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Year : 2018  |  Volume : 56  |  Issue : 1  |  Page : 12-16

Esthetics in ophthalmology: Noninvasive options of facial rejuvenation

Department of Orbit, Oculoplasty, Reconstructive and Aesthetics Services, Sankara Nethralaya, Medical Research Foundation, Chennai, Tamil Nadu, India

Date of Web Publication4-Jun-2018

Correspondence Address:
Dr. Atanu Barh
Department of Orbit, Oculoplasty, Reconstructive and Aesthetics Services, Sankara Nethralaya Medical Research Foundation, 18 College Road, Chennai - 600 006, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_27_18

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Facial aging is an ongoing biological process governed by both intrinsic and extrinsic factors. Conventionally, surgical treatments remained superior for decades due to satisfactory outcome. Expensive and invasive esthetic surgical procedures have been replaced by more affordable, less invasive procedures. For the past few years, novel nonsurgical treatment modalities are on the rise due to less patient morbidity and faster recovery. The intention of this article is to present a comprehensive review of the currently available nonsurgical methods to revert facial aging.

Keywords: Aging, botulinum, esthetics, fillers

How to cite this article:
Barh A, Mukherjee B. Esthetics in ophthalmology: Noninvasive options of facial rejuvenation. TNOA J Ophthalmic Sci Res 2018;56:12-6

How to cite this URL:
Barh A, Mukherjee B. Esthetics in ophthalmology: Noninvasive options of facial rejuvenation. TNOA J Ophthalmic Sci Res [serial online] 2018 [cited 2020 Feb 28];56:12-6. Available from: http://www.tnoajosr.com/text.asp?2018/56/1/12/233719

  Introduction Top

Oculoplasty traditionally referred to surgeries on the eyelids, orbit, and lacrimal system. In recent years, the subspecialty of oculoplasty has expanded in the scope of practice. There are essentially two types of oculoplasty surgery: Reconstructive, or functional and cosmetic, or esthetic. Reconstructive surgery is performed to correct functional impairments caused by developmental abnormalities; traumatic injuries, such as fractures and burns; and various diseases including neoplasms. Reconstructive plastic surgery may also be done to approximate a normal appearance as it is a function of facial architecture. Esthetics is an essential component of oculoplasty and involves techniques intended for the “enhancement” of appearance through surgical and medical techniques and is specifically concerned with maintaining normal appearance, restoring it, or enhancing it beyond the average level toward an esthetic ideal. The desire to look youthful has exponentially grown with the improvement in the quality of life, expendable earning, and shift in priorities in the current generation of young Indians. Better technology, minimally invasive procedures, and greater accessibility have made esthetic procedures, surgical and nonsurgical, far more attractive. Since the periocular area is the one which captures one's attention, these patients frequently present to ophthalmologists for guidance and advice. Ophthalmologists are in a better position with their knowledge and training than cosmetic dermatologists or plastic surgeons to evaluate and treat these patients. However, most general ophthalmologists are unaware of the options available to them. This review article is to enumerate the nonsurgical options of facial rejuvenation available to us which can be undertaken at minimal risk to the patient.

Facelift is a procedure that improves visible signs of aging in the face and neck. Rhytidectomy is a Greek word: Rhytis means “wrinkle” and ektome means “excision,” that is, surgical removal of wrinkles. Conventional facelift surgeries are effective in most of the cases but have significant patient morbidity. Over a period of time, minimally invasive to noninvasive OPD-based procedures have become more popular than conventional surgical treatment options. With the advent of neurotoxin and facial fillers, there is a paradigm shift in cosmetic therapies. Other recent nonsurgical modalities include ultherapy, intense pulsed light, laser lift, radio frequency skin tightening, and plasma skin tightening.

