Eyelid Tightening by CO2 Fractional Laser, Alternative to Blepharoplasty Yoon-Soo Cindy Bae-Harboe, MD,*† and Roy G. Geronemus, MD*†
BACKGROUND Multiple approaches to achieve eyelid tightening have been introduced over the years. However, a solid foundation of knowledge as to the origins of the aging appearance is paramount to target the specific causes of this natural phenomenon. OBJECTIVE This review aims to touch upon the diverse modalities used to achieve the best therapeutic approach for eyelid tightening. MATERIALS AND METHODS A review of published articles on eyelid tightening using blepharoplasty and lasers was conducted. This information combined with an illustrative case example is presented. RESULTS
Although multiple treatment options exist, there are advantages and disadvantages for each.
CONCLUSION Understanding the cause of the aging periorbital area with appropriate application of the various treatment options available will lead to a natural and youthful appearing result. Fractional ablative CO2 laser remains an excellent alternative to traditional blepharoplasty. The authors have indicated no significant interest with commercial supporters.
A
ging, specifically skin laxity causing the appearance of excess skin around the eyelids, is a common complaint that many dermatologists encounter in consultation. Eyelid skin tightening can be achieved in a variety of ways. These include ablative and nonablative fractionated laser resurfacing in addition to multiple plastic surgery approaches.1–3 The most important aspect when evaluating the periorbital area is that the correct cause of the aging eyelid be made. Many components can contribute including, but not limited to periorbital fat prolapse, orbicularis muscle hyperactivity, and periorbital excess skin.4 Roberts and colleagues have identified 11 features of a youthful versus aging periorbital area. These features include brow with a pleasant arch, no redundant lid skin or periorbital fat, short apparent vertical height of the lower lid (10–12 mm), gentle transition between the cheek and lid skin, no dark circles, no tear trough deformity, and smooth skin in the following areas:
infrabrow, crow’s foot, malar and lower lid.3 Nearly half of the components involve “smooth skin” that traditional surgical approaches cannot deliver. Evaluating patients for these different signs of periorbital aging may help direct them to the best therapeutic approach. Blepharoplasty has been the surgical paradigm to address periorbital rejuvenation. Although the approach to blepharoplasty has evolved, the effects are limited to manipulating excess skin, muscle, and fat, components responsible for the aging periorbital area.3 Surgeons have pioneered additional ways in which the appearance of the aging periorbital area can be improved with coronal foreheadplasty, endoscopic brown lifts, arcus marginalis release, and the transpalpebral cheek lift to name a few3; however, these surgical procedures do not address the texture of the skin, fine lines, pigmentation, or actinic damage, all of which play a role in the appearance of overall aging. To focus on these issues, plastic
*Laser & Skin Surgery Center of New York, New York, New York; †Ronald O. Perelman Department of Dermatology, NYU Langone Medical Center, New York, New York
·
© 2014 by the American Society for Dermatologic Surgery, Inc. Published by Lippincott Williams & Wilkins ISSN: 1076-0512 Dermatol Surg 2014;40:S137–S141 DOI: 10.1097/DSS.0000000000000165
·
·
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Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
EYELID TIGHTENING BY CO2 FRACTIONAL LASER
surgeons have tried complementing blepharoplasties with dermabrasion, chemical peels, and more recently laser resurfacing.4 The use of dermabrasion and chemical peels before blepharoplasty is limited because it is difficult to determine the degree of skin contraction and has the potential to interfere with the healing of the treated skin.4 Blepharoplasty specifically carries complications of scleral show, ectropion, hollow appearing eyelid sulcus (from over correction), vision loss (from retrobulbar hematomas or globe perforation), and diplopia (from impaired ocular motility). Other risks include corneal abrasion, lagophthalmos, cellulitis, postblepharoplasty ptosis, dry eye syndrome, lower lid malposition, chemosis, asymmetry, and scarring.4 In contrast, many nonsurgical therapies have been investigated through the years to defer surgical blepharoplasties, these include ablative CO2 laser, erbium-doped yttrium-aluminium-garnet (Er:YAG) laser, fractional ablative