Thorough exam, consultation key to comprehensively addressing periorbital region
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Key takeaways:
- Assessing the area above the midface and below the eyes is necessary before treating the periorbital region.
- Treatment goals and expectations should be discussed and understood by both patient and provider.
A comprehensive examination and consultation are crucial to ensure optimal results while avoiding unintended consequences when addressing the periorbital region.
My practice, located in Nashville, approaches aesthetic improvements with a goal of achieving an elegant, yet somewhat understated result. We perform treatments with simultaneous objectives of correcting congenital and age- or environmental-related changes and taking a proactive, preventive approach to aging and aesthetics.
Assessing the patient’s face in its entirety allows the provider to understand how changes to one area will affect other features and, therefore, make the best treatment recommendations. Unfortunately, I frequently see treated patients who are unhappy with the outcome of a previous procedure that uncovered an underlying anatomic condition that should have been recognized prior to treatment to avoid the untoward outcome. Many of these cases involve treatment in the periorbital region.
Our four main nonsurgical choices for periorbital rejuvenation and correction include neuromodulators, soft tissue fillers, laser skin resurfacing and topical oxymetazoline drops. Depending on patient needs, we often use a combination therapy approach to achieve best outcomes. The aesthetic provider must assess the forehead above and the midface below the eyes and consider the relative factors that are affecting those areas when treating the periorbital region.
Uncovering the unwanted
Horizontal forehead lines occur due to chronic contraction of the frontalis muscle typically in response to brow ptosis, the presence of dermatochalasis, and/or upper eyelid ptosis. If the frontalis muscle is treated with neuromodulator in the setting of brow or eyelid ptosis or upper eyelid dermatochalasis, the underlying conditions will be exacerbated as the ability to compensate for them will be lost. I frequently advise patients who seek consultation for eyelid and periorbital rejuvenation who have significant neuromodulator effect in the forehead that I am unable to make a treatment recommendation until I can assess the natural lid and brow positions.
Neuromodulators injected in the lateral canthal region can affect the ability of the lower eyelid to contract effectively with subsequent loss of orbicularis oculi ability to pump lymphatic fluid out of the lower lid, leading to subsequent lower eyelid puffiness or fullness. Careful assessment of lower eyelid tone and strength of orbicularis contraction can avoid this complication.
When correcting infraorbital hollows, if there is concomitant midfacial volume depletion or the eye is very prominent (a condition known as a negative vector), the midface area should be addressed first to ensure adequate support. A careful pretreatment assessment can identify those patients in whom the midface needs to be corrected in order to provide support for the infraorbital region. Treatment of the undereye area only in these patients will lead to a suboptimal outcome.
A treatment recommendation can only be made after the patient’s goals have been identified and are clearly understood by both parties. Some patients are goal-oriented and will undergo whatever procedure is necessary to achieve a desired outcome, whereas others are surgically averse, do not have any “downtime” for post-treatment recovery, etc. For example, let’s consider two patients who have a modest amount of upper eyelid ptosis but have different treatment goals and expectations. One may choose to undergo surgical correction of the upper eyelid, whereas the other may choose to use oxymetazoline drops indefinitely. Both decisions are reasonable and both patients can leave the office happy even though they have very different treatment plans for the same condition.
Pearls for the consult
Observation is integral to my evaluation. I pay close attention to patients’ facial expressions: how they hold their eyebrows, whether their forehead is consciously or subconsciously contracting throughout the course of our conversation, and their muscle distribution and strength when they are asked to animate and during our casual conversation. Careful observation of patients without their knowledge they are being actively observed provides an opportunity to see how muscles are used during the course of typical conversations and interactions. It also provides an opportunity to note skin appearance, eyelid position, static and dynamic facial rhytids and a host of other important observations. If patients are told they are being carefully examined or photographed, their natural inclination is to change their expression. The physical examination during a facial aesthetic consult begins as soon as I begin speaking with a patient and taking a history. This strategy allows me to make treatment recommendations that are most likely to preserve and enhance a patient’s natural appearance.
I also learn what type of lifestyle they have. Do they interact with the public or work virtually and never see professional colleagues? Even if they do not have a formal job, their lives may be extremely full and busy. It is important to learn if they have upcoming public appearances, or events, trips, etc. These factors all must be considered when making recommendations about treatments and procedure timing.
Conclusion
No one part of the face is independent from another, making it crucial to understand facial anatomy and aesthetic balance. Closely observing patients and their natural facial expressions — before they know they are being “examined” — assists providers in making the optimal treatment recommendations to achieve best outcomes.
For more information:
Brian B. Biesman, MD, can be reached at bsbiesman@drbiesman.com.
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