Periocular aging and the changes associated with it

Smoking, sun damage, genetics, stretching from swelling, and the wear and tear from chronic rubbing and blinking all contribute to changes around the eyelids as we age.

Skin changes: Around our mid-30s the skin around the eyelid starts to thin and lose its elasticity. Slowly this can result in excess skin in the upper eyelids which will cover the crease. The term dermatochalasia, which means excessive loose skin, is used to describe this condition.

Orbicularis oculi: As mentioned previously, this circumferential muscle is responsible for eyelid closure. Stretching of this muscle with time also contributes to the overhanging skin. It is the chronic use of this muscle, combined with squinting and sun damage which result in the static wrinkles we see around the eyes termed “crows feet.” There are two types of wrinkles, static and dynamic. Dynamic wrinkles only appear when we are using that specific muscle. For example, if you were to stand in front of a mirror and actively raise your brows you will see dynamic wrinkles in your forehead from activity of the frontalis muscle. Static wrinkles, on the other hand, are present at all times, even when the muscle is at rest. Botox is a neurotoxin and a paralytic agent that acts by inhibiting the action of those specific muscles and thus temporarily (three to five months) decreases static wrinkles. Facial fat and volume: As we age, the facial

Facial fat and volume: As we age, the facial fat begins to absorb resulting in volume loss in the face. Around the eyes, the loss of midface fat can contribute significantly to the lower eyelid “bags,” and this may be the primary reason they are formed. In the past 10 years most of the modern techniques in periocular rejuvenation take into account this concept of volume loss. Modern techniques in volume replacement include injection of synthetic materials such as Restylane and Juvederm, which are hyaluronic acid products lasting nine to 12 months. An alternative is injection of the patient’s own fat after a small amount of liposuction; this fat injection lasts a lifetime. It should also be mentioned that soft tissue around the eyes descends with time due to gravity.

Septum: This structure can weaken over time, resulting in herniation of orbital fat and also contributing to the lower eyelid “bags.”

Orbital fat: Not only the orbital fat pockets can herniate through a weakened septum but they too can be partially absorbed and with time give rise to a gaunt and “hollowed” look. Older surgical techniques would remove the excess herniated fat, resulting in a worsening of the “hollowed look.” (Pictured below is a patient who had aggressive fat removal 20 years ago which resulted in the hollowed appearance.) Unfortunately many “old school” surgeons are unwittingly contributing to an epidemic of post-blepharoplasty hollowness.



Figure 1 — A 67 year old female who underwent aggressive
blepharoplasty with fat removal 18 years ago. As you can see there
is significant post-operative hollowness around the eyes which
makes the patient look older and “emaciated.”