Eye Rejuvenation

What is good eye rejuvenation?

Most people focus on one area of the eye. This may be the upper or lower eyelids as the first sign is often laxity & wrinkles. Proper eye rejuvenation takes into consideration many factors including laxity, the eye itself (pupils & scleral show), as well as volume changes of the orbit & tear trough. Balanced & natural rejuvenation address:

• Skin quality, namely wrinkles, laxity & pigmentation / dark circles.

• Volume of the orbit (eye area) including the orbital margin, medial cheek & trough. Volume also refers to the adjacent temple area & brow volume itself.

• Positioning of the brow & eyelids in relation to the eye itself.

• Muscles that surround the eye, this includes crow’s feet & under eye area.

• Fat bags & under eye area in the context of volume loss & pathology.

Can lasers help rejuvenate the eye area?

Lasers can have a profound effect on rejuvenating the eye area. This especially applies to static wrinkles (wrinkles at rest), as well as upper & lower eyelid laxity. The laser of choice depends on many factors including the clinical presentation, your skin type (colour) as well as your allowed downtime. As a guide:

• Level one treatments: for mild wrinkles & wrinkle prevention. Devices used include Tixel, Clear & Brilliant, low level LaseMD, Fraxel. 1-2 day recovery.

• Level two treatments: for mild to moderate wrinkles. Devices as above, however recovery 2-3 days.

• Level three treatments: for moderate wrinkles. Treatment includes high density thulium, moderate density CO2 fractional laser resurfacing, medium depth TCA peels, as well as combination therapy with HIFU & radiofrequency

• Level four treatments for moderate to severe wrinkles: hybrid laser resurfacing using both erbium & CO2 fully ablative lasers.

• Level five treatments for severe wrinkles. In this situation I combine heavy laser resurfacing with surgical procedures such as blepharoplasty. Recovery following this procedure ranges from 9 to 14 days.

What are the limitations of laser resurfacing?

There are three main limitations of lasers.

• Lasers do not replace volume, they merely tighten the skin. Volume loss is a major component of chronological aging, especially in the orbital (eye) area. Volume can only be replaced with dermal fillers or fat transfer.

• Lasers can only treat skin type 1-3, in the context of wrinkles & tightening. For darker skin types including Asian, Middle Eastern & Mediterranean patients, heavy resurfacing will result in prolonged post treatment darkness (post inflammatory hyperpigmentation). In this group of patients, the use of RF or HIFU devices in addition to threads & dermal fillers are advisable.

• Deep ablative laser resurfacing is associated with a downtime approaching 8+ days. The deeper the wrinkles, the more intense the procedure. In some cases, it may take 3-6 months before redness fades.

Why is volume replacement so important in eye rejuvenation?

The eyelid skin is made up of three distinct layers: a visible outer layer on the surface called the epidermis, a collagen-rich underlayer called the dermis, and an inner layer beneath the dermis called the subcutaneous or fat layer. With age there is a decrease in both collagen & fat. This results in ‘hollowness’ that clinically presents as deep-set eyes, shadows & tear troughs.

Volume replacement, with dermal fillers or fat transfer address fat loss. Lasers & energy devices address the upper layers of skin. Hence eye rejuvenation should address all three layers of the eyelid skin.

Does PRP work for the under eye area?

In short; no. PRP is often combined with microneedling. The latter can be effective in some patients, however I do not use it for the under eye area. Microneedling the eyelid area can lead to purpura, namely bleeding under the thinnest skin on the body. PRP does not give volume, nor does it consistently improve skin quality (including dark circles & under eye rejuvenation). The initial results are from swelling of the area. This result can be replicated with injections of saline or salt water. After the swelling of a series of PRP injections settles down, there is minimal, if any changes to the under-eye areas.

A more reliable, less risky procedure is under eye or tear trough dermal fillers. This procedure takes 2-3 minutes to perform, does not cause bleeding & in most cases gives a predictable increase in volume with a subsequent decrease in wrinkles. For patients with a tear trough, it decreases shadowing.

What is the best treatment for dark circles?

Treatment is based upon the causes of dark circles. In some cases it is pigmentation, on other it is due to increasedvascularity (blood vessels), volume loss & anatomy also plays a part, as well as laxity. In other cases it is due to overactive muscles. Medical conditions such as eczema, hay fever & allergies also contribute to dark circles.

I prescribe treatments such as anti-inflammatory eye creams, hyaluronic acid, lasers, injectables, & skin tightening devices to improve the eye area. For more on dark circles, go to the section on this website where I explain this common complaint in greater detail.