Facial aging process

Facial aging is a complex procedure caused by both intrinsic and extrinsic factors. Intrinsic changes result from cellular apoptosis and genetically determined processes. Cellular changes in the facial skin are characterized by thinning of epidermis with variability in the size and shape of epidermal cells, loss of fibroblasts, melanocytes and Langerhans cells, and shortening of capillary loops.[1],[2],[3] Extrinsic factors facilitating aging are mainly due to prolonged exposure to various environmental factors including photodamage, dehydration, inadequate nutrition, toxins, and injuries.[3]

Age-related specific changes are observed in four planes: Skin, fat, muscles, and bones. In skin, fibroblasts attached to normal collagen allow stretching and balance further collagen production and degradation. With aging, the dermal collagen gets fragmented by the action of matrix metalloproteinase. Fibroblasts collapse and no longer attach to the fragmented collagen leading to loss of structural integrity.[4] Treatment that stimulates the production of new, nonfragment collagen improves the appearance and health of aged skin (e.g., laser).

Facial fat is divided into superficial and deep compartment by the superficial musculoaponeurotic system (SMAS). They maintain the facial arcs and curvatures, for example, the arc of jawline and arc of forehead.[5] Age-related absorption or ptosis of this fat cause loss of normal facial arcs and curvatures. Rohrich and Pessa demonstrated in cadavers that facial fat exists as multiple well delineated, independent compartments with specific anatomic relationships to one another.[6] These compartments serve as a “glycosyltransferase-programmed stereosubstitution” for the injection of facial fillers and treatment of one area can improve the appearance of the adjacent area.[7]

Facial mimetic muscles are one of the determining factors for facial aging. Over the time, repeated contractions of this muscles lead to increase in the resting tone of the muscles. This, in turn, redistributes the arrangement of the superficial and deep facial fat. Deep fat layer becomes thinner and the superficial pad of fat gets thicker. This mechanism leads to a loss of the youthful curvilinear contour, thus changing the shape, morphology, and three-dimensional topography of the face.[8] Botulinum injection is very useful in such cases to reduce the increased muscle tone.

Age-related bony remodeling causes a decrease in the space available for the soft tissue in the midface, results in a “folding in” configuration of the soft tissue that resembles like an accordion.[9] The most consistent findings include a change in the contour of the orbit, decreased midface vertical height, and a decrease in the glabellar, pyriform, and maxillary angle. These inadequate bony structures can be augmented by solid implants or injectable fillers.

  Botulinum Toxin Top

The most common nonsurgical cosmetic facial procedures are botulinum toxin Type A injections, which has historical ties to the field of ophthalmology. Developed by an ophthalmologist, it was devised for the treatment of strabismus and blepharospasm.

In December 1989, Botox © manufactured by Allergan was approved by the US Food and Drug Administration (FDA) for the treatment of strabismus, blepharospasm, and hemifacial spasm in patients over 12 years old. In 2002, the FDA announced regulatory approval of botulinum toxin Type A to temporarily improve the appearance of moderate-to-severe frown lines between the eyebrows. Subsequently, cosmetic use of botulinum toxin Type A has become widespread with many viewing it as less intrusive and/or artificial than other types of plastic surgery. It is a potent neurotoxin protein derived from the Clostridium botulinum bacterium. It relaxes the muscle tone by cleaving synaptosome-associated protein-25 on the internal surface of neuronal membranes, thereby inhibiting vesicle fusion and release of acetylcholine. Duration of action is usually 3–6 months.[10]

Types: Serotypes-A, B, Cα, Cβ, D, E, F, and G. Type A is most potent and used clinically.

Clinically available variant of botulinum toxin A includes:[11]

  • Botox (OnabotulinumtoxinA): 100 U vial
  • Dysport (AbobotulinumtoxinA): 300 U vial
  • Xeomin (IncobotulinumtoxinA): 100 U vial.


Most useful for dynamic wrinkles, that is, caused by increased muscle tone.[12] Following are suitable sites for botulinum toxin injections [Figure 1]:
Figure 1: Sites where botulinum toxin can be injected. (a) Horizontal forehead lines (frontalis); (b) Frown lines (glabellar complex); (c) Crow's feet (orbicularis oculi); (d) Bunny lines (nasalis); (e) Nasolabial folds (levator labii superioris alaequae nasi); (f) Radial lip lines (orbicularis oris); (g) Marionette lines (depressor anguli oris); (h) Chin line (mentalis)

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  • Horizontal forehead lines (frontalis)
  • Frown lines (glabellar complex)
  • Crow's feet (orbicularis oculi)
  • Bunny lines (nasalis)
  • Nasolabial folds (levator labii superioris alaequae nasi)
  • Radial lip lines (orbicularis oris)
  • Marionette lines (depressor anguli oris)
  • Chin line (mentalis).

