Dr Nikola Milojevic explains how dermal fillers, botulinum toxin and plasma can be used to address the signs of ageing in the upper and lower eye
The history of eyelid procedures dates back to 25 A.D. when Aulus Cornelius Celsus, a Roman philosopher, described the excision of excess skin of the upper eyelid.1 Coming forward to the 1970s, Dr Bob Flowers from Hawaii introduced the supratarsal fixation for the upper eyelid crease,2 which is where a low eyelid is re-established by fixating a fold higher up; a procedure very popular among Asian patients to this day. Dr Flowers was a close friend and colleague of my late father Professor Bosko Milojevic, and they worked on this procedure together, hence my fascination with the periorbital area from a very early age.3
More pertinent to this article was the accidental discovery of botulinum toxin for wrinkles. In 1987, a Canadian ophthalmologist, Dr Jean Carruthers was treating blepharospasm in her patients with botulinum toxin, and, to her surprise, noticed a side effect of wrinkle reduction around the eyes.4
Then, in 2007, ophthalmologist and oculoplastic surgeon Dr Raman Malhotra first described the non-surgical ‘eye bag’ removal procedure using hyaluronic acid (HA) dermal fillers, and my practice has been enriched by this procedure ever since. With these new advances, we are able to apply a more holistic approach to treatment and, increasingly, we’re able to perform procedures effectively, with fewer risks and downtime than surgical procedures.
The anatomy and physiology of the ageing upper face is well known and documented.5 In the lower eye area, there is often tear trough depression due to a genetic predisposition associated with the tear trough ligament.6 In most cases, however, the hollow or dark circle appearance is due to mid-cheek malar fat pad atrophy and the subsequent parting between the lower eye bag fat pad and the malar fat pad, which slides lower with gravity. The decreased elasticity of the overlying ageing skin also contributes to this hollow, as well as skeletal ageing.7,8 In the upper eyelid, the skin increasingly sags and droops due to a loss of elasticity in individuals with a genetic predisposition or due to extrinsic factors.9
Upper and lower eyelid ageing is a problem for many patients – according to the British Association of Aesthetic Plastic Surgeons (BAAPS), blepharoplasty was the second most common surgical procedure in 2016 in the UK, with the first being breast augmentation.10 Patients usually present with the complaint that they look tired, despite the fact that they often feel full of energy and lead healthy lives.
Common presentations in my clinic for eye concerns include:
Below, I will detail some of the common treatments I perform in my clinic related to the above concerns.
This is a complex procedure, only to be performed by those with extensive experience in the administration of dermal fillers and a thorough knowledge of facial anatomy. The choice of material is key, and more permanent options, such as permanent fillers, which patients may seek, are simply contraindicated here due to the long-term risk of side effects.12 In my opinion, the only option for treatment of the tear trough is a cross-linked HA dermal filler, as it is reversible using hyaluronidase, which gives patients and practitioners reassurance. Also, the cross-linking ensures that the results last,13,14 and with the right choice of filler, from my experience, these results can last as long as 12-24 months. In some cases, I have even seen results last longer than 24 months.
It is important that the thickness of the filler has been chosen correctly; practitioners must note that they are unlikely to use the same type of filler for different patients. In patients with shallow dark circles and thin skin, a filler with a low G-prime, designed for rejuvenation may be used. However, in patients with larger eye bags and significant volume loss, it is more appropriate to use a filler with a high G-prime and volumise the upper cheek to help fill the tear troughs.15 On average, I use 1ml filler per eye.
I prefer to use a needle as I feel that it offers a much more precise way to achieve good results without side effects, as opposed to the cannula. As long as practitioners know the anatomy of the area, they can avoid side effects such as bruising and vascular compromise. Sometimes bruising is an unavoidable side effect, although if managed properly, it should not adversely impact the lifestyle of the patient. It is important to inject deep and, in most cases, just above the periosteum. I use many different techniques including the bolus technique, linear threading, and the pyramid technique, where I deposit a small amount of filler with a low G-prime closer to the surface.16
In my opinion, the only option for treatment of the tear trough is a crosslinked HA dermal filler, as it is reversible using hyaluronidase, which gives patients and practitioners reassurance
I use all of these techniques in most of my patients to achieve the best results, as, in my opinion, they work in synergy for results which are the most natural, with the least side effects. Of course, depending on the depth of the tear trough, or whether the skin under the eye is thin or thick, some of the techniques may or may not be necessary. With as many as 30 injections around each eye, I build the dermal filler to correct the depression and to literally hide the eye bag in what I call a ‘patchwork technique’, which is not possible with a cannula.
A massage of the treated area is very important, and the patient should be advised of strict aftercare instructions to avoid side effects such as redness, bruising and oedema, which tend to last for up to a week.17 Patients should avoid exercise and alcohol for 24 hours, and should apply ice and arnica gel to the treated area. Long-term swelling, unevenness and lumps can occur, however, they are rare. In my experience, these issues are either resolved by a vibrating massage or hyaluronidase. The massage should be very strong and pressured in nature, with a vibrating motion of the fingers necessary, to literally break down any clumping or areas of persistent oedema.
