State-of-the-art periorbital rejuvenation requires going beyond skin-tightening surgeries to address underlying structures from a three-dimensional, volumetric standpoint, says an expert.
"To really transform people or turn the clock back, we need to look beyond surface treatment," says Ebby Elahi, M.D., an oculofacial surgeon and assistant clinical professor of ophthalmology, Mount Sinai School of Medicine.
More specifically, he says dermatologists and cosmetic surgeons must look at the entire face from a three-dimensional, volumetric standpoint, considering relative positions of various facial components as well as overall composition and volume.
"For example," he tells Dermatology Times, "the distance between the two inner canthi should be the same as the width of the palpebral fissure, or the lower lid should have a 10 to 15 degree upward angle."
The best is never average
More recently, researchers used computer simulation to average out the features of scores of faces, he says.
"The interesting thing was that the average tends to go toward a more attractive appearance, suggesting that somehow, in our brains, what we find attractive is essentially an average of the population as opposed to deviations from the standard," Dr. Elahi says.
However, he adds that the people considered most attractive frequently have features that veer away from the standard, thereby setting them apart - think Gisele Bündchen's nose.
"This may suggest that the average is good enough, but the best is never average," he says.
Similarly, researchers have analyzed where the eyes tend to focus when looking at a human face. "Large asymmetries can go essentially unnoticed, because that's not how we look at each other," Dr. Elahi says.
Accordingly, he says that when physicians perform any type of cosmetic surgery, "We're really doing psychosocial surgery. So it's important to understand not only what we can do, but also what the intended goal is - concentrating our efforts on how people wish to be perceived as opposed to repairing or restoring structures in vacuum."
Additionally, various studies have examined what happens to the aging face. Perhaps most importantly, Dr. Elahi says that over time, "The face rotates forward, resulting in a retraction of the jaw structure and a forward movement of the forehead."
Simultaneously, faces tend to lose midface volume as they age.
"As we tend to lose bony volume," he says, "the soft tissues follow. In addition to the overall changes and the descent or laxity of the soft tissues, the baseline infrastructure underneath is shrinking and changing."
As for specific treatments, Dr. Elahi has been working on new devices, including a porous polyethylene implant (patent pending), designed to increase the volume within the orbit to replace the fat loss that naturally occurs over time.
"How much that affects a person's appearance depends to some extent on the overall position of the eye compared to the orbit," he says.
Some patients have a positive vector, with eyes relatively protrudent in relation to their cheek, while others possess a negative vector or a neutral angle, he says.
Dr. Elahi is also working with a manufacturer (IOP) on applications for hydrogel implants in patients with anophthalmic sockets.
In such patients, a nonfunctioning eye or the loss of an eye leads to fat shrinkage, which causes disfigurement, Dr. Elahi says.
"These devices are injectable pellets that expand to several times their size once they're inside the body and hydrated. The idea is to inject these pellets in the orbit and allow them to expand so everything gets pushed forward," he says.
Disclosure: Dr. Elahi has applied for a patent on the orbital implant but possesses no financial interest in any companies or other products mentioned in this article.