CO2 laser and nonablative fractional laser, radio-frequency technology, chemical peels, soft tissue fillers, and neuromodulators.2 Each modality has its strengths and weaknesses, and some of these approaches may be combined to complement one another (Table 1). Historically, ablative carbon dioxide resurfacing has been the gold standard for skin resurfacing and therefore an efficacious approach to treat the dermatochalasis of the eyelid skin.5 In a comparative trial, both CO2 laser and Er:YAG laser demonstrated similar degrees of tightening; however, the Er:YAG laser left 33% of patients treated with scarring.6 In addition, the Er:YAG laser does not coagulate as well as the CO2 laser, impairing visibility during laser surgery. Overall, the major disadvantages of these ablative modalities are the long recovery periods and side effects that can include acneiform eruptions, prolonged erythema, pigmentary changes (particularly hypopigmentation, which can also be seen after chemical peels leaving a line of demarcation between treated and untreated areas), ectropion, infection, and scarring.5–7 To avoid the significant potential side effects from ablative methods, the development of nonablative
S138
approaches have been developed, the most notable being the concept of fractional photothermolysis.8 Fractional photothermolysis delivers microthermal zones—columns of controlled thermal injury to the skin, leaving healthy untreated skin which allows for rapid reepithelialization. This technology enables the delivery of dermal coagulative injury without confluent epidermal damage. These efforts to improve nonablative technology led to the development of a fractional ablative CO2 laser—a method demonstrating controlled tissue vaporization and thermally induced dermal coagulation extending to greater depths than seen in both traditional CO2 lasers and newer nonablative lasers.8 These findings correlated to greater tissue contraction, collagen production, and dermal remodeling than that seen with nonablative devices.9 The development of ablative fractional resurfacing has led to clinical improvement mirroring ablative CO2 resurfacing with a quicker recovery, but without carrying the unwanted side effects and long recovery period. Furthermore, studies comparing the efficacy of ablative and nonablative fractional lasers have shown the superiority of the former modality in treating eyelid rhytides and skin texture.2 Tierney and colleagues have demonstrated this clinical observation by histologic and radiologic studies of skin after ablative fractional laser treatment.10,11 More specifically, the authors found greater improvement in tissue tightening associated with greater depth of penetration at longer pulse durations. In addition, ultrasound visualization of treated skin revealed that tissue ablation reaches the level of the midreticular dermis.11 As mentioned earlier, the depth achieved by the ablative fractionated technology has been shown to extend deeper than that of the traditional CO2 laser— up to 1.5 mm compared with several hundred micrometers, respectively. Although the effects of ablative fractional CO2 resurfacing rival the effects of a surgical blepharoplasty, prospective head-to-head investigations comparing these 2 approaches have not been investigated. Roberts and colleagues performed a retrospective review on 174 patients undergoing traditional fully ablative CO2 laser resurfacing on the eyelids with and
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
BAE-HARBOE AND GERONEMUS
TABLE 1. Treatment Options for the Aging Periorbital Area: Advantages and Disadvantages Treatment Retinoic acid
Advantage
Disadvantage
Gentle
Minimal effect
Improves skin texture, hyperpigmentation, fine lines
Skin irritation
Various strengths and formulations
Deeper peels can leave a sharp demarcation between treated and untreated areas
Long-term use Chemical peels: superficial, medium, deep
Prolonged erythema Dyspigmentation, particularly hypopigmentation Scarring Neuromodulators
Targets “Crow’s feet”
Can worsen fat herniations of the lower lid
Can be used to complement other approaches
No tightening Does not improve actinic damage or pigmentary changes to the skin
Soft tissue filler
Targets tear troughs
No tightening
Dermabrasion
Can be used to complement other approaches Targets actinically damaged skin
Does not improve actinic damage or pigmentary changes to the skin Infection
Can help smooth skin
Dyspigmentation Scarring Fine control difficult due to instrument bulkiness
Topical polymer
Reduction of eye bags, lax skin, wrinkles
Radio-frequency
Decreased down time
Temporary
