The eyes may be “windows of the soul” but the periocular area may also give away other secrets, such as our age and even aspects of our lifestyle – late nights, poor diet, sun-worshipping and smoking. Periocular tissues are delicate and mobile, making this area one of the earliest to develop fine lines (rhytids), pigmentation and sagging skin, the signs of ageing that cause distress when we identify them in our reflections.
The periocular area can be defined by the margins of the orbicularis oculi, a circular muscle whose margins extend from just above the eyebrows and upper bony rim of the eye socket to just below its lower bony rim and horizontally from the temple to the bridge of the nose. Contraction of the orbicularis results in eyelid closure and it also contracts during other expressive facial movements such as smiling, hence the term “laughter lines” which we start to see at the outer corners of our eyelids from our early thirties. The skin of the eyelids is thinner than any other skin on our bodies and becomes thinner with time, which in addition to age-related loss of subcutaneous soft tissue and pigmentary changes from sun damage, may lead to the appearance of dark circles.
The periocular area is also affected by changes within other facial compartments; the outer third of the eyebrow commonly descends with time due to loss of support in the forehead; this descent combined with loss of skin elasticity may result in a hooded appearance of the upper eyelid. Descent and deflation of the soft tissues in the cheek may cause exposure of the lower bony rim of the eye socket, leading to the appearance of the “tear trough” a deep ridge above which “eye bags” sometimes appear. These are composed of fat from the eye socket, exposed by the baring of the bony orbital rim and are a source of cosmetic concern for many.
Given the impact of the ageing changes described in the brow and cheek, rejuvenation of the periocular area should also address descent and deflation of these areas to be effective and to promote a natural-looking youthful and harmonious facial appearance. The approach will depend on factors such as age, skin type and individual variations in facial anatomy and as a result should be tailored to the individual. Botulinum toxin, dermal fillers, chemical peels, microneedling and surgery or a combination of these are used to rejuvenate this area.
Botulinum Toxin (BT)
A naturally occurring neurotoxin, BT causes selected nerve endings to die back, thus preventing their corresponding muscle from contracting. This can be appreciated from about 3 days post-injection; full regrowth of the nerve endings results in restoration of muscle function after 3 months.
Targeted injections of BT within the orbicularis muscle can help to relax the outer portion of the muscle, reducing the concertina-like folding of the “crows’ feet” and elevating the eyebrow, thus reducing the upper eyelid hooding and bestowing more awake and refreshed appearance. BT injected into the central portion of the brow reduces the depth of the vertical lines established from years of frowning. In addition to reducing the appearance of existing rhytids, BT can help to prevent new ones from forming. Possible unwanted effects include localized bruising at injections sites and rarely, double vision, drooping of the eyelids and difficulty with eyelid closure.
Dermal Filler (DF)
Volume loss from the brow, cheek and tear trough areas can be addressed using DF of which there are many types. Broadly speaking, they fall into two categories; autologous (the person’s own tissue) such as fat and non-autologous such as hyaluronic acid (HA). HA can also be used to improve periocular skin texture and tautness, reducing translucency and the appearance of dark circles. The proximity to the eye, thinness of the skin and highly mobile nature of the soft tissues make the periocular area a particularly unforgiving site for injectables and therefore requires specialist expertise. Risks include superficial migration of product, leading to a lumpy appearance or a bluish tinge under the skin; infection, inflammation and allergy. There have also been rare reports of blindness in the worldwide literature. Permanent and semi-permanent non-autologous DFs are not recommended in the periocular area as unlike HA they cannot be easily dissolved and require surgery to remove. The effects usually last for a minimum of 6 months.
This can be achieved using chemical peels, microneedling and low viscosity HA. By creating a low-grade inflammatory response within the dermis of the skin, the production of new collagen is stimulated, improving the texture of the skin and reducing the appearance of dark circles and fine lines. A course of treatments at intervals of 2-3 weeks over several months is usually recommended for best results. The main side effects are short-lived and include localized redness/puffiness and in the case of chemical peels, dry skin.
Blepharoplasty refers to the removal of redundant skin and/or fat from the eyelids. “Eyebags” can be removed and the tear trough smoothed out by repositioning fat over the bony rim in the lower eyelid. If the main problem is lower eyelid bags without any excess skin, this procedure may be performed from the inside of the eyelid, thus avoiding visible scarring. The incision for an upper lid blepharoplasty is made within the natural skin crease, so the scar blends into a pre-existing line, usually healing almost invisibly.
Brow and cheek descent can also be addressed surgically and may be performed in combination with blepharoplasty. Surgery may be performed under local or general anaesthetic as a day patient. Substances which inhibit blood clotting e.g. aspirin, warfarin, ginger, garlic, ginkgo biloba and vitamin E should be avoided pre-operatively in order to discourage post-operative bleeding which, if severe may compress the optic nerve risking visual loss. Recovery takes several weeks due to localized bruising and swelling; the eyelids may not fully open or close in the first few postoperative days.
If you are considering rejuvenation of your eyelid area it is worth noting that addressing changes in the adjacent areas of your face will complement treatments undertaken in the periocular area and that whilst surgery may be recommended for some, there are other less invasive options available.