Periorbital rejuvenation is one of the most important areas of rejuvenation of the aging face. The eye area is important in contact between individuals, with eye-to-eye communication occurring in approximately 80% of all interactions. The orbital area conveys information on general health and impressions regarding individual health, fatigue, interest, and emotion. For many individuals with limited budgets or limited interest in facial rejuvenation, the eye area is the focus of facial rejuvenation surgery.
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Periorbital rejuvenation and, in particular, eyebrow position and posture have seen a change over the past several years. Male brow position has always been accepted as lower than female position, even in youth. The brow was, essentially straight, with a slight lateral upgoing, but not so severe as to create a frown or concerned appearance when at rest with frontalis muscle relaxation. The female brow position and posture has changed significantly from the high-arched and overly elevated position of the 1950s and 1960s (or with overly exuberant brow lift surgery even today). In style today is a rather straight brow with generally lower posture than in past years but, still, with significant medial elevation and slight lateral elevation. The entire brow is much straighter than accepted for women in the past. This posture can be attained predictably with modern brow-lifting procedures, either open (preferably in order to weaken or even remove the corrugator supercilii muscles) or closed for less scarring and quicker recovery time.
Brow elevation in order to rid the lateral upper facial area of rhytides should be performed conservatively and cautiously, as an overly elevated brow does not occur in nature and gives the patient a very "operated on" appearance. Even complete paralysis of the upper, lateral orbicularis oculi muscles may overly elevate the lateral brow. Some correction of an overly elevated brow may be accomplished with opposing muscle paralysis (in this case frontalis muscle or portions of it but with the expense of loss of facial animation, to some extent). Also, relaxed brow posture should be correct and what the person desires prior to any need for paralytic agents, fillers, brow-hair manipulation, or makeup. The heavy skin of the forehead, even without a brow or a significant brow, changes to the very thin and delicate upper eyelid structures and skin rather abruptly, and that area of change should be at the correct position and in the correct postures as desired by the patient in consultation prior to surgery.
History of the Procedure
Improvement of aging facial features with cosmetics and surgery essentially parallels the developments of facial plastic surgery through time. Rejuvenation of the periorbital area, although obviously important, lagged behind that of midfacial and lower facial rejuvenation for many years. The coronal and brow lift procedures with ancillary procedures (eg, canthopexy  ) have been popularized mainly over the last 30 years.
The aging face has many characteristics, including gravitational (postural), animational, and textural rhytides. Generalized loss of subcutaneous volume with the interplay of sun damage and aging skin is a large topic and is not discussed at length in this article. Largely, surgical procedures help the first two problems, and resurfacing procedures help textural skin problems. Other articles address the many changes in complete facial rejuvenation (eg, nasal tip droop, earlobe lengthening, upper lip atrophy, lower lip pout). The perioral region is an important focus of attention in facial rejuvenation.
Conversely, the orbital area reflects aging in a number of ways. With time, the brow falls, tending to fall laterally more than centrally. When this occurs, a relative redundancy of upper eyelid skin is present. A disservice is done to the patient if this alone is corrected and the brow position is not corrected first. The precious skin of the upper eyelid is sacrificed, yet a large number of aging factors of the upper face are not rejuvenated with the procedure of upper eyelid blepharoplasty.
If skin resection is excessive, the resulting lagophthalmos preempts proper positioning of the brows. The brow generally descends before the face, resulting in relative excess skin lateral to the eyes. Coupled with squinting and facial animation, this results in the characteristic "crow's feet" at the lateral orbital commissures.
The inferior brow generally adheres well to the superior orbital margin, but true descent of the brows commonly occurs. Once a large amount of upper eyelid skin redundancy is present, the patient feels subjectively and objectively that the upper lids are heavy and the eyes are not opening fully. To unweight the upper eyelid region, the frontalis muscle is used, sometimes spastically. This leads to horizontal creases of the forehead termed "worry lines."