Noninvasive
Nonablative Lasers
Variable degree of improvement
Noninvasive
Limited to tightening and lifting
Decreased down time
Multiple treatment sessions needed
Noninvasive Nonfractional ablative lasers: CO2 laser, Er:YAG laser
Effective for skin laxity, fine lines
Acneiform eruptions, prolonged erythema, pigmentary changes (particularly hypopigmentation), ectropion, infection, and scarring
Ablative fractional CO2 laser
Effective for skin laxity, fine lines, actinic damage, dyspigmentation, festoons
Acneiform eruptions, erythema, pigmentary changes, infection, and scarring
Blepharoplasty
Effective for removing excess skin, muscle, and fat
Does not improve actinic damage or pigmentary changes to the skin Scleral show, ectropion, hollow appearing eyelid sulcus, vision loss, diplopia, corneal abrasion, lagophthalmos, cellulitis, postblepharoplasty ptosis, dry eye syndrome, lower lid malposition, chemosis, asymmetry, and scarring
Long recovery period
Shorter recovery period than CO2 laser
without blepharoplasty. Photographs of patients who had a follow-up period of at least 5 months or greater after their procedure were included in their investigation. They found that “excellent” results ($95%
wrinkle reduction) were seen in 5% of patients with traditional blepharoplasty, 29% after laser only, and in 49% after laser and laser blepharoplasty (using a CO2 laser for transconjunctival approach for
40:12S:DECEMBER SUPPLEMENT 2014
S139
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
EYELID TIGHTENING BY CO2 FRACTIONAL LASER
blepharoplasty). However, these results were confounded by the concurrent procedures performed on these patients. A proportion of patients in the blepharoplasty group, the laser resurfacing group and the laser resurfacing with blepharoplasty group had the following procedures at the time of their procedure: brow lift (68%; 42%; 68%), face-lift (64%; 42%; 56%), and lid tightening (5%; 21%; 48%), respectively. Because it was a retrospective study, it can be presumed that those patients chosen for a combination approach were more likely to have worse periorbital aging than those in the other 2 groups. Further analysis demonstrated that 83% and 85% of patients in the laser only and the laser + laser blepharoplasty groups, respectively achieved greater than 75% wrinkle reduction.3 The percentage of patients obtaining Class I “Optimal” Comprehensive Eyelid Tightening (smooth lid, no lowering of lid margin, no visible muscle hypertrophy, scar not visible) was the same at 71% in both the laser resurfacing group and the laser resurfacing with blepharoplasty group.3 Because of evolving technology, dermatologists can further improve these results using a fractional ablative CO2 laser. In our practice, patients seeking improvement of their periorbital skin are seen in consultation. Any history of previous blepharoplasty is noted because these patients have a higher risk of ectropion, and laser parameters must be adjusted accordingly. The patients are informed about the procedure and what to expect during the healing process (swelling, oozing, crusting, bleeding, and redness that will resolve with time). A pretreatment and posttreatment regimen, as well as follow-up, is reviewed at this time. The patients are instructed that they will need an escort on the day of their procedure because they will be administered a narcotic and anxiolytic for procedure purposes. Pretreatment preparation includes initiating a 1-week course of prophylactic antibiotic and antiviral medications 1 day before the procedure. On the day of the procedure, the patients are administered an intramuscular dose of ketorolac (60 mg), an oral dose of diazepam (5–10 mg), and an oral dose of acetaminophen/oxycodone (5/325 mg). A topical anesthetic (7% lidocaine/7% tetracaine) is applied to the treatment areas for 60 minutes and supplemented
S140
with a local injection of 1% lidocaine with 1:100,000 epinephrine (typically
BACKGROUND Multiple approaches to achieve eyelid tightening have been introduced over the years. However, a solid foundation of knowledge as to the origins of the aging appearance is paramount to target the specific causes of this natural phenomenon. OBJECTIVE This review aims to touch upon the diverse modalities used to achieve the best therapeutic approach for eyelid tightening. MATERIALS AND METHODS A review of published articles on eyelid tightening using blepharoplasty and lasers was conducted. This information combined with an illustrative case example is presented. RESULTS
Although multiple treatment options exist, there are advantages and disadvantages for each.
