Newer fractional devices for eyelid rejuvenation may decrease downtime.

Newer fractional devices for eyelid rejuvenation may decrease downtime.

• Laser resurfacing in periorbital area can address fine lines, ‘crepiness’
• Nonablative devices have had best safety profile, but require several treatment sessions
• Lasers an alternative for those who may not qualify for surgery

Periorbital rejuvenation remains an important element of aesthetic medicine. And options vary, including botulinum toxins, dermal fillers, blepharoplasty, laser resurfacing, radiofrequency treatments, chemical peeling, topical cosmeceuticals and more.

In the past, eyelid rejuvenation often required a long period of downtime, accompanied by some substantial risks. But that’s not necessarily the case anymore.

Laser and radiofrequency treatments of the periorbital area and eyelid proper are not a novel idea, but the newer fractional devices provide an increase in safety and, as a result, have contributed to a subsequent increase in popularity of these procedures.

Of course, there is no substitute for blepharoplasty for the patient with redundancy and tenting of the upper lids, but the new laser and light procedures are finding their niche in this huge market.

Laser resurfacing can address certain components of the periorbital area that are not remedied by blepharoplasty, such as fine lines and “crepiness.” We also use it for patients who have already had a blepharoplasty and do not have enough redundancy for a second surgical procedure. Laser resurfacing is also good for those patients who are not satisfied with their surgery or who have visible surgical scars. Eyelid treatments with laser and radiofrequency have become an important adjunct to surgery in this area.

First things first

The most important step prior to beginning treatment of the periorbital area with any device is to become familiar with its specialized anatomy and the safety issues associated. First, the anatomy:

The upper eyelid is considered to be the portion of the skin below the eyebrow extending to the lash line, including all structures beneath to the conjunctiva. The lower eyelid extends from the lower lash line to the orbital rim.

The eyelid skin is different from the skin in other areas of the body. It measures 1 mm at its thickest point on the lid, which is at the point just inferior to the brow. The thinnest part of the lid measures a mere 0.3 mm in total thickness near the lash margin (Hwang et al. J Craniofac Surg. 2006). In addition, the orbicularis muscle lies directly beneath the skin, with little to no fat to act as protection. Performing resurfacing into this muscle is entirely possible, which then can result in scarring and ectropion. It is crucial to remember the thinness of the skin in this area when choosing your laser settings.

Protective measures

When performing laser or light procedures on any portion of the lid, the globe must be protected. Corneal shields should be placed prior to any procedure treating the eyelid proper. The most commonly used shields are stainless steel, as they do not conduct heat due to their buffing and electro-polishing. Another option is the plastic corneal shield. However, we do not use the plastic corneal shields due to the possibility of heating of the shield during the procedure.

Prior to insertion of the shield, anesthetic (proparacaine) drops are placed into the eye. The anesthetic effects are virtually instantaneous, so the shields can be inserted immediately. The rims of the shields should be checked for any sharp points prior to insertion. The easiest way to place the shields is to have the patient look down, then insert the upper edge of the shield beneath the upper eyelid. Then you should ask patient to look up and carefully put in the lower edge of the shield. Use your thumb to evert the lower lid to make it easier to insert. Once the shield is in place, it provides a smooth surface on which to track the laser handpiece, being careful not to place pressure on the globe itself.

Nonablative procedures

The first cases of eyelid resurfacing appeared in the literature in the 1990s with the use of the CO₂ laser. Since the introduction of the fractional lasers, the procedure has increased in popularity.

The fractional laser devices are typically divided into ablative and nonablatives types. The nonablatives include lasers that emit wavelengths in the range of 1,410 nm to 900 nm. The nonablative lasers have had the best safety profile. The biggest risk with the nonablatives is post-inflammatory hyperpigmentation. To date, there are no published reports of scarring of the eyelids with nonablative fractional resurfacing.

Last year, Kotlus and Schwarcz published a series of patients treated with a 1,550 nm nonablative fractional erbium laser in Dermatologic Surgery. They reported an improvement in eyelid laxity of at least 50 percent in 55 percent of the patients treated. More importantly, they reported no complications of scarring, postoperative dyspigmentation or persistent erythema.

As with all nonablative laser procedures, several treatment sessions are required for the most optimal results. In our experience, the nonablative devices don’t typically deliver much in the way of tightening on the face. However, tightening of the eyelids is virtually universal with these treatments. The nonablatives will not burn the eyebrows or the eyelashes, making it easy to perform the procedure.

Ablative technologies

Though the first resurfacing devices to be used on the lids, the ablative devices still require more recovery time than the nonablatives. However, only one or two sessions are generally required for favorable results.

The fractional CO₂ (10,600 nm), erbium: yttrium aluminum garnet (2,940 nm) and erbium: yttrium scandium gallium garnet (2,790 nm) are the ablative lasers used for resurfacing. All three of these varieties are available in a fractional delivery system, using micron spot sizes and allowing for deep penetration.

Remembering the thinness of the lid, most of these fractional devices can deliver pulses to a depth that would reach the globe, if used at their maximum settings. Energy levels used on the lids need to be adjusted to account for the anatomy of the eyelid.

There are only a few published reports on ablative resurfacing of the lids, making it difficult to determine which ablative device is most effective. Just as on non-eyelid skin, the CO₂ results in more heat-related collagen contraction, whereas the erbiums are thought to tighten via wound contraction.

Despite the repeated discussions of their mechanism of action, most likely this is for academic purposes, with the clinical results being similar.

In spite of the newfound safety with these fractional devices, risks still exist. To date, the reports of scarring with ablative fractional resurfacing seem to be most common on the neck and periorbital areas (Biesman. Lasers Surg Med. 2009).

Last year, Fife, Fitzpatrick and Zachary published a report of ectropion following eyelid resurfacing with a fractional CO₂ laser, noting that even in the most experienced hands, complications can occur in the periorbital area.

Radiofrequency tightening

Radiofrequency tightening devices have also been used on the eyelids for periorbital rejuvenation. Monopolar radiofrequency is safe and effective for eyelid tightening.

In one prospective study including 72 patients, 88 percent of those treated noted some improvement in upper eyelid tightening. The monopolar device used a 0.25 cm² “shallow tip.” There were no major complications in the trial (Beisman et al. Lasers Surg Med. 2006). No other published reports are available on eyelid tightening using other radiofrequency devices.

Periorbital rejuvenation is an important aspect of both eye function and aesthetic appearance. Hooding and lid laxity have traditionally been treated using surgery, but laser resurfacing has now become an effective complement to surgery.

Though not a replacement for traditional surgery, lasers can serve as an excellent alternative for those who may not qualify for surgery, or for those who may not want to undergo blepharoplasty.

More research on ideal energy and density settings would improve results and safety with these devices. With this knowledge, laser resurfacing of the periorbital area will likely be a universal therapy.

Contact Dr. Benchetrit and the team at COSMEDICA for information about all the  options available at (514) 695-7450. 

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