A comparatively newer hypothesis encourages intradermal injection of botulinum toxin rather than intramuscular injection. It directly increases the pliability and elasticity of the skin, probably by increase in collagen synthesis as well as its remodeling of the newly synthesized collagen. The exact mechanism is still unclear, but it is useful for static and fine wrinkles.[13]

Preparation, procedure and dosage

Botulinum toxin is available as a powder. Sterile normal saline is used to reconstitute it before injection. Dilution volumes range from 1 to 4 mL/100-unit vial. Reconstituted solution can be preserved up to 6 weeks at 4°C. Small amount of the solution is injected into the muscle or intradermally using a tuberculin syringe and 30G, 1-inch needle. Local anesthesia is usually not required. Postoperative bruising can be minimized by advising patients to discontinue aspirin or any medicine having anticoagulant effects 2 weeks before treatment.[14] Dosage depends on the site and severity of the wrinkles [Figure 2].[12]
Figure 2: Guidelines for botulinum toxin injection. (a) Glabellar lines; (b) Canthal lines; (c) Horizontal forehead lines; (d) Bunny lines – nasalis and procerus; (e) Orbicularis oris; (f) Mentalis; (g) Platysma

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  • Glabellar lines: Inject 4 units (0.1 mL) into each of 5–7 sites, 2 in each corrugator muscle and 1 in procerus muscle for a total dose of 20–30 U
  • Canthal lines: Inject 4 units (0.1 mL) into 3 sites per side (6 total injection points) in the lateral orbicularis oculi muscle for a total of 24 units/0.6 mL (12 units per side)
  • Horizontal forehead lines: Inject 4 units (0.1 mL) into each of 5 forehead line sites (20 units); treat in conjunction with glabellar lines with 0.1 mL (4 units) into each of 5 glabellar line sites (20 units), for a recommended total of 40 U
  • Nasalis: 1 per side, total 2–5 U
  • Procerus: 1 in midline, total 1 U
  • Orbicularis oris: 2–6sites, total 4–10 U
  • Mentalis: 1–2 sites, total 2–8 U
  • Platysma: 2–12/band, total 10–40 U.

Side effects include ecchymosis/edema/erythema of skin, transient headache, blepharoptosis or eyebrow ptosis, allergic reaction, and facial asymmetry.[15] Although botulinum toxin is comparatively safe for human use, it has been not recommended in patients having neuromuscular disorder (e.g., myasthenia gravis), allergy to any component, pregnancy, lactation, keloid scar, and active infection or inflammation.[14]

  Dermal Fillers Top

Materials injected within or beneath the skin to improve its physical appearance by soft-tissue augmentation are known as fillers.[16] An ideal filler material should be safe, biocompatible, resistant to infection, nonteratogenic, noncarcinogenic, and nonallergic. It should fix to the surrounding tissue and maintain the desired facial contour.[17] Although the ideal filler still to be developed, there are various cosmetically accepted fillers are available in the market which are approved by FDA. These include

  • Hyaluronic acid with/without 0.3% lidocaine: 3–12 months
  • Human collagen: 2–6 months
  • Poly-L-lactic acid (PLLA): 18–24 months
  • Sodium hydroxylapatite: 2 years
  • Permanent-Silicon, Fat autogenous.

Mechanism of action

They act by filling the hollow space. Hyalurons helps in hydrations of the surrounding tissue, activation of the fibroblast, and remodeling of collagen, thus improves the skin elasticity.[18] PLLA is a synthetic, biodegradable inert peptide polymer. It gradually replaces the loss of volume by stimulating fibroblasts which lay down new collagen.[19] The calcium hydroxyl apatite-based filler is a long-lasting synthetic semi-permanent dermal fillers. It acts as a scaffold for new tissue formation and stimulates collagen formation leading to thickening of the skin.[16]

Indications: following are the sites where fillers can be injected effectively [Figure 3].[20]
Figure 3: Sites where fillers can be useful. (a) Forehead; (b) Frown lines; (c) Brow; (d) Superior sulcus; (e) Temporal fossa; (f) Nasal dorsum; (g) Nasojugal and malar grooves; (h) Malar eminence; (i) Jawline; (j) Nasolabial fold; (k) Lips; (l) Prejowl sulcus; (m) Mentum

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  • Forehead
  • Frown lines
  • Brow
  • Superior sulcus
  • Temporal fossa
  • Nasal dorsum
  • Nasojugal and malar grooves
  • Malar eminence
  • Jawline
  • Nasolabial fold
  • Lips
  • Prejowl sulcus
  • Mentum.