CONCLUSION Understanding the cause of the aging periorbital area with appropriate application of the various treatment options available will lead to a natural and youthful appearing result. Fractional ablative CO2 laser remains an excellent alternative to traditional blepharoplasty. The authors have indicated no significant interest with commercial supporters.
A
ging, specifically skin laxity causing the appearance of excess skin around the eyelids, is a common complaint that many dermatologists encounter in consultation. Eyelid skin tightening can be achieved in a variety of ways. These include ablative and nonablative fractionated laser resurfacing in addition to multiple plastic surgery approaches.1–3 The most important aspect when evaluating the periorbital area is that the correct cause of the aging eyelid be made. Many components can contribute including, but not limited to periorbital fat prolapse, orbicularis muscle hyperactivity, and periorbital excess skin.4 Roberts and colleagues have identified 11 features of a youthful versus aging periorbital area. These features include brow with a pleasant arch, no redundant lid skin or periorbital fat, short apparent vertical height of the lower lid (10–12 mm), gentle transition between the cheek and lid skin, no dark circles, no tear trough deformity, and smooth skin in the following areas:
infrabrow, crow’s foot, malar and lower lid.3 Nearly half of the components involve “smooth skin” that traditional surgical approaches cannot deliver. Evaluating patients for these different signs of periorbital aging may help direct them to the best therapeutic approach. Blepharoplasty has been the surgical paradigm to address periorbital rejuvenation. Although the approach to blepharoplasty has evolved, the effects are limited to manipulating excess skin, muscle, and fat, components responsible for the aging periorbital area.3 Surgeons have pioneered additional ways in which the appearance of the aging periorbital area can be improved with coronal foreheadplasty, endoscopic brown lifts, arcus marginalis release, and the transpalpebral cheek lift to name a few3; however, these surgical procedures do not address the texture of the skin, fine lines, pigmentation, or actinic damage, all of which play a role in the appearance of overall aging. To focus on these issues, plastic
*Laser & Skin Surgery Center of New York, New York, New York; †Ronald O. Perelman Department of Dermatology, NYU Langone Medical Center, New York, New York
·
© 2014 by the American Society for Dermatologic Surgery, Inc. Published by Lippincott Williams & Wilkins ISSN: 1076-0512 Dermatol Surg 2014;40:S137–S141 DOI: 10.1097/DSS.0000000000000165
·
·
· S137
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
EYELID TIGHTENING BY CO2 FRACTIONAL LASER
surgeons have tried complementing blepharoplasties with dermabrasion, chemical peels, and more recently laser resurfacing.4 The use of dermabrasion and chemical peels before blepharoplasty is limited because it is difficult to determine the degree of skin contraction and has the potential to interfere with the healing of the treated skin.4 Blepharoplasty specifically carries complications of scleral show, ectropion, hollow appearing eyelid sulcus (from over correction), vision loss (from retrobulbar hematomas or globe perforation), and diplopia (from impaired ocular motility). Other risks include corneal abrasion, lagophthalmos, cellulitis, postblepharoplasty ptosis, dry eye syndrome, lower lid malposition, chemosis, asymmetry, and scarring.4 In contrast, many nonsurgical therapies have been investigated through the years to defer surgical blepharoplasties, these include ablative CO2 laser, erbium-doped yttrium-aluminium-garnet (Er:YAG) laser, fractional ablative CO2 laser and nonablative fractional laser, radio-frequency technology, chemical peels, soft tissue fillers, and neuromodulators.2 Each modality has its strengths and weaknesses, and some of these approaches may be combined to complement one another (Table 1). Historically, ablative carbon dioxide resurfacing has been the gold standard for skin resurfacing and therefore