It’s a sad fact that ‘the windows to the soul’ are also one of the first areas of the face to show signs of ageing including dark circles, crow’s feet and under-eye bags and puffiness. Even sadder still, there are multiple causes for these skin issues.
The subcutaneous fat tissue around the eye area diminishes with ageing and is especially sensitive to facial movements that contribute to wrinkles. Sun exposure not only causes wrinkle-inducing squinting, it increases the levels of enzymes that break down collagen in the skin. The thin skin around the eyes is less resistant to harsh chemicals, extreme weather and UV rays. Add to that the damage caused by glycation in the body, which occurs when simple sugars attach themselves to proteins in collagen and result in weakened cross-linked collagen fibres and lax skin. With these multi-pronged attacks on the area it’s no wonder that complaints about the eyes are so common. We look at the top causes for concern and how they can be treated.
The underlying causes
While dark circles have a hereditary component, thinning skin and loss of fat and collagen also make the reddish-blue blood vessels under the eyes more obvious and contribute to the appearance of dark circles. There are other factors at play too. Pollution and topical irritants trigger inflammatory responses, which contribute to puffy eyes, while sun exposure prompts the body to produce melanin, which can make the area under the eyes appear darker. In people with allergies, excessive rubbing of the skin around the eyes can worsen the circles. Dark circles can often be the result of shadows cast by puffy upper eyelids, which are compounded by hollows under the eyes created by the infraorbital fat pad becoming thinner as we age, leaving the muscle under the eye to become more visible. Thanks to a combination of ageing, genetics and sun damage, microscopic blood vessels under the eyes can lose their fortitude. The body then forms tiny new veins that show up as dark circles. Obviously the right treatment depends on the underlying cause.
Hyperpigmentation beneath the eyes can be treated with creams that ‘bleach’ the skin using ingredients such as hydroquinone or kojic acid, or laser skin resurfacing to remove the dark patches.
Hypervascularity is the term used to describe blood vessels beneath the skin’s surface. These can be treated with certain lasers, such as V-Beam, Pulse Dye Laser, as well as Intense Pulsed Light, which may alleviate some of these vessels.
Dermatochalasis is the term used to describe shadows caused by lower eyelid “bags”. Mild cases can be improved by placing fillers in the tear trough/shadowed area to mask the problem. For more serious cases, surgery to remove the baggy skin is the best solution. A series of three to five Fraxel treatments (see wrinkles and sagging for more detail) is another option as it will help to stimulate collagen growth and assist in tightening sagging skin.
WRINKLING AND SAGGING
The underlying causes
As we age collagen breakdown exceeds collagen production, resulting in a thinner epidermis and crinkly skin and fine lines becoming increasingly visible. Elastin production also slows, which causes the eyelids to lose elasticity and begin to hood and droop. Expression lines caused by repetitive movements like squinting and laughing cause creases (crow’s feet) in the epidermis and as fat and bone diminish in the area the skin begins to sag and hollow.
A series of Fraxel laser treatments helps to stimulate collagen production in the epidermis, encouraging the growth of healthier skin cells. Fraxel works by causing controlled micro-injury to the skin by creating tiny micro-thermal zones, which then stimulate new collagen production. Fraxel dual is a non-ablative fractional thulium laser that is actually two lasers in one: the 1927nm wavelength allows us to treat superficially (improving pigmentation) while the other, the 1550nm wavelength, targets skin texture (improving deep lines and acne scars). The components can be used together or separately depending on the client’s needs.
Botulinum toxin injection
Botulinum toxin injection for treatment of facial wrinkles is the most frequently performed cosmetic procedure in the world and is also one of the most common entry procedures for clinicians seeking to incorporate aesthetic treatments into their practice. Treatment of frown lines and crow’s feet are the cosmetic indications approved by the US Food and Drug Administration and, along with treatment of the horizontal forehead lines, offers predictable results with few adverse effects. It works by blocking signals from the nerves to the muscles. As the injected muscle can no longer contract, wrinkles are able to relax and soften. However, those lines caused by sun damage and gravity will not respond to treatment.
Fillers can be used to replace lost volume in the eye area and is useful for clients whose wrinkles are caused by tissue folds from loss of fat and bone. (See hollowness/puffiness for more detail.)
Chemical acid peels can be used to get rid of superficial wrinkles and weathered skin underneath the eye, by peeling off the surface layers to reveal a smooth new layer of skin beneath. Peels range from a ‘lunchtime’ peel with minimal downtime to a deep peel that will require time to heal.
