PEER-REVIEW | FACIAL AESTHETICS | Figure 1 Anterior view of periorbital area
Frontalis muscle Corrugator muscle
Pre-aponeurotic fat Procerus muscle
Infra-orbital fat Orbicularis oculi muscle
Aspects of art and beauty A comprehensive knowledge of facial proportion, divine proportion and artistic dimension must be incorporated into all aesthetic medical procedures. At the periorbital level, it remains important and the doctor should always maintain symmetry with procedures and steer away from treating to an unnatural proportion. Another important point is to maintain results that are not just natural, but also age-appropriate. With facial volumisation, one can usually achieve very natural looking results in the mature woman, but removing every single wrinkle might not be suitable for the age of the patient. It is also important to understand the patient’s lifestyle and career, for example, to ensure that the results are a complement to these.
would contribute to the aforementioned hue of dark
skin around the eye. The muscles involved in the periorbital area include
the orbicularis oculi muscle, which has both a palpebral and orbital part. It is a very thin muscle with a dark red (vascular) colour. The orbital part also contributes to lifting the superficial malar and cheek fat pads. The orbicularis oculi muscle is a concentric muscle with a sphincteric action to close the eye. The other muscles surrounding the periorbital region have an impact with vectors pulling on the area. These include the corrugator muscles, which have a medial and inferior pulling action on the skin of the upper eyelid, and also on the eyebrows. The frontalis muscle is the only elevator of the upper face and has a superior lifting on the upper eyelid skin. The lifting action of the frontalis muscle is used more
often in a person with excess upper eyelid skin. This muscle should therefore be spared from muscle relaxing injections in these patients, as the mimetic action of the frontalis is crucial to lift this excess skin. The fat pads in the periorbital and surrounding regions
are very important in maintaining a youthful and aesthetically pleasing appearance. Unfortunately, these fat pads atrophy quite rapidly with age. The fat pads that should be clearly identified by doctors wanting to enhance the periorbital region include, inferiorly, the superficial fat above the orbicularis oculi muscles, the superficial cheek fat, infraorbital fat pads, the suborbicularis oculi fat (SOOF), the malar fat pad, and superiorly, the preaponeurotic and nasal fat pads. The fat pads not only atrophy with ageing, but also
move inferiorly with gravitation, and the muscles and septae keeping them in place thin and stretch, resulting in an inferior and anterior descent and projection of the orbital fat pads. It is vital to understand the pathology with regard to ageing around the eyes in order to successfully rejuvenate and enhance this region. The orbital septum becomes lax and the infraorbital
fat pad moves anteriorly and inferiorly, resulting in ‘bags’ under the eyes. At the same time, the malar fat pad atrophies and descends, exacerbating the tear trough (lid–cheek junction) and the nasojugal groove. The decline of periorbital fat results in hollowness above and below the eye, as well as sagging skin over the lost volumes and unnatural shadows.
62 ❚ March 2013 |
prime-journal.com The delicate
skin around the eye should be treated with the utmost respect, especially when performing ablative or resurfacing procedures.
Treatment plan for the periorbital area The aforementioned aspects should be taken into consideration when evaluating the patient for treatment. The treatment options can be divided according to the depth of the pathology (Table 1). However, the majority of patients will have a combination of factors relating to the aged appearance of the periorbital area, and as a result, combination therapies will always be more successful than single treatments alone. The delicate skin around the eye should be treated
with the utmost respect, especially when performing ablative or resurfacing procedures: one should keep in mind that the epidermis and dermis is much thinner here compared with the rest of the face. In patients with loose skin around the eye, skin tightening procedures such as radiofrequency, fractional laser, chemical peels, mesotherapy or skin needling can be performed.
Figure 2 Lateral cross sectional illustration of periorbital area
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