The periorbital complex includes the eyelids, eyelashes, eyebrows, and bony structures that surround the eye. Aesthetic treatments for the periorbital region have been a cosmetic concern since the time of the early Egyptians, at which time various dyes were used to enhance the lashes and brows, and to accentuate the eyes. Since then, there has been significant progress. The advent of botulinum toxins for the treatment of glabella furrows heralded a new focus on this region, and at the present time botulinum toxin is the most popular minimally-invasive cosmetic procedure in the United States.1 Soft tissue augmentation is used to renovate both the infraorbital region and the supraorbital region. Bimatoprost has been approved for the treatment of eyelashes, and recent publications have documented its efficacy for eyebrow hypotrichosis.2 Radiofrequency and lasers have been used to both tighten and improve the quality of the skin, while topical cosmeceuticals have also been effective in some instances. The periorbital region is an important component of communication between individuals and is often the first area to show signs of aging. Patients thus often view it to be of socially significant concern.
In order to understand what occurs in the periorbital region with aging, it is helpful to have some parameters of a youthful brow position and shape in a youthful face and to know how the soft tissue and bony structures of this area change with time. The eyebrows, composed of thick, pigmented terminal hair, not only protect against rain and sweat but also serve to express emotions, communicate, and contribute to differentiation between males and females.3 The eyebrows serve as a site for both frontalis insertion and interdigitation with the orbicularis oculi. A fat pad exists in a split in the muscle sheath, allowing for eyebrow movement, and continues into the upper lid.4
In many people, the brow descends with age. This occurs as the elasticity of the forehead region decreases and the frontalis is no longer able to suspend the brow. With this descent of the brow, there is less suspension of the upper eyelid, which tends to droop. One study of the aging brow in Indian women found that, in the population studied, with age the lateral brow descended while the medial brow stayed relatively constant.5 These authors recommended â€œbrow reshaping by restoration of the brow apex lateral to the level of the outer corneal limbusâ€ as a goal for cosmetic rejuvenation of the periorbital area. This goal may be attained surgically provided that the patient is a candidate for surgery and amenable to the procedure. However, many patients prefer not to have this region addressed surgically if an alternative is available.
In addition to these changes noted in the soft tissue, there are significant changes in the bony structures of the periorbital region. A CT evaluation of 60 women and 60 men found a significant increase in the orbital width and aperture with aging,6 a change that