In many individuals, raising the eyebrows through frontalis action leads to overelevation of the central brow and a surprised look to the facies. The individual often is keenly aware of this and tends to try to raise the lateral brow and lower the central brow. The musculature of the forehead does not allow this directly, but the frowning or concentrated "thinking" look of the central interbrow region is caused by the interplay of corrugator supercilii muscles and procerus muscle action coupled with central brow descent. This interplay of the upper facial muscles leads to the characteristic changes observed in the upper face in all individuals.
Everyone ages, but the rate and individual nuances of needed and desired corrections vary.
The etiology of the aging face is discussed in the Problem section. The interplay of environmental forces acting on the skin and leading to actinic and weathering changes are fundamentally different from those changes that result purely from aging. This is discussed at length in Skin Resurfacing, Chemical Peels.
Pathophysiology also is discussed in the Problem section. The only other relevant action involves the interplay between squinting action (mediated by the orbicularis oculi muscles) and the action of a broad smile with elevation of the entire cheek substance by the large muscles of the lateral cheek. Paralysis or surgical alteration of the lateral orbicularis muscle obviously does not greatly alter the rhytides caused by panfacial animation.
The aging face has common characteristics. Descent of the brow and mid face causes a hollowing of the periorbital region that can be iatrogenically augmented by overly aggressive blepharoplasty procedures. Lateral canthal descent and canthal attenuation occur with time, and this can lead to ectropion, particularly laterally. This also can be worsened iatrogenically with overly aggressive skin resection during lower eyelid blepharoplasty procedures.
Components of the "tired-eye" look also require discussion. This common complaint usually is caused by lower eyelid medial problems. Three parts comprise this problem.
First, the lateral cheek descends with aging and tends to do so more in individuals with morphologically prone eyes (MPE), eyes that are morphologically prone to ectropion with lax lateral canthal ligaments, downgoing palpebral fissures, limited lateral malar prominence, and a tendency toward a sunken midfacial structure.
Second, this leads to a hollowness of the medial canthal and central upper facial area. This hollowness can be termed the nasojugal groove or, slightly differently and more central in the lower mid face, the tear-trough deformity. Some individuals are born with this area of the lateral nose and cheek depressed, leading to a tired look in the area. Atopic individuals often have this appearance, although no link between allergy and changes in the mid face is documented in the literature.
Finally, another component of aging in this area is the shadow from the central brow area if it is retruded (relatively retrodisplaced). The third component of the tired-eye look in this area is the presence of true pigment within the skin of the central lower eyelid and occasionally extending across the lower eyelid, even without the presence of true lower eyelid bags. This pigmentation has not been studied but clinically it responds to treatments used for the abolition of melanin and hemosiderin pigmentation.
The indication for facial rejuvenation surgery largely is the patient's desire. Consider the extent, anatomy, and pathology of aging of a particular patient when deciding on procedures for the patient.
For example, a patient may report upper eyelid heaviness and a tired look to the eyes. A true ptosis requiring correction may be present, or, more commonly, interplay of brow descent and upper eyelid skin fullness exists. If the brows are in good position, an upper eyelid blepharoplasty may be all that is required to improve the patient's feelings about his or her appearance. Conversely, a truly descended brow is not corrected with an upper eyelid blepharoplasty procedure, and the entire orbital area may have a worsened appearance after the skin is resected from the upper eyelid. Once the impetus for static contraction of the upper eyelids is gone, they descend even further than preoperatively, worsening the lateral and medial periorbital regions, which are not addressed with the upper eyelid blepharoplasty procedure.
The medial canthal area requires special consideration even though it is not well addressed by a brow lift procedure. The tear trough (Flowers) and nasojugal groove areas have been difficult areas to address with anything other than complex midface lifts. Many patients present with depressions in this area, which may or may not be overhung with lower eyelid fat. The clinician needs to differentiate whether a true groove exists in the area and determine the extent of the groove and its direction (just along the infraorbital margin or extending into an extended groove, sometimes ending in a festoon or malar bag). Pigmentation of the skin often contributes to this darkness in the area.
The anatomy of the periorbital region is extremely important in the area's features of aging and in the correction of those features.
