Periocular Aesthetics: An Emerging Era

The periocular region is the first to display early ageing changes, and there are several concerns that stand out for the patient: Eyelid skin fold, lower lid bags, under eye dark circles and hollows to name a few.

Soft tissue facial rejuvenation around the eye has traditionally focussed on surgical procedures that are based on the principles of removing ‘excess’ tissue and lifting the tissues against gravity. Over the years, these ‘excisional’ procedures have fallen into disrepute both for the patient as well as the physician, to pave the way for minimally invasive facial rejuvenation. More and more patients with periorbital aging changes are actively hoping to avoid invasive surgeries. If surgery is indeed required, a hidden incision is an understandable desire. The time is right therefore, to collate excellent write-ups from the leaders in periorbital aesthetics.

Periorbital hyperpigmentation has been extensively studied and has several anatomic reasons as well as pathological pointers that can be improved by a variety of treatments. Vrcek et al. present a nice review of the pathogenesis, evaluation and management of infra-orbital dark circles.[1]

The second important aesthetic concern in the eye region is the lower lid area. Not only do the eyelid ‘bags’ need to be identified as fluid or fat, but the presence of several hollows or valleys in this area makes it complex. The evaluation requires a thorough knowledge of the periocular anatomy, as several surgical and non-surgical treatment options come into play in this region. The review article discusses the so-called ‘hills and valleys’ in the under eye region in a simplified manner for the dermatologist.[2]

In the face, it is now clear that tissue does not merely respond to the effects of gravity. There is compelling evidence that the primary theme in facial aging is ‘volume loss’.[3456] In the periorbital region too, the under eye hollows may actually be caused by volume loss that mimics gravitational descent. Approaching the aging face in this new light of volume loss allows us to think differently. Instead of excising and lifting the tissues, we now think of ‘filling’ the face.[7] Fillers work wonderfully for the lower lid tear trough. Injectable fillers are not only less invasive than surgery but frequently the aesthetic result is better than surgery. Personally, I find fillers to be far more effective than performing a fat-repositioning surgery or a mid-face lift.

Injectables in the periocular region have recently received a lot of attention due to its severe and sight-threatening complications. Hwang's article in this issue focuses on the current concepts and understanding of these complications.[8]

With the increasing interest in Dermatosurgery, the dermatologists are more closer to blepharoplasty than ever. The principles and safe limits of upper eyelid blepharoplasty should be known to any physician involved in this surgery. Similarly, it is important to know the options of blepharoplasty in the lower eyelid (trans-cutaneous vs. trans-conjunctival), and the factors that decide the choice. Scawn et al. have simplified the decision making and surgical approach to blepharoplasty in their article.[9]

The periorbital region is complex regarding its three-dimensional anatomy as well as function. Oculoplastic surgeons have long been at the forefront of this paradigm shift toward minimally invasive facial rejuvenation. This is an era of cross-specialisation and teamwork. Let us collate the core talents of dermatology, ophthalmic plastic surgery and facial plastic surgery to achieve precise, safe and effective options for facial rejuvenation. In the periorbital region, the highest skills of attention to detail, delicacy and hidden incisions will win the race, and deliver better results with minimally invasive techniques.