an efficacious approach to treat the dermatochalasis of the eyelid skin.5 In a comparative trial, both CO2 laser and Er:YAG laser demonstrated similar degrees of tightening; however, the Er:YAG laser left 33% of patients treated with scarring.6 In addition, the Er:YAG laser does not coagulate as well as the CO2 laser, impairing visibility during laser surgery. Overall, the major disadvantages of these ablative modalities are the long recovery periods and side effects that can include acneiform eruptions, prolonged erythema, pigmentary changes (particularly hypopigmentation, which can also be seen after chemical peels leaving a line of demarcation between treated and untreated areas), ectropion, infection, and scarring.5–7 To avoid the significant potential side effects from ablative methods, the development of nonablative
S138
approaches have been developed, the most notable being the concept of fractional photothermolysis.8 Fractional photothermolysis delivers microthermal zones—columns of controlled thermal injury to the skin, leaving healthy untreated skin which allows for rapid reepithelialization. This technology enables the delivery of dermal coagulative injury without confluent epidermal damage. These efforts to improve nonablative technology led to the development of a fractional ablative CO2 laser—a method demonstrating controlled tissue vaporization and thermally induced dermal coagulation extending to greater depths than seen in both traditional CO2 lasers and newer nonablative lasers.8 These findings correlated to greater tissue contraction, collagen production, and dermal remodeling than that seen with nonablative devices.9 The development of ablative fractional resurfacing has led to clinical improvement mirroring ablative CO2 resurfacing with a quicker recovery, but without carrying the unwanted side effects and long recovery period. Furthermore, studies comparing the efficacy of ablative and nonablative fractional lasers have shown the superiority of the former modality in treating eyelid rhytides and skin texture.2 Tierney and colleagues have demonstrated this clinical observation by histologic and radiologic studies of skin after ablative fractional laser treatment.10,11 More specifically, the authors found greater improvement in tissue tightening associated with greater depth of penetration at longer pulse durations. In addition, ultrasound visualization of treated skin revealed that tissue ablation reaches the level of the midreticular dermis.11 As mentioned earlier, the depth achieved by the ablative fractionated technology has been shown to extend deeper than that of the traditional CO2 laser— up to 1.5 mm compared with several hundred micrometers, respectively. Although the effects of ablative fractional CO2 resurfacing rival the effects of a surgical blepharoplasty, prospective head-to-head investigations comparing these 2 approaches have not been investigated. Roberts and colleagues performed a retrospective review on 174 patients undergoing traditional fully ablative CO2 laser resurfacing on the eyelids with and
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
BAE-HARBOE AND GERONEMUS
TABLE 1. Treatment Options for the Aging Periorbital Area: Advantages and Disadvantages Treatment Retinoic acid
Advantage
Disadvantage
Gentle
Minimal effect
Improves skin texture, hyperpigmentation, fine lines
Skin irritation
Various strengths and formulations
Deeper peels can leave a sharp demarcation between treated and untreated areas
Long-term use Chemical peels: superficial, medium, deep
Prolonged erythema Dyspigmentation, particularly hypopigmentation Scarring Neuromodulators
Targets “Crow’s feet”
Can worsen fat herniations of the lower lid
Can be used to complement other approaches
No tightening Does not improve actinic damage or pigmentary changes to the skin
Soft tissue filler
Targets tear troughs
No tightening
Dermabrasion
Can be used to complement other approaches Targets actinically damaged skin
Does not improve actinic damage or pigmentary changes to the skin Infection
Can help smooth skin
Dyspigmentation Scarring Fine control difficult due to instrument bulkiness