Starting from the most superior area and proceeding downward on the face, the scalp, which is composed of a number of layers, is encountered first. The acronym "SCALP" (S for skin, C for subcutaneous tissue, A for loose areolar layer, L for galea aponeurotica, P for periosteum) is taught in medical school and adequately describes the layers. The presence of a large structure essentially floating on the loose areolar layer (eyebrows at the end of the long expanse of forehead) leads to the descent observed with time.
Transverse forehead rhytides largely result from frontalis muscle action. The frontalis acts broadly to elevate the brows, usually somewhat more centrally than laterally. The corrugator supercilii muscles are the depressors and central contractors of the medial brow. They insert into the medial eyebrow skin to a variable distance (up to the central brow in some individuals) and originate in the periosteum of the nasal root. They envelop the supratrochlear nerve, which supplies sensation (branch of cranial nerve V) to the central forehead area.
The supraorbital nerve is more lateral and passes through the supraorbital region either in a foramen or beneath a ledge in the central brow region. This also is a sensory nerve and a branch of cranial nerve V and supplies a slightly more lateral but larger area than the supratrochlear nerve. The procerus muscle is a small muscle at the root of the nose that serves to elevate the nasal skin and depress the brow. It inserts into the central interbrow skin and originates in the periosteum of the nasal root. The muscle can cause a transverse rhytide at the nasal root.
The contour of the eyebrow is important. Central, low brows often are not a concern for individuals once the frown lines are removed. The high arched brows produced by the coronal lifts of the past generally are not desirable today, although a relatively high lateral brow remains a component of the desirable aesthetic periorbita. Similarly, many individuals generally do not desire an exaggerated tilt to the lateral orbit compared to the medial orbit, but a slight tilt and tightness of the lower eyelid is a desirable feature in orbital rejuvenation. The overly high brow is not desirable for anyone, but it is particularly feminizing in the male patient.
The lateral canthal ligament has 3 attachments to the lateral orbital rim: superior, inferior, and posterior. Some or all of these may need to be disinserted for significant elevation of the lateral attachment of the lower eyelid. Often, a canthoplasty may be performed in which the attachment merely is tightened and slightly elevated for the desired effect. The medial canthal area generally is not addressed except in reconstructive procedures because of limited descent with aging and concern over the lacrimal apparatus in the area.
The nasojugal and tear-trough areas largely are defined by the bony margins of the lateral nose and the medial orbital region as it descends into the maxilla.
Orbicularis oculi muscles cause the eyelids to close. Lateral overactivity can lead to laugh lines in the crow's feet area of the lateral periorbital region. The importance of the pretarsal region of the lower eyelid orbicularis muscle recently has been elucidated, and it must be conserved during lower eyelid blepharoplasty.
Lagophthalmos with a preexisting overly elevated eyebrow or a low brow with insufficient upper eyelid skin for proper eyelid closing after brow elevation is the only contraindication to brow lift procedures. This condition usually is iatrogenic.
A high hairline previously was a contraindication to brow lift procedures. It likely remains so for coronal lifts, but hairline incisions can be made that actually lower the hairline while raising the brows. This results in a scar at the hairline, which is acceptable to many individuals who wear bangs. Often the scar can be evened by placement into and back from the hairline; this also results in a less prominent scar over less of the hairline.
Careful forethought must be done prior to brow lifting, as an overly elevated brow is very difficult to correct, even with recruitment of posterior scalp tissue, as there is often scarring present, which disallows brow lowering in the forehead and suprabrow areas after previous brow lifting procedures. A relaxed posture muscle should be ascertained, even if slight holding of the brow with finger pressure is needed to show the patient their nascent brow posture (some individuals almost have a spastic frontalis action with instant brow elevation with eye opening, particularly in their plastic/cosmetic surgeon's office). The exact position of the brow and the exact brow posture must be known by both the surgeon and the patient preoperatively and discussed well prior to operative marking and the normal excitement on operating day. Care should be taken to ascertain where the brow skin transitions to eyelid skin and structures without consideration of shaping done by plucking or waxing. If an overly elevated brow is the only way of clearing lateral orbital rhytides, consideration should be given to incomplete correction of this area or other means of smoothening the skin of the area. For example, carbon dioxide laser resurfacing is a marvelous adjunct to tightening the skin of this area without undue lateral brow elevation.
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