Microneedling is a minimally invasive procedure suitable for treating the crow’s feet and forehead areas using a device to create microscopic wounds around the eyes, microneedling with miniature fine needles injures the skin, which then heals itself by producing more collagen and elastin. It has become increasingly popular due to its cost effectiveness, safety and results. It does not require extensive training. The procedure is performed under topical anaesthesia after prepping the skin with antiseptic and saline. The skin is stretched with one hand, and perpendicularly, rolling is done five times each in the horizontal, vertical, and oblique directions with the other hand. Ideally the client’s skin should be prepared preoperatively for at least a month with vitamin A and C formulations twice a day to maximise dermal collagen formation. Says Sean Abel of Clinic Care, “The eye area is fine and fragile and cannot be treated with deep needles. Most systems have a starting/minimum length of 0.5mm, for this area, a starting point should be 0.1mm.”
The underlying cause
On a young face, fat pads sit beneath the eye to support it. However, over time the thin membrane that holds the fat pads weakens, and the bone surrounding the eye begins to diminish and migrate downward, causing hollows under the eye area.
Fillers such as Restylane and Juvederm can be used to fill out the tear troughs, dark circles and under-eye wrinkles with hyaluronic acid gel, which can add natural-looking volume to the eye area as well as smooth out wrinkles and hollows. While dermal fillers are better options for static wrinkles underneath the eyes as botulinum toxin relaxes the muscles both in conjunction with one another may be best for effective results.
In severe cases of bags or puffiness under the eyes, a cosmetic surgeon will likely need to eliminate excess skin and reposition fat pads with a blepharoplasty. During a lower blepharoplasty excess fat and muscle along with sagging skin is removed to leave the skin beneath the eyes smoother and tightened.
The underlying causes
As the skin ages, wrinkles appear and the levator muscle of the eyes stretches, along with the upper eyelid skin. The other issue that is often related to a hooded eyelid is the fall of the eyebrows. Another eyelid concern that contributes to “hooding” is ptosis, which results in the upper eyelid falling from gradual weakening of the muscle responsible for lifting the eyelids.
Eyelid Thermage is a nonsurgical treatment to tighten and lift the eyelid skin. The Thermage device was cleared by the FDA for cosmetic indications and uses radiofrequency energy to create a uniform heating effect in the deep dermis, which tightens existing collagen as well as stimulating the production of new collagen resulting in a tighter appearance to loose and sagging skin. It works best on wrinkly eyelids, with mild to moderate hooding and is also used to help maintain eyelid surgery. However, it is not suited to treat crow’s feet, under-eye fat pads or significant, heavy hooding. For most patients, the response to treatment is gradual, with progressive improvement over one to six months. 80-90 percent of patients show measurable and noticeable effects at six months. All patients show an increase in collagen in biopsy studies.
Upper lid blepharoplasty
Hooded eyelids are best treated by the blepharoplasty procedure which removes excess skin on the upper lids along with a small amount of fat. The fat can create puffiness on the upper lids while the hooded appearance is created by excess skin. The incision is placed directly in the upper lid skin crease and will be virtually indistinguishable when healed. This is usually done under a brief general anaesthetic as an outpatient procedure.
Skin care for the under-eye area
Many clients are under the impression that a retinoid product should not be used under the eye. In fact it is recommended to use a retinoid around the periorbital region, but it is crucial to instruct the client to proceed with caution. As the skin around the eyes is so thin and sensitive, initial retinoid use can worsen the appearance of fine lines and wrinkles by drying the area.
Clients must start slow to minimise irritation and dryness of the under-eye area, by applying the product only two or three times per week and putting a simple, hydrating moisturiser on top of it. Once the skin has adjusted, the retinoid can be used every night. A weaker strength is also recommended, 0.05 percent or less to ensure the client’s skin can tolerate the product without irritation.
As with any retinoid use, the client must be reminded that sun protection is essential. Even if the client is not using a retinoid under the eyes, the sun’s rays are linked to both dark circles and premature ageing, so clients should be encouraged to use sun protection around the eye area. Of even greater concern is the fact that although the skin around the eyes represents less than one percent of the skin’s make-up, 10 percent of skin cancers occur in that area, due to the fact the eyes protrude outward and tends to absorb more UV rays and the skin is 10 times thinner than the rest of the skin on the body, making it more susceptible to UV damage.
However, it pays to note that the active ingredients in sunscreens are some of the few ingredients in skin care products regulated by the F.D.A. but that doesn’t mean they have been tested for use around the eyes. Many manufacturers will err on the side of caution by labelling that their products are not for use around the eye area. Unless an eye cream with an SPF is being used, the next best thing is a mineral-based, hypoallergenic, broad spectrum, non-comedogenic sun block with ingredients like zinc and titanium dioxide as the main actives (ingredients like oxybenzone or avobenzone can sometimes irritate the skin) applied underneath the eye area whenever exposed to the sun.
As the eye area is often affected by more than one of the above appearance concerns, many clients would be best advised to take a long-term approach to the under-eye area using a combination of professional treatment solutions, along with an effective skin care regimen, including daily use of retinoids and sun protection. υ
Written for BeautyNZ by Je t’aime Hayre.