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Dr. Andrew JaconoAchieving superior results when addressing patients' aging eyes requires an extensive algorithm. The process includes identifying patient concerns, offering the best approaches to address those concerns and understanding the indications for the myriad of procedures that are available, according to Andrew Jacono, M.D., a Manhattan, N.Y., based facial plastic surgeon.
Dr. Jacono, Assistant Clinical Professor of facial plastic surgery at the New York Eye and Ear Infirmary and the Albert Einstein College of Medicine, says doctors need to think strategically. For example, recommending fillers to patients who have loose skin, in addition to lost volume, could result in an unhappy patient. Or relying on the traditional approach to blepharoplasty might result in a more sunken, aged appearance to the eyes.
"It's still common practice to remove the fat pad from around the eyes with traditional blepharoplasty," he says. "With or without fat grafting, it still de-volumizes the eyes."
Less invasive options to replenish volume around the eyes are limited to fillers and fat grafting. Fillers are best for younger patients, in their 30s, 40s and 50s, who don't want surgery. Younger patients are more likely to be satisfied with the results from fillers because they're less likely to have other signs of periorbital aging, such as wrinkles, dermatochalasia and laxity of the orbicularis muscles, which cause lower eyelid drooping, according to Dr. Jacono.
"The two hyaluronic acid fillers that are widely used around the eyes are Restylane [Galderma] and Belotero [Merz Aesthetics]. They tend to create much less of a Tyndall effect than other fillers," he says. “The Tyndall effect is the appearance of a bluish discoloration under the eyes that can develop with other hyaluronic acid fillers used around the eyes.”
Restylane, according to Dr. Jacono, has a greater lifting capacity than Belotero. The elastic modulus or G prime of Restylane is much higher than Belotero, which means it is more supportive. A good analogy, he says, is that Restylane or high G prime fillers are like Jell-O and low G prime fillers are like syrup.
"I like to use Restylane better for deeper injections just above the bone and periosteum of the orbit the fill and lift the tear trough, but you can inject Belotero more superficially in eyelid skin because it gets less lumpy with a lower G prime. It's common for me to combine the use of Restylane and Belotero, using Restylane for the deep injections, over the bony prominence, then Belotero more superficially to blend away more superficial defect in the orbicularis muscle and skin," he says.
One problem with using fillers is that injecting them into a patient with loose lower eyelids can result in the fillers ballooning where the eyelids are loosest.
“You have to be very conservative with filler use in older patients," Dr. Jacono says.
This 36-year-old patient has a genetic predisposition for lower eyelid aging demonstrating steatoblepharon and orbital devolumization with minimal changes in the skin and orbicularis muscle. A transconjunctival blepharoplasty with fat transposition was performed, as she had deep hollowing under her eyes. A simple fat excision transconjunctival blepharoplasty would have accentuated the dark circles under the eyes. Photo credit: Dr. Andrew JaconoHowever, many patients who are concerned about their aging eyes will eventually accept surgery as a solution. Some get filler fatigue, becoming tired of having to come back for filler touchups. Others are no longer satisfied with the results from fillers. Some of these patients might first graduate to fat grafting for more permanent results, according to Dr. Jacono, who says that he sees a lot of patients who request fat transfer. Filling the devolumized area under the eyelid bags (the tear trough) with fat grafting might work if the bagginess is not too prominent. But filling around large bags isn't necessarily going to correct the problem, according to Dr. Jacono.
Like fillers, fat grafting doesn't address concerns beyond replenishing volume. And there are other drawbacks with using fat. In a significant percentage of patients (about 30%, in Dr. Jacono's experience) fat will reabsorb. As a result, there is a significant percentage of patients treated with fat grafting that have less than optimal outcomes. And while fat transfer is considered less invasive than blepharoplasty, patients often have to endure about a week of bruising from procedure-related trauma.
Dr. Jacono sees the bigger fat bags as an opportunity for lower lid blepharoplasty that involves repositioning existing fat bags around the eyes.
“If somebody has relatively large bags around the eyes, it makes sense to move it down and suture it to the devolumized area during blepharoplasty; this is called a lower eyelid fat transposition,” Dr Jacono says. “Fat transposition is more predictable than autologous fat grafting. When you use fat that you suck out of the body during fat grafting, the fat is a free graft (it doesn't have a blood supply) and, thus, can reabsorb and not incorporate. When you transpose orbital fat from around the eye, it is attached to the blood supply. The fat survives 100 percent of the time in fat transposition because it is a pedicled vascularized flap," he says.
For patients to be candidates, they have to have enough local fat to move or transpose.
"I usually rely on fat grafting when patients don't have enough fat around the eyes," Dr. Jacono says. "Or, in a case where a patient has had a previous traditional eyelid surgery, where the fat was removed from around the eyes, I use more fat grafting."
The take-home message? "All of these techniques work if they're done in the right patient, with specific anatomic problems, at the correct stage of aging."
Dr. Jacono reports no relevant disclosures.