Tri Eye Treatment Journal By Dr Maryam Zamani, as featured in Aesthetics Journal

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Dr Maryam Zamani provides an overview of the aesthetic treatments available for rejuvenation of the eye, and details her ‘Tri Eye Rejuventation’ and ‘Tri Eye Transformation’ techniques

The eyes are the aesthetic centre of the face and are often referred to as the ‘window to the soul’. The periorbita is an area where we can often see the first signs of ageing and is cause for common requests for rejuvenation in aesthetic practices. Complaints include excess skin, fine lines and wrinkles, puffiness around the eyes and pigmentation issues. To understand these issues we need to understand the process by which they occur.

Starting in the third decade of life, redundancy of upper eyelid skin a begins and continues to progress until that skin rests on the uppereyelid lashes. This results in a hooded appearance that can also c be accentuated by the descension of the brow and underlying fat pads. In the fourth decade of life, the lateral canthal rhytids and accentuation of the lower eyelid folds are apparent at rest. This is followed by the herniation of fat pads in the upper and lower eyelids (Figure 1).1

With age, the cheek, periorbita and subobicularis fat atrophy while the orbital retaining ligament relaxes. The process results in a downward displacement of the lid-cheek junction and an indentation between the lower eyelid and the cheek, also known as the tear trough.2 Other factors can influence the appearance of the tear trough as well. Volume loss accentuates the nasojugal grove and the inferior orbital rim creating a hollow appearance (Figure 1).3 Some individuals are predisposed to having lower eyelid fat prolapse that can further accentuate the loss of volume directly inferior.4 Bone resorption in facial ageing in conjunction with soft tissue atrophy has created a move away from removal of excess skin and towards a trend to replace volume and induce collagen stimulation. Restoration of the periorbita is multifaceted and entails smoothing of the lower eyelid, often using a combination of different modalities, such as botulinum toxin, fillers, lasers, radiofrequency and ultrasound technology, to achieve the best aesthetic outcome.

Increased collagen degradation and decreased collagen synthesis means the adult skin loses approximately 1% of its dermal collagen content on an annual basis.5,6

Treatment Options

Technological advancements have been made to increase collagen synthesis. Skin rejuvenation can be categorised into two main categories: invasive and non invasive. In the last decade, there has been increased demand for noninvasive procedures for skin rejuvenation and a simultaneous explosion of new non-surgical techniques and combinations of such treatments to improve and rejuvenate the skin around the peri-orbita. These modalities include Intense Pulsed Light (IPL), fractionated laser treatments, radiofrequency and ultrasound technology. The evolving list of nonablative lasers and light systems also includes broadband infrared light, dual yellow laser, pulsed dye (585, 595 nm), Nd: Yag (1064, 1320nm), Diode (910, 1450 nm) and Er: Glass (1540 nm lasers).7 IPL is a non-coherent light that covers a large wavelength to be absorbed by the desired chromophores. It works by causing reversible thermal damage to collagen in the dermal layer and helps fibre remodeling without ablation to the epidermis.8 Regia et al showed improvement in flaccid skin related to the increase of collagen in the deep reticular dermis, promoting a skin tightening effect with IPL.8 Periorbital and facial treatment with IPL may help those patients with Fitzpatrick Skin types I-IV with pigmentation and vascular issues with secondary benefits of mild collagen induction.9

Radiofrequency is another nonablative skin rejuvenation modality used to cause shrinkage of dermal collagen and promote the formation of new collagen through controlled neocollagenesis without integumental injury. Radiofrequency devices are able to achieve greater depths of thermal injury with tissue penetration to the level of the dermis and subcutaneous layer without producing thermal burns.5 Such treatments are generally a succession of four to eight treatments depending on the particular device used.

Nd: YAG 1064 laser and the Norseld Dual Yellow Laser are non- ablative lasers used for aesthetic rejuvenation of the face. Nd: YAG 1064 can be used successfully and selectively to target haemoglobin in reticular vessels seen in the peri-orbita and temples (Figure 2).10 Norseld Dual Yellow Laser also uses the 578 nm yellow wavelength to target chromphores associated with oxyhaemoglobin in red telangectatic vessels. The Norseld laser is highly successful in treating small red telangectatic vessels along the eyelid margin.11

Fractional resurfacing for aesthetic enhancement continues to evolve using ablative, non-ablative and fractional technologies because of their improved safety profile. These three approaches mainly differ in the mode of thermal damage, degrees of efficacy and downtime.12 Fractional laser technology has gained increased popularity in improving scars, fine lines, dyspigmentation, and wrinkles because of its favourable side effect profile, recovery time and outcome.12,13 Common indications for both non-ablative and ablative resurfacing are for periorbital wrinkles, photo ageing and dyschromias. Laser resurfacing is used to help remove a specific layer of skin down to a specific depth of skin. In doing so, fine lines and wrinkles can be softened, pigmentation improved and skin tightened. Ablative lasers have the advantage of predictable depth of tissue ablation. Erbium; YAG lasers such as the iPixel by Alma can represent an improvement over CO2 lasers in producing less downtime.12,14,15 Fractional resurfacing produces specific microthermal zones of photothermolysis creating columns of injury whereas ablative skin resurfacing creates a confluent area of epidermal and dermal injury.16 Fractional thermolysis leaves intervening areas of normal skin untouched whereby re-epithelialisation and repair can occur rapidly. These treated zones compromise 15-25% of the skin surface per treatment depending on the machine, wavelength, fluency and stacking application of the laser. From my experience, generally two to six sessions are needed to complete a treatment. Similar to ablative resurfacing, the thermally ablated tissue is repopulated by fibroblast-derived neocollagenosis and epidermal stem cell production.12 The advantages of the fractionated laser treatmentinclude reduced erythema, oedema, downtime and dyschromic changes, particularly important in treating Fitzpatrick skin types V and VI.12 Such treatment modalities have an important role in treating the delicate lower eyelid skin, particularly in patients that are not yet candidates for lower eyelid blepharoplasty. In a comparative split-face trial with fractional Er:YAG and microfractional CO2 laser resurfacing showed greater efficacy and patient satisfaction for the fractionalCO2 laser,17 however recovery time and risks for CO2 laser were higher. The spectrum of adverse sequel range from mild (prolonged erythema, milia) to moderate (transient to permanent dyspigmentation, local infection) to severe (hypertrophic scarring, ectropian, systemic infection).1