  Patient Selection Top

Fillers are most effective in individuals who are younger than fifty and who do not have sufficient looseness of the cheeks and neck to warrant a surgical facelift. However, it can be used in any adult patient. Fillers should be avoided in following conditions:

  • Severe allergies/history of anaphylactic shock
  • Allergy to cow collagen/eggs/lidocaine
  • Inflamed or infected skin (i.e. Herpes)
  • Tendency to form keloids or hypertrophic scars.

Selection of fillers: Depends on types of aging changes. For example,

  • Hyalurons – to fill a depression, plump a lip
  • Calcium hydroxyl – for volume augmentation of the cheek and a secondary lift effect in the nasojugal region
  • PLLA – global volume restoration.


  • Erythema/induration/bruising
  • Granuloma/abscess formation
  • Vascular occlusion/blindness (rarely).

  •   Procedure Top

    Injection technique is very important. Injections that are placed too superficially may cause the appearance of irregularities, lumps, or bumps. Injections that are placed too deeply may simply be ineffective for the volume of filler injected. Different fillers have different technique of injection. For example, hyaluronic fillers can be injected in a linear threading technique along the length of the wrinkles in areas such as the nasojugal fold, marionette lines or procerus furrow. A multipoint “droplet” technique along the length of the rhytids or contour may be used in the tear trough region or nasojugal fold. PLLA is usually used to provide global volume restoration. Initially, after injection, the volume delivered disappears within 24–48 h. Over the period of several months, collagen deposition is stimulated and the overall appearance gets improved.

      Ultherapy Top

    The device combines microfocused ultrasound (MFU) with high-resolution ultrasound imaging for visualization of area up to 8 mm depth where the MFU energy will be applied.[21] Short duration (25–30 ms) pulse produces <1 mm 3 thermal damage to a depth of up to 5 mm within the mid-to-deep reticular layer of the dermis and subdermis while sparing overlying papillary dermal and epidermal layers of skin.[22] The treatment produces heat (60°C–70°C) in collagen layer, leading to contraction of the collagen layers and stimulation of de novo collagen synthesis, thus tightens and fills the skin.[23] Tightening and lifting of sagging facial and neck skin and improvements in the appearance of wrinkles can be achieved by targeting the facial SMAS and platysma.[24] The FDA approved this in 2009 for cosmetic use. Action is perceived after 4–6 months after therapy and it is said to be permanent.

    Patient selection

    It is best suited for patients with mild-to-moderate skin and soft-tissue laxity.[25]

    Adverse effects are very few including discomfort during treatment, dermal papules, and facial neuropraxia.[26]

      Intense Pulsed Light Top

    It uses nonlaser high-intensity light sources; light pulses are produced by bursts of electrical current passing through a xenon gas-filled chamber.[27] A handpiece is used to deliver the energy pulse onto the skin surface. The heat produced in dermal layers leads to collagen contracture leading to tightening of the skin.[28] Furthermore, it stimulates the fibroblasts which in turn increases new collagen synthesis, thus helps in skin remodeling.[29] The most commonly targeted wrinkles are those in the perioral and periorbital regions. Superficial lines respond well than deep furrows. Results are often subtle and require multiple treatment sessions. Concomitant botulinum toxin injection produces better results in cases of dynamic wrinkles.[30]

      Laser Lift Top

    High-energy beams of light to stimulate cell turnover, which helps exfoliate damaged or discolored skin cells while stimulating collagen production.[31] The long recovery time and causes long-lasting side effects, such as persistent erythema, hypo- or hyperpigmentation, infection, or scarring.[32] Recently, fractionated lasers have been introduced to reduce these side effects. The term “fractional laser” means that the beam of light only targets a fraction of the skin at a time; reduces recovery time and thermal damage.[33] Most commonly used lasers are fractional CO2 laser therapy and Erbium laser therapy. Multiple sessions of 30 min to 2 h are required. Side effects include swelling, redness, itching; which usually settle down in 5–7 days.

