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'R' Power: Raising lower lid rejuvenation to the power of R in five systematic steps

Article-'R' Power: Raising lower lid rejuvenation to the power of R in five systematic steps

Key iconKey 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.

Dr. Swartz
In lower eyelid rejuvenation, careful attention to a series of specific steps will assure that each patient's individual needs are being effectively addressed, says one expert.

"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.

36-year-old female (left) with reduced aperture while smiling before Botox treatment and (right) with increased aperture following Botox treatment.

"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."

36-year-old female (left) with reduced aperture while smiling before Botox treatment and (right) with increased aperture following Botox treatment66-year-old female (left) with improperly placed Restylane in lower eyelid and (right) with improved contour following treatment with hyaluronidase.

'R'ESURFACE & 'R'ELAX 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.

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