What is so special about eye rejuvenation in Ethnic skin types?

Asian & ethnic skin types have characteristics that are more commonly seen in the periocular or eye area. Understanding the key differences is especially important for eye rejuvenation.

• Dark circles are much more common in ethnic skin types.

• Malar hypoplasia

• Pigmentation is more common

• Skin responses are different

• Contraction is better in darker skin types, so it is not all bad news! Darker skin patients respond better to devices such as Morpheus8. This is because there is less breakage of collagen (elastosis) & collagen bundles are thicker in ethnic skin.

• Eyelid creases are also different (especially when creating a double eyelid). Caucasian patients have a crease that is between 4-7 mm from the margin, whilst Asian creases are 1-2 mm. This has to be taken into account for procedures like blepharoplasty.

What is a tear trough and can dermal fillers help?

An anatomical tear trough is a groove in the undereye area. Some patients have more prominent troughs. If suitable, troughs are treated non-surgically with dermal fillers. Hyaluronic acid is the most common dermal filler used in this area. Fillers work by volume replacement & collagen stimulation. This in turn reduces shadows, shallows the tear trough, and diminishes the look of ‘dark circles.’

How much filler is usually required to treat the undereye area?

The volume required to treat the trough itself is actually very small; somewhere in the order of 0.1 to 0.3 of a ml. As a guide a teaspoon holds 5 ml. In the majority of cases, filler is required to build the other structures that support the trough. The most common area to support is the ‘lid cheek junction.’ Thus, the actual volume required to properly rejuvenate the eye area is between 1 to 3 ml, depending on the anatomy & age-related volume loss of each patient.

What is fat transfer & can it help?

Fat transfer as the name suggests, involves taking fat from one area of the body, & transferring it to another. I do employ this technique to treat large areas of volume loss, however I discourage fat transfer, including nano-fat for the under eye area. This is my reasoning: Nano fat can improve skin quality, however in comparison to lasers, peels, & energy devices, the results are modest.

• Predictability is uncertain (as compared to dermal fillers). Even with meticulous processing & correct injection techniques fat is not as predictable as dermal fillers.

• Lumps & bumps are more common with fat transfer than with dermal fillers.

• Reversibility is more difficult with fat as compared to HA fillers.

• Fat transposition is a useful technique performed by ophthalmologists as a secondary procedure intraoperatively.

What is Laser Resurfacing & what can it do for the eye area?

Laser resurfacing is a new treatment that uses pulsed heating known as thermomechanical energy to contract & tighten eyelid skin. As it is not a laser, healing times are super fast & it can be used on all skin types, including dark / ethnic skin. Typically, 2-4 sessions are performed one month apart. This treatment is non-invasive & often does not require numbing cream.

What are other no downtime treatments for the eyelid area?

There are several methods I employ to rejuvenate the eye area with minimal downtime, they include-

Tixel resurfacing. This uses short contact heat to stimulate collagen & tighten skin.

RF using Tempsure or Pelleve. I have replaced Thermage with this treatment.

• Dermal fillers to replace volume.

• HIFU for the upper lids & brow.

• Muscle relaxants & anti-wrinkle injections for the crow’s feet area.

Can chemical peels rejuvenate the eye area?

Yes. Medium to deep peels including combination peels as well as croton oil phenol peels can rejuvenate the eye area. These peels are known as segmental peels. Skin healing takes 7 to 10 days, depending on the type of agent I use.

How can injectables & muscle relaxants treat eye wrinkles?

Simple injectables including muscle relaxants can have a profound effect on dynamic wrinkles such as ‘crow’s feet.’ Injections take less than a minute to perform & typically last 3- 6 months.

Most frequently dermal fillers are combined with muscle relaxants to improve volume as well the overall aesthetic of the periocular (eye) area.

Can eye creams help?

Eye creams can be useful in some but not all cases. They can be incorporated as part of an antiaging- prevention routine, or as part of a targeted approach to rejuvenation. Anti-aging eye creams contain retinol, niacinamide, hyaluronic & ascorbic acid. They should be titrated accordingly.

Pigmentation due to post inflammatory hyperpigmentation is a frequent cause of dark circles. Look for creams that contain argan oil, arbutin, ascorbic acid, citric acid, licorice root extract AHAs, & botanicals. Pigment reflectors can also be useful, including zinc, titanium & iron oxides.

Vascular causes: Increased blood flow can lead to pigmentation, dark circles & congestion of the undereye area. Creams that contain peptides, vitamin K & caffeine can help. Lasers are often used in combination with creams.