MedEsthetics magazines offers business education and in-depth coverage of the latest noninvasive cosmetic procedures for physicians and practice managers working in the medical aesthetics industry.
Issue link: https://medesthetics.epubxp.com/i/156138
UNDEREYE SOLUTIONS "There are a lot of topical preparations aimed at reducing pigment and blood in the undereye area," says New York plastic surgeon Andrew N. Kornstein, MD, FACS, "but the only good adjunct I've found is Retin A (Medicis, medicis.com), which improves circulation, helping to bring an ample blood supply to fat transfers. Some topicals do decrease inflammation and these can help some patients over time, but they are slow to act and don't really get at the root of the problem. We do recommend Retin A and Lifeline (International Stem Cell Corp., lifelineskincare.com). Lifeline hasn't been proven with studies as Retin A has, but it does seem to be a legitimate way to boost stem cells, offering a kind of inside/outside approach along with fat grafts." Mitchell Chasin, MD, medical director of Reflections, Center for Skin & Body in Livingston and Martinsville, New Jersey, prefers retinols to Retin A for the eye area. "They are less irritating, especially if they are combined with antioxidants like vitamin C," he says. "As far as proprietary topical preparations, we have gotten the best patient feedback on Teamine (Revision Skin Care, revisionskincare.com)." Simon Ourian, MD, Epione, Beverly Hills, California, often prescribes a bleaching agent for home use when he treats sun damage on the lower eyelid with fractional CO2 laser. "Patients with skin types III through VI must also use a bleaching agent, such as a combination of 2% to 4% hydroquinone, 2% kojic acid and 0 .1% Retin A. The melanin will return unless these patients continue to use the bleaching agent for six months to a year." Lisa A. Zdinak, MD, chief surgeon and medical director, Precision Aesthetics, New York, feels that hydroquinone can be too harsh for the delicate eye area. "I have been giving my patients Elure cream (Syneron, elureskin.com) to use on the lower eyelids at home. It is very mild, easily tolerated and effective," she says. 50 SEPTEMBER/OCTOBER 2013 | MedEsthetics "I especially avoid fillers with particles for fear of transportation of the particles and vascular occlusion." "When fillers are placed deep, there is a residual effect even after three years because the filler treatment stimulates collagen synthesis," Dr. Chasin continues. "I always mix lidocaine with epinephrine into the fillers I use, even if the filler already contains some lidocaine. The additional mixture restricts blood vessels to minimize bruising and makes the filler less viscous so it is easier to place." Dr. Zdinak also prefers Restylane for linear tear trough defects, but when the tear trough is very broad, she uses the patient's own blood to fill out the majority of the deformity. "I use the Selphyl Platelet Rich Fibrin Matrix System (Aesthetic Factors, selphyl.com) to convert plasma to dermal filler," she says. "Then, in about three weeks, I have the patient come back and I take care of any residual hollowing using a hyaluronic acid product. I do not like any other fillers beneath the lower eyelids, and I especially avoid fillers with particles for fear of transportation of the particles and vascular occlusion. I have seen several people treated overseas with particulate fillers that grew out of control forming popcorn-like growths beneath the eyelid skin." We are unlikely to see a resolution to the question of whether fat grafting or synthetic fillers are better for the tear trough anytime soon. The latest research on the subject (Dermatologic Surgery, May 2013), which was done at the Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea, gives high marks to collagenase-digested fat cell grafts for correcting dark circles around the eyes. The authors treated 82 patients with fat aspirated from the medial thigh using the Coleman method and digested with Clostridium © THINKSTOCK What About Topicals? "Autologous fat is a great filler but it is just too unpredictable for the undereye area. Most patients want an in-and-out type of procedure that can be easily reversed if they don't like the results. I use Belotero (Merz Aesthetics, merzaesthetics.com) or Restylane, which are much better for this area than any of the other fillers," he says. "They don't absorb a lot of water, which means there is less swelling. "I almost always use cannulae instead of a syringe to inject fillers in the eye area," says Dr. Chasin. "Using cannulae means less bruising and less pain. I make a small opening and inject a mixture of lidocaine with epinephrine before inserting a Dermasculpt Cannula (dermasculpt.net) or Magic Needle (Needle Concept, magic-needle.com), really a cannula. I place it right against the bone. Placing filler deep means less risk and it lasts longer, typically two to three years. Deep placement is imperative in the lateral part of the eye. Shallow placement increases risks of lumpiness and it typically lasts only about a year.