      Radio Frequency Skin Tightening (Thermage) Top

    Monopolar radiofrequency is another noninvasive way to obtain skin tightening by immediate collagen contraction with a single treatment.[34] This technology produces electric current to generate heat through resistance in the dermis and subcutaneous fat.[35] Long-term studies are yet to come up with efficacy and analysis of side effects for the skin using this method of skin rejuvenation.

      Plasma Skin Tightening Top

    Plasma is the fourth state of matter in which electrons are stripped from atoms to form an ionized gas. For skin rejuvenation, nitrogen gas is used to form plasma. It is able to purge oxygen from the surface of the skin, reducing the risk of undesirable hot spots and scar formation. On formation, the plasma is directed through a quartz nozzle out of the tip of the handpiece and onto the skin surface to produce uniform controlled heat which helps in collagen synthesis. It has low-energy (1.0–1.2 J) and high-energy (3.0–4.0 J) protocol. Low-energy protocol has shown good results in the improvement of fine lines and textural irregularities, whereas high-energy protocol offers the added benefit of increased tissue tightening.[36]

      Conclusion Top

    The understanding of facial aging process in different structural planes determines the choice of appropriate nonsurgical treatment modality. Nonsurgical treatments are ideal for mild-to-moderate facial aging and are superior to surgical interventions in terms of postoperative morbidity and faster recovery in such cases. Multiple therapies are usually required for sustained desirable result.

    Financial support and sponsorship


    Conflicts of interest

    There are no conflicts of interest.

      References Top

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    El-Domyati M, Attia S, Saleh F, Brown D, Birk DE, Gasparro F, et al. Intrinsic aging vs. Photoaging: A comparative histopathological, immunohistochemical, and ultrastructural study of skin. Exp Dermatol 2002;11:398-405.  Back to cited text no. 2
    Rabe JH, Mamelak AJ, McElgunn PJ, Morison WL, Sauder DN. Photoaging: Mechanisms and repair. J Am Acad Dermatol 2006;55:1-9.  Back to cited text no. 3
    Fisher GJ, Varani J, Voorhees JJ. Looking older: Fibroblast collapse and therapeutic implications. Arch Dermatol 2008;144:666-72.  Back to cited text no. 4
    Coleman SR, Grover R. The anatomy of the aging face: Volume loss and changes in 3-dimensional topography. Aesthet Surg J 2006;26:S4-9.  Back to cited text no. 5
    Rohrich RJ, Pessa JE. The fat compartments of the face: Anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg 2007;119:2219-27.  Back to cited text no. 6
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    Le Louarn C, Buthiau D, Buis J. Structural aging: The facial recurve concept. Aesthetic Plast Surg 2007;31:213-8.  Back to cited text no. 8
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    Blasi J, Chapman ER, Link E, Binz T, Yamasaki S, De Camilli P, et al. Botulinum neurotoxin A selectively cleaves the synaptic protein SNAP-25. Nature 1993;365:160-3.  Back to cited text no. 10
    Bakshi E, Hartstein ME. Compositional differences among commercially available botulinum toxin Type A. Curr Opin Ophthalmol 2011;22:407-12.  Back to cited text no. 11
    Small R, Hoang D. A Practical Guide to Botulinum Toxin Procedures. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.  Back to cited text no. 12
    Bonaparte JP, Ellis D. Alterations in the elasticity, pliability, and viscoelastic properties of facial skin after injection of onabotulinum toxin A. JAMA Facial Plast Surg 2015;17:256-63.  Back to cited text no. 13
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    Kinney BM, Hughes CE 3rd. Soft tissue fillers: An overview. Aesthet Surg J 2001;21:469-71.  Back to cited text no. 17
    Wang F, Garza LA, Kang S, Varani J, Orringer JS, Fisher GJ, et al. In vivo stimulation of de novo collagen production caused by cross-linked hyaluronic acid dermal filler injections in photodamaged human skin. Arch Dermatol 2007;143:155-63.  Back to cited text no. 18
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    Botulinum Toxin
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    Patient Selection
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