Topical polymer
Reduction of eye bags, lax skin, wrinkles
Radio-frequency
Decreased down time
Temporary
Noninvasive
Nonablative Lasers
Variable degree of improvement
Noninvasive
Limited to tightening and lifting
Decreased down time
Multiple treatment sessions needed
Noninvasive Nonfractional ablative lasers: CO2 laser, Er:YAG laser
Effective for skin laxity, fine lines
Acneiform eruptions, prolonged erythema, pigmentary changes (particularly hypopigmentation), ectropion, infection, and scarring
Ablative fractional CO2 laser
Effective for skin laxity, fine lines, actinic damage, dyspigmentation, festoons
Acneiform eruptions, erythema, pigmentary changes, infection, and scarring
Blepharoplasty
Effective for removing excess skin, muscle, and fat
Does not improve actinic damage or pigmentary changes to the skin Scleral show, ectropion, hollow appearing eyelid sulcus, vision loss, diplopia, corneal abrasion, lagophthalmos, cellulitis, postblepharoplasty ptosis, dry eye syndrome, lower lid malposition, chemosis, asymmetry, and scarring
Long recovery period
Shorter recovery period than CO2 laser
without blepharoplasty. Photographs of patients who had a follow-up period of at least 5 months or greater after their procedure were included in their investigation. They found that “excellent” results ($95%
wrinkle reduction) were seen in 5% of patients with traditional blepharoplasty, 29% after laser only, and in 49% after laser and laser blepharoplasty (using a CO2 laser for transconjunctival approach for
40:12S:DECEMBER SUPPLEMENT 2014
S139
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
EYELID TIGHTENING BY CO2 FRACTIONAL LASER
blepharoplasty). However, these results were confounded by the concurrent procedures performed on these patients. A proportion of patients in the blepharoplasty group, the laser resurfacing group and the laser resurfacing with blepharoplasty group had the following procedures at the time of their procedure: brow lift (68%; 42%; 68%), face-lift (64%; 42%; 56%), and lid tightening (5%; 21%; 48%), respectively. Because it was a retrospective study, it can be presumed that those patients chosen for a combination approach were more likely to have worse periorbital aging than those in the other 2 groups. Further analysis demonstrated that 83% and 85% of patients in the laser only and the laser + laser blepharoplasty groups, respectively achieved greater than 75% wrinkle reduction.3 The percentage of patients obtaining Class I “Optimal” Comprehensive Eyelid Tightening (smooth lid, no lowering of lid margin, no visible muscle hypertrophy, scar not visible) was the same at 71% in both the laser resurfacing group and the laser resurfacing with blepharoplasty group.3 Because of evolving technology, dermatologists can further improve these results using a fractional ablative CO2 laser. In our practice, patients seeking improvement of their periorbital skin are seen in consultation. Any history of previous blepharoplasty is noted because these patients have a higher risk of ectropion, and laser parameters must be adjusted accordingly. The patients are informed about the procedure and what to expect during the healing process (swelling, oozing, crusting, bleeding, and redness that will resolve with time). A pretreatment and posttreatment regimen, as well as follow-up, is reviewed at this time. The patients are instructed that they will need an escort on the day of their procedure because they will be administered a narcotic and anxiolytic for procedure purposes. Pretreatment preparation includes initiating a 1-week course of prophylactic antibiotic and antiviral medications 1 day before the procedure. On the day of the procedure, the patients are administered an intramuscular dose of ketorolac (60 mg), an oral dose of diazepam (5–10 mg), and an oral dose of acetaminophen/oxycodone (5/325 mg). A topical anesthetic (7% lidocaine/7% tetracaine) is applied to the treatment areas for 60 minutes and supplemented
S140
with a local injection of 1% lidocaine with 1:100,000 epinephrine (typically
![[Upper eyelid blepharoplasty with the CO2 laser].](/assets/img/hold.png)
