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Publish date: Jul 1, 2008
By: Linda Marie Wetzel
Source: Cosmetic Surgery Times
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Key Points
- A conceptual five-step approach describes the categories of challenges that must be addressed when rejuvenating the lower eyelids
- This approach also provides guidelines for determining the best options for individualized treatment.
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Dr. Swartz
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"I came up with the five R's to make it easy to remember that there are multiple things that must be considered when talking about rejuvenating eyelids," explains Nancy Swartz, M.S, M.D., F.A.C.S. Dr. Swartz is a fellow of the American Academy of Ophthalmology and the American Academy of Cosmetic Surgery (AACS), and serves on the teaching staff of Wills Eye Hospital and the University of Pennsylvania School of Medicine. She presented details of her approach at this year's annual AACS meeting in Orlando, Fla.
'R'EMOVE In this case, "removal" refers to excess fat or skin from the lower eyelid area. Historically, lower lid rejuvenation consisted mostly of various excision techniques aimed at reducing the amount of tissue in this area. According to Dr. Swartz, there is a place for these procedures but, in general, they are overused.
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36-year-old female (left) with reduced aperture while smiling before Botox treatment and (right) with increased aperture following Botox treatment.
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"Excess skin is less of a problem than people think, and removal of tissue can be overdone," Dr. Swartz says. "I believe that, in rejuvenation, it's often a better idea to consider steps other than excision."
'R'EINFORCE "Reinforcing" consists of repairing structural defects in the lower lids. The major structural defect is laxity, the presence of which can be documented in several ways according to Dr. Swartz.
Using the distraction test, the lower lid is grasped and pulled away from the globe. If the tissue can be pulled 7 mm or further, then horizontal laxity is present. In a second assay for skin tone, the snapback test, the lower lid is pulled down as the patient is instructed not to blink. If the lid does not quickly pop back to position, or if the patient must blink to restore the lid to normal position, the lower eyelid is considered to have poor tone.
Tightening the lower eyelid horizontally usually involves reinforcing the lateral canthal tendon via canthoplasty or canthopexy. When the presence of lax tendons is compounded by both loose skin and loose orbicularis muscle, Dr. Swartz also performs a redraping of the orbicularis muscle.
"We don't just excise the extra skin and orbicularis muscle, but we must support what's there," Dr. Swartz tells Cosmetic Surgery Times. "In addition to tightening the tendon, what I tend to do is attach the orbicularis muscle to the periosteum of the orbital rim laterally so that the muscle is well supported. This reduces the likelihood that the patient will develop lower eyelid retraction post-operatively."
These terms describe "resurfacing" the eyelid skin and "relaxing" the muscles to reduce dynamic wrinkles and reshape the eyelids.
"Removing skin does not improve the quality of what's left," Dr. Swartz explains. "Wrinkles don't go away because you remove skin. You have to directly address the skin itself."
The choice of CO2 lasers, chemical peels or fillers depends on the patient — the specific needs of the skin as well as lifestyle issues. For example, laser resurfacing results in skin erythema that may persist for weeks or months. In circumstances in which this is not acceptable to the patient, Dr. Swartz prefers using hyaluronic acid fillers to tighten the lower lid skin.
Use of neuromodulators such as Botox (botulinum toxin type A; Allergan, Irvine, Calif.) is an established treatment option for wrinkle correction around the eyes. But, she explains, a small injection of Botox into the central aspect of the pretarsal orbicularis can diminish the appearance of a hypertrophic orbicularis muscle, or "orbicularis roll," that appears under the eyes of patients when they smile. And injecting Botox into the pretarsal orbicularis at the lateral canthal angle can increase the aperture of the eye, particularly when the patient smiles.
Dr. Swartz warns that careful placement is the key to achieving successful results. Botox injected too deeply inside the orbital rim (underneath the septum) may affect the extraocular muscles, resulting in double vision; deep injections outside the orbital rim can affect muscles that elevate the lip, resulting in a crooked smile. If the medial orbicularis muscle is weakened, tear drainage can be compromised.
'R'EFILL Hyaluronic fillers such as Restylane (Q-Med, Uppsala, Sweden) and Juvéderm (Allergan) are the components of the final R — "refilling," or correcting deflation of the lower eyelid and the orbit.
"Most of the aging in the lower lid results from losing volume, and as the skin and subcutaneous fat thins, we uncover the hills and valleys of the structures underneath," Dr. Swartz notes. "In reality, what's there has always been there, but we've just lost the fullness that created those large smooth curves of the face that we had in youth."