Ultherapy is another non-invasive treatment modality using microfocused ultrasound (MFU) with visualisation to create thermal micro-injuries also known as thermal coagulation points (TCP) in the dermis and subdermal tissue. Despite its lower energy, MFU is capable of heating tissue to greater than 60C to a depth of 5mm within the mid to deep reticular layer of the dermis and subdermis, while sparing the overlying papillary dermal and epidermal layers of the skin.18,19 MFU causes collagen fibres in the superficial musculoaponeurotoic system and deep reticular dermis to contract and stimulate de novo collagen.18 An ultimate lift is created in the healing of the TVP resulting in firming, tightening and shrinking of the dermis and subdermal tissues. The efficacies of Ultherapy treatments vary on the vector direction of treatment and the total energy supplied. Off label, Ultherapy has been used for improving the infraorbital skin laxity by both tightening the obicularis oculi muscle and the orbital septum.18,20,21 Ultherapy has a reputation of being painful; however with proper pre-treatment analgesics, this is well controlled.22 Pain, oedema, headache, numbness, paresis, PIH, bruising and welts are potential transient risk profiles that need to be discussed with the patient.23

Botulinum toxin is an effective neuromodulator used in aesthetic rejuvenation to temporarily paralyse the muscles of facial expression thereby decreasing wrinkle lines created by muscle activity. In the periorbita, botulinum toxin has FDA approval for treatment of the crow’s feet and glabellar lines and can be effective in treating the lower eyelid lines and elevating the tail of the eyebrow. As a low risk procedure, botulinum toxin is considered a relatively safe treatment to help diminish the lines created by facial expression.24

Hyaluronic acid (HA) fillers are now playing an even bigger role in treating the ageing eye and face as a three dimensional approach to rejuvenation with particular attention to proportional ideals. In determining the HA to use in the periorbita it is essential to look at the viscosity (how the gel flows from the needle) and elastic modulus (gel stiffness) of the product. In treating the periorbita, I prefer using products from the Juvéderm Vycross family, particularly Volbella in the anatomical tear trough because of its lower HA concentration of 15 mg/ml. A lower HA concentration means the gel is less hydrophilic and will absorb less water from surrounding tissue, causing less oedema.25 HA can be injected into the peri-orbita and malar region with both deep (pre-periosteal and submuscular) and dermal injections in order to temporarily help reduce the appearance of lines and wrinkles. While techniques vary, most incorporate serial depots of HA along the inferior orbital rim, into the subobicularis oculi muscle either in a ‘haystacking’or injection-withdrawal technique to layer support. An often undertreated and neglected area for HA treatment is temporal hollowing and can have a significant impact on overall facial rejuvenation. All HA injections in the periorbita carry significant risk and great care to understand and respect the underlying anatomy must be taken to minimise potential pitfalls.

Tri Eye Rejuvenation and Transformation

In treating the periorbita, there is a vast array of combination treatments that can be implemented. I find that often the most successful aesthetic results come from combining different modalities together to create a more unified approach to rejuvenation and improve overall patient satisfaction. Creating a patient specific treatment plan to combat specific issues is needed for a complete rejuvenation. The combination of botulinum toxin type A and hyaluronic acid appear to rejuvenate the periorbital and temporal areas, glabella, and crow’s feet areas with minimal adverse effects and with higher rate of patient satisfaction.26 In my practice, I have created a triad of treatments in two specific non-surgical protocols called the ‘Tri Eye Rejuvenation’ and ‘Tri Eye Transformation’ to address the ageing periorbita. I have a significant number of patients who present in my clinic complaining of the appearance of the skin around the eyes but who are not yet surgical candidates or do not feel ready or willing to have surgery. The ‘Tri Eye Rejuvenation’ combines botulinum toxin, HA fillers and Ultherapy in two sessions, ten to 14 days apart, to treat brow ptosis, crow’s feet and the tear trough in a younger patient generally aged 30-50. In the first visit, Ultherapy is used to treat the brow and the lower eyelid and to promote lifting and tightening of the periorbita. 10-14 days later patients return for treatment of the tear trough and temples with HA fillers and toxin to the crow’s feet (Figure 3). All patients are educated about waiting three to six months to observe the final improvement from Ultherapy and that botulinum toxin and HA treatments require maintenance.

Alternatively ‘Tri Eye Transformation’ combines HA filler, laser and the iPixel to treat patients that suffer more from periorbital volume loss resulting in fine lines, wrinkles and prominence of vasculature. This treatment has approximately three to six days of downtime. In the first visit, Norseld or Nd: Yag is used to target telangectactic and reticular vessels in the periorbita. On the same visit, iPixel is used to fractionally ablate the periorbital skin. Three more sessions of iPixel are completed monthly and upon satisfaction of this resurfacing, HA filler is injected to help augment the volume loss in the temples and periorbita, which includes the tear trough and mid cheek segments.

Conclusion

Both these and other combination treatments used for rejuvenation of the periorbital region have been tested to show relatively long-lastingefficacy and high patient satisfaction.27, 28 Integrated treatments for the eye area using variant procedures creates a greater understanding of the multifaceted changes that occur in the ageing face.

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