal collagen degradation. Dyschromia can be improved via inhibition of tyrosinase activity, decreasing melanosome transfer and increasing shedding of keratinocytes. Only tretinoin and tazarotene have US Food and Drug Administration (FDA) approval for the treatment of photodamage, and both can have side effects, such as dryness, redness, flaking, and irritation to the skin, limiting their use by patients. Over-the-counter retinoids such as retinol is less irritating than retinoic acid but is also 20-fold less potent than tretinoin.

Peptides and growth factors are thought to improve wrinkles and lines by upregulating collagen production, downregulating collagen degradation, aiding in tissue repair, and via intercellular signaling. There has been some concern that the use of cosmeceuticals containing human growth factors could be associated with the development of skin cancer in predisposed individuals, although there are no reports in the literature.

Topical bimatoprost 0.03% was FDA-approved in 2008 for the enhancement of eyelashes. Its use results in darkening, increased eyelash length, and density (thickening). Its safety and efficacy have been well established along with a good tolerability profile. The authors have patients apply nightly for 4 months to achieve optimal results; then patients can begin a maintenance regimen of applying the product 3 to 4 nights weekly. In addition, patients can apply the product to the eyebrows, but this is off-label and not well-studied. The most common side effects are redness and pruritus.

It is the practice of the authors to maximize the use of tretinoin and sunscreen before adding other topical agents to their regimen. Gentle cleansers and moisturizers are typically needed to combat the side effects of the tretinoin.

Skin resurfacing

Improvement of skin texture, color, scarring, and wrinkling is an important part of periorbital rejuvenation and can be achieved through many different techniques, including chemical peels, dermabrasion, and laser therapy. In general, as the depth of injury increases, the results become more dramatic, but the healing time and potential risks also increase, regardless of the tool or device used. Eye protection is important when performing periocular procedures. Resurfacing can be performed as monotherapy, but more often is used as an adjunct to other therapies and surgical procedures.

Chemical skin resurfacing (peels)

Chemical peels are an effective option to treat photodamaged skin, rhytides, scarring, and dyschromia. Based on the depth or level of injury, peels are classified as superficial, medium, or deep. Peels can induce exfoliation, epidermal thickening, skin lightening, and new collagen formation, leading to skin rejuvenation. They have a well-known safety profile, relatively low cost, and predictable downtime. It is particularly important to evaluate the patients’ expectations as well as their skin type in order to achieve desired results. Patients with Fitzpatrick skin types IV to VI have increased risk for developing dyspigmentation after treatment as well as hypertrophic and keloid scarring. As a result, these individuals would benefit most from superficial or medium-depth peels. Skin preparation is commonly used before a peel and can include topical tretinoin, hydroquinoine, sun protection, and herpes prophylaxis for deeper peels. The depth of any peel can be altered by the skin preparation, and the method of application of the peeling agent.

Superficial chemical peels affect mainly the epidermis, with occasional involvement of the papillary dermis, and can be used to treat mild acne scarring, mild photoaging, solar lentigenes and keratoses, as well as epidermal dyschromia. The major advantage is that they can be used in all skin types with minimal risk of inducing postinflammatory hyperpigmentation. The types of peels in this category include glycolic acid, salicylic acid, 10% to 25% trichloroacetic acid (TCA), and Jessner solution (combination of resorcinol, salicylic acid, and lactic acid in 95% ethanol) and mainly affect the superficial epidermis. Higher concentrations of glycolic acid (70%) or TCA (25%) can cause the level of injury to extend to the basal layer and create regeneration of the entire epidermis, significantly aiding in the treatment of acne, mild photoaging, and melasma, but not quite as effective to induce dermal remodeling. The depth of the wound caused by the various dilutions of TCA is paramount to the therapeutic efficacy. The side effects of superficial peels are fairly minimal and include irritation, erythema, allergic or contact dermatitis, and temporary burning and stinging sensation. The downside is that repeat series of treatments are generally needed to obtain effective results and are usually separated by several weeks.

Medium-depth chemical peels affect the papillary dermis and part of the upper reticular dermis and can be used for mild to moderate photoaging, mild rhytides, and blending of skin after using other resurfacing procedures. In order to create controlled injury, the agents most commonly used are 35% TCA in combination with Jessner solution, glycolic acid at 70% concentration, or solid carbon dioxide. The depth of injury is determined by the degree of skin frosting, rated from I to III after the acids have been applied ( Table 1 ). The Jessner–TCA combination induces new collagen production that persists at least 4 months after a single treatment and reduces dyschromias due to superficial melanin retention or deposition. Medium-depth peels are especially effective in improving advanced photoaging in the periorbital area. Special care around the eyes is necessary to prevent acid to be wicked into the eye from tearing or into tears running down the cheek, which can cause the peel to travel down the cheek, creating linear streaks. Applying a small amount of petroleum ointment at the lateral canthus can help to prevent these side effects. The expected after-procedure effects include edema, crusting of the skin, and eventually re-epithelization by 1 to 2 weeks.

Deep chemical peels result in tissue injury that affects the midreticular dermis and can be used to improve deeper rhytides, moderate to severe photoaging, and extensive actinic keratoses. The peels in this category include 50% TCA, occluded phenol, and occluded or unoccluded Baker-Gordon formula (3 mL of 88% phenol, 2 mL of tap water, 8 drops of Septisol, and 3 drops of croton oil). Because of the thin skin in the periorbital area, if a deep chemical peel is chosen, a modified Baker-Gordon formula should be used, which includes mineral oil in place of water and fewer drops of croton oil. Deep chemical peels can be very effective, but are also associated with more potential complications, including risk of scarring, textural changes, hyperpigmentation or hypopigmentation, and risk of ectropion of the lower eyelid if used near the eyes. If an ectropion does develop, it tends to be self-limiting and corrects spontaneously or with conservative care. More specifically, phenol peels can cause cardiac, renal, and pulmonary toxicities and require careful cardiac monitoring and hydration with intravenous fluids before and during the procedure to facilitate phenol excretion. Wound-healing process is similar to when medium-depth peels are used, but wound dressings and wound care are necessary due to more extensive dermal damage.