Periorbital Rejuvenation

Transcription

1 Outline Periorbital Rejuvenation Daniel Straka, MD Oculofacial Plastic Surgery Plastic Surgery Ohio/Ophthalmic Surgeons and Consultants What happens as we age? What is considered beautiful or youthful? How do we achieve our goals? Surgical and nonsurgical interventions Aging Changes Anatomy of Aging What causes the changes we see with age? An entire lecture could be given on this subject Degenerative changes Tissue decent due to gravity Fat/tissue atrophy Bone remodeling Skin deterioration Exogenous and endogenous factors Solar exposure Cigarette smoking Medications Alcohol use BMI Endocrinologic factors Studies have shown people infer age based on visual cues from around the eyes 1 1. H. Rexbye, J. Povlsen. Visual signs of aging: what are we looking at? Int J Ageing Later Life, 2 (1)(2007), pp What is beautiful? In order to achieve results one needs to understand what is aesthetically pleasing The Youthful Eye involves multiple aesthetic subunits inclduing the brow-upper lid continuum as well as the lower lidcheek/midface continuum Brow Male vs female: men thicker, lower, less curvature Gently curved, apex aligned with the lateral corneal limbus Medial aligned with the lateral nasal ala Some feel the lateral canthus is more appropriate apex Upper Lid Varies significantly with race Upper eyelid rests 1-2mm below limbus VPF 9-10 mm, HPF Apex slightly medial to pupil Eyelid crease height Lower lid Upward slant from medial to lateral canthus Lower lid position 1-2mm above limbus Smooth, continuous curve at the lid/cheek junction Midface/cheek Volumized, round malar fat Heart-shaped, prominences over the zygomatic arch and point at the chin S-shaped curve (double ogee) when viewed from the side (convexity at the brow, concavity at the orbital wall, convexity of the upper midface, concavity at lower midface 1

2 How do we achieve our goals? Surgical Comprehensive approach that focuses on brows, eyelids, and cheeks as they relate to the entire face Surgical Non-surgical Brow position Upper eyelids Lower eyelids Cheek/midface Brow Lift Endoscopic Brow Lift Endoscopic Local anesthesia with MAC/Propofol drip Hides incisions, endoscopically release the brow from attachments along supraorbital/superior orbital rim Difficult with high hairline and long forehead Pre-trichial Better for high forehead/hairline Hair loss at incision Coronal Large incision with significant risk of hair loss and anesthesia Direct Great deal of versatility Can be unilateral Scar formation Fitzpatrick Skin Types!, II My procedure of choice Ideal patient Short, flat forehead with moderate rhytids Longer forehead (>7cm brow cilia to hairline) much more difficult to perform Mild to moderate brow ptosis Does well to elevate temporal and medial brow Endobrow Video 2

3 Upper eyelid Ptosis Blepharoplasty Assessment Brow position Degree of excess skin Fat prolapse or atrophy Muscle Lid crease prominence Technique Skin only vs skin-muscle flap Fat Resection, sculpting, transposition, transfer Lid crease reformation Ptosis repair External vs internal Ptosis Degree of ptosis (MRD1) Underlying etiology (neuromuscular disease, congenital, etc) Lower Eyelids Lower Lid Blepharoplasty Aging changes Volume loss and tissue laxity leads to effacement of the ligamentous attachments to bone and soft tissue resulting in hollows AND prominence of the lower lid/orbital fat pads (no atrophy) Some component of orbital fat hypertrophy as well Traditional surgery involves subtractive techniques for the lower lid fat pads, however a comprehensive approach should address volume loss and tissue decent My approach: listen to patient goals and determine a balance between restoring volume and subtracting volume (fat pads) Evaluation Patient concerns Degree of skin laxity, fine rhytids, complexion Degree of tendon laxity Degree of fat prolapse Degree of midface/soof decent/volume loss Beware of negative vector eyelid Preferred technique Transconjunctival incision with fat excision and redraping (transposition) Possible SOOF lift Laser resurfacing Periorbital Hollows Septal confluence Orbitomalar Zygomatic 3

4 Nonsurgical Interventions Neurotoxins Fillers Laser therapies Botulinum Toxin Uses Seven serotypes A through G Only types A and B approved for injection in the US Type A toxins Onabotulinum toxin A BOTOX FDA approved for glabella and crows feet Abobotulinum toxin A Dysport FDA approved for glabellar lines Incobotulinum toxin A Xeomin FDA approved for glabellar lines All Type A toxins used off label for numerous dynamic facial rhytids Mechanism: pre-synaptic blockade of neurotransmitter (ACh) release Forehead rhytids Glabellar rhytids Bunny lines Smile lines (Crows feet) Brow contouring Other Key point: botulinum toxin does not treat static rhytids, only dynamic Evaluation Forehead Important to examine how the patient moves No single injection pattern works for every patient Start low, generally 5-15 units, can go higher if patient desires Can drop brow, especially closer to cilia Most important, determine the patient s goals, concerns 4

5 Glabella Smile Lines 11 Lines, between 3-5 injection sites Generally units Stay outside of the orbital rim units per side Avoid zygomaticus muscles Brow contouring Fillers Selective paralysis of brow depressors leads to relative overaction of brow elevators Generally few millimeters HA gels Restylane family Juvederm family Belotero Non-HA: Neo-collegensis Calcium hydroxylapatite (Radiesse) Poly-L lactic acid (Sculptra) Artefill (Bovine collagen with PMMA spheres) Collagen Autologous fat transfer Periorbital Filler Applications Glabellar lines Superior sulcus Brow contouring Temporal wasting Tear trough Cheek augmentation 5

6 1 2/15/2017 Laser resurfacing Ablative Non-ablative Intense pulsed light (IPL/BBL) What does it treat Dyschromatopsias Browns, reds Static rhytides Pores Lesions Scars Hair removal BEFORE / AFTER Two weeks post 2 tx courtesy of Laura Brougher, RN BBL Parameters: 515 nm filter, 11 J, 20 ms, 20 C cooling 2009 Sciton, Inc. All rights reserved Rev. A B&A BBL 6

7 Resurfacing video Other skin treatments Chemical peel Microdermabrasion Needling Skin Skin Dyschromatopsias Static rhytides Pores Lesions Scars Skin care regimen Sunscreen and avoidance Laser therapies Ablative (Erbium:Yag, CO2) Non-ablative BBL/IPL References 1. H. Rexbye, J. Povlsen. Visual signs of aging: what are we looking at? Int J Aging Later Life, 2 (1)(2007), pp Buchanan DR, Wulc AE. Contemporary thoughts on lower eyelid /midface aging. Clin in Plast Surg, 42 (1), 2015; Lam VB, Czyz CN, Wulc AE. Brow-eyelid continuum: An anatomic perspective. Clin in Plast Surg, 40(1), 2013;1-19 7