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31-year-old female (left) with hypertrophic orbicularis accentuated with smiling and (right) with softening of roll after treatment with Botox.
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To contour the lower eyelid and fill the area of volume loss, Dr. Swartz injects Restylane deeply, just above the periosteum. Because Juvéderm causes some patients to experience fluid buildup which may distort the appearance of the lower lid, Dr. Swartz does not use it for contouring; however, she does use Juvéderm to correct issues with skin quality. The injection of microscopic droplets just beneath the epidermis gives the skin more thickness and turgor. Dr. Swartz prefers these products, not only because they stimulate the production of natural collagen in the skin, but because particulates in other types of fillers could result in an embolus to the retina and subsequent loss of vision.
Dr. Swartz also reminds cosmetic practitioners that a dilute hyaluronidase solution may be used to reverse the effects of excess amounts of hyaluronic acid filler. "Just inject a little under the surface of the skin where it will thin the filler a little and make it easier to smooth out an area or move it to another place," Dr. Swartz says.
"Everyone's eyelids are different and everyone has different issues," Dr. Swartz says. "The five R's are a conceptual way of categorizing the types of problems that can happen with the eyelids we want to rejuvenate."
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CosmeticSurgeryToday.com talks with Dr. Marc Cohen about the often overlooked area of the face between the upper eyelids and the hairline: the forehead. Dr. Cohen also explains how the introduction of hyaluronic acid fillers caused a gradual transition from traditional brow lifts to less invasive forehead rejuvenation. Read or listen to interview.
Dr. Nancy Swartz speaks with CosmeticSurgeryToday.com on the advantages of seeking a specialist for your cosmetic eye surgery, or blepharoplasty and the evolution from surgically invasive procedures to now being able to treat many conditions with dermal fillers like Botox or Restylane. Read or listen to interview.
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by Carol Saline, Senior Editor: Medicine & Health, Philadelphia Magazine
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| I first heard Botox being touted a decade ago, after an ophthalmologist who’d been using it to treat involuntary eye-twitching noticed that it also helped crow’s-feet disappear. I was skeptical; Botox, though highly diluted, is derived from a bacterium that can poison food. But then, last April, the FDA approved it for cosmetic use, and I made an appointment with Marc Cohen, an ophthalmic plastic surgeon who’d been using the stuff for years. I opted to treat my crow’s-feet and the “bunny” lines on the bridge of my nose. Cohen applied a numbing solution, then took out the needle and gave me six virtually painless pinpricks in my trouble spots. It took five minutes. No swelling; no bruising. I barely had to retouch my eye makeup before going to work. In a few days, the lines were considerably lessened. Unfortunately, the effect is only temporary; I’ll need another treatment (at $300-$600 a pop) in three to four months. |
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November 18, 2010
Use of facial fillers on the rise as alternative to plastic surgery
By GLORIA HOCHMAN
For the Inquirer
Lynn Shapiro, 59, of Bridgeton, N.J., has no idea how much she has spent on twice-a-year facial injectables in the past few years, and she's not interested in finding out. She just knows that she likes the way she looks and is thrilled about the way she feels. "Whatever I'm spending," she says, "it's worth it."
....... Shapiro's fillers and eye surgery were done by Marc Cohen, who is board-certified in ophthalmology and cosmetic surgery. Cohen has offices in Voorhees and Bala Cynwyd.
"Eyelids are the most complicated and challenging part of the face on which to work," Cohen says. "They are delicate structures, and the key is to achieve a look that is natural, attractive and preserves function."
Over the years, Cohen says, the approach has changed significantly. "Pick up any magazine and you'll see that people look younger when they have fairly full upper eyelids, not the hollowed-out Marilyn Monroe look that people used to envision when they considered cosmetic eye surgery. So we remove less tissue than we used to and we use fillers - both under the brow and beneath the lower lids - to add volume and create those more youthful, sweeping curves."
For full article click here
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Answer from Daniel A. Monti, director of the Jefferson-Myrna Brind Center of Integrative Medicine at Thomas Jefferson University and Hospital
........ We normally blink every 12 seconds on average. We blink less whenever we concentrate for a long time on a computer, a book or the road while driving. Our eyes get dry from this exposure, too. To offer you the very best advice on dry eyes, I consulted leading Philadelphia ophthalmologist and cosmetic eye surgeon, Nancy Swartz, MD. She relayed that there are several things you can do to keep your eyes better lubricated:
Sunglasses are not just a fashion statement: Dr. Swartz tells you how to protect you skin from the sun.
Read entire article
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