Eyes Wide Open

Created on 15th January 2012

Lisa Jennings investigates eye rejuvenation...

Dark circles, crow's-feet and baggy eyelids are all ageing, so it's hardly surprising that Botulinum toxin (botox) and hyaluronic acid filler treatments such as Restylane are so popular. Indeed, botox is the number one non-surgical cosmetic procedure in the US.

When considering a patient for eye rejuvenation, most practitioners who use injectable treatments tend to divide the face into the upper and lower part, with the dividing line being just below the eyes. Before botox became popular, collagen was used to treat both parts. However, it wasn't ideal for the upper part for two reasons. Collagen doesn't give lasting results as it's metabolised by the body in four to six months. More importantly, upper lines tend to be dynamic, and only visible in motion. Dermal fillers can be used in crow's-feet to treat residual static lines but botox is the first line of treatment. However, there is more scope for using dermal filler than it's commonly believed.

Filling in

Dr Lucy Glancey explains, "As we age we lose facial fat which results in elongation of the lower eyelid, lower position of the lid to cheek junction and exposure of the lower lid herniated fat pads. This results in three grooves in the mid face: the naso-jugular, orbito-malar and mid-cheek grooves. Patients complain they are looking ‘tired' and have ‘developed dark circles around the eyes'."

One of the easiest and fastest ways to correct this is by using dermal filler to fill the grooves and eliminate dark shadows created by the loss of volume. Dr Glancey says, "There are three main categories of patients that come to my practice seeking such treatment. The first is young patients in their 20s or early 30s who have flat, thin faces. The lack of facial fat can lead to premature ageing, with the naso-jugular groove being one of the first indications. This is also known as the tear trough because it looks like a depression created by the tears as they fall.

"The second category is patients in their late 40s or early 50s, who had a good initial amount of subcutaneous fat and bony support which has delayed the aging process, meaning dark circles are observed at a later date. This process can be accelerated by rapid weight loss which is popular among middle-aged women."

"The third category is those who have had lower blepharopasty (excess skin removal from the lower eyelids) in their early 30s and had too much fat removed, leading to the replacement of an ‘eye bag' with a hollow eye."

Bags of opportunities

Filling the naso-jugular groove is the most common treatment, alongside botox. This is because it tends to appear earlier than other wrinkles. Some people complain that they have ‘eye bags' but although some cases are genuine, exposure and accentuation of the naso jugular groove alone can lead to ‘pseudo-eye bags'.

The best treatment is a fine-grade hyaluronic acid dermal filler such as Restylane. This is soft, malleable, immediately correctible and ideal to mould without leaving lumps. The filler is injected deeply: superficial placement can result in a lumpy appearance. The procedure is almost painless, and topical application of anaesthetic cream is sufficient to deal with it.

For mid-cheek lines, hyaluronic acid-based fillers are used once again. Afterwards, the patient may experience bruising and swelling which usually settles in one to two weeks. Anaesthetic cream or a regional block can be used for pain management. The treatment usually lasts six to twelve months.

Dr Glancey says, "If the patient is apprehensive, I use the saline test. This involves injecting saline into one cheek and taking photographs. The photographs are given to the patient so they can have more time to observe and decide."

Dark looks

There may be other causes for dark circles. Hyperpigmentation is common in people with dark skins as they inherit a genetic tendency for dark pigmentation around the eyes. Dr Glacey says, "This can respond to melanocyte suppressing agents such as Hydroquinone, as well as some lasers in particular the Ruby laser."

In patients with pale skins, dark circles can be due to the underlying blood vessels being visible through the very pale, thin skin. Glancey says, "This gives the appearance of a bluish-purplish tinge to the lower eyelid and can respond to vascular lasers."

When it comes down to it, practitioners need to be aware of all the different treatment methods, as in some cases there are multiple causes for a condition. However, with the right combination, looking tired can be a thing of the past.
CSMUK