Patient education and management of expectations before the procedure is important, and will go a long way to improving outcomes and patient satisfaction. Recorded complications include allergies, infections, vascular compromise and even blindness,18 however these are rare and extensive knowledge and experience in offering this treatment will help to avoid such concerns.
As the skin surrounding the eyes loses elasticity, wrinkles around and under the eyes become more permanent. These are wrinkles of expression, and the main muscle that causes these wrinkles is the orbicularis oculi.
When treating patients with dermal fillers for tear troughs, I often also advise toxin treatment of the orbicularis oculi for two reasons. Firstly, because the combination treatment on the lower eye area with dermal fillers has a better cumulative effect, and secondly, for those with lowered upper eyelids, this treatment may raise the eyebrows and open the eyes up.
The usual dose of botulinum toxin around the eyes is 2.5-5 units per injection at three superficial injection points and, for wrinkles under the eye, it is possible to inject a lower dose of 1.25-2.5 units, up to the mid-pupillary line.
Plasma is a Greek word which means ‘anything formed’,18 and it is one of the four fundamental states of matter; the others being solid, liquid and gas. Plasma can be described as a cloud of protons, neutrons and electrons, where all the electrons have come ‘loose’ from their respective molecules and atoms, giving the plasma the ability to act as a whole, rather than as a group of atoms. Plasma is more like a gas than any of the other states of matter due to the atoms not being in constant contact with each other.
Aesthetic fractionated plasma devices19 use a special generator to produce a micro current. The electrical discharge generated is used to treat indications through the applicator, which is composed of a plastic handpiece and a medical stainless-steel electrode. The electrical discharge causes a temperature rise in a targeted part of the skin in a very selective way, with high energy density.20 This causes sublimation spots of the superficial corneocytes, without affecting the basal cell layer, creating a lifting effect.20
Plasma devices can be used to remove the excess skin on the upper eyelid. In many cases, only one treatment is needed, but sometimes a second treatment is necessary after four to six weeks, to remove all excess skin. They can also be used for rejuvenating the whole face, as well as removing moles, xanthelasma (yellow cholesterol deposits in the skin around the eyes) and even scars.21
I believe the fractionated devices achieve better results and less side effects when compared to their predecessors, which were not fractionated.22 From speaking to colleagues and peers, and from my own experience with non-fractional devices, damage to the surrounding tissue side effects were much more common. I believe this is due to the continuous beam of energy used, compared to the pulsating beam of the fractionated devices. The fractionated devices also do not go as deep, and evaporate the excess skin superficially.
Topical anaesthesia is applied to the upper eyelid and crow’s feet wrinkles 45 minutes before the procedure. You should draw the area to be treated first and then treat from the top to the bottom, as well as alternate spots from the right to the left side to make it more comfortable for the patient. Also, you use a ‘spray movement’, moving the hand, operating the device up and down on the area being treated, in a repetitive motion. Each spot will sublimate the tissues, creating a retraction. Thus, causing sublimation spots of the superficial corneocytes without affecting the basal cell layer (sublimation, without ablative effects on the skin).
It is recommended by the product manufacturer of the device I use, that during each treatment you should not sublimate more than one third of the surface treated,28 to avoid side effects. During the session, ask your patient to open and close their eyes, to allow maximum precision in the zone which is being treated. Only one pass over the same spot is also recommended. The treatment usually takes between 10-15 minutes, patients report minimal pain, and significant skin retraction is seen immediately after the treatment.23
Some patients may experience a light oedema and swelling in the treated area which will disappear in a few days. They will also have some mild crusting of the skin, lasting between seven and 15 days. After the procedure, I instruct patients to wash their face with a mild cleanser, apply gauzes soaked in a normal saline twice a day for three days, and apply sterile petrolatum several times a day until healing is complete. Treatment with topical antibiotic ointment for six to nine days is also necessary, as well as steroid cream. Avoiding sun exposure for seven to eight weeks is advised.
The aesthetic specialty is continually finding new solutions for facial rejuvenation, and with the introduction of new fractionated plasma devices, we can have a complete approach to the rejuvenation of the eye area.
Until recently, we were able to treat most eye bag and tear trough problems using dermal filler techniques and botulinum toxin to reduce the wrinkles under and around the eyes. Now, we also have a new approach to effectively treating excess drooping of the upper eyelid skin using plasma. The plasma devices can significantly lift the upper eyelid tissue, with minimal downtime and without the risks of a surgical procedure. Most importantly, these results are permanent, but just like the surgical alternative, blepharoplasty, nothing is precisely 100% permanent, as the skin continues to age, and it may be necessary to repeat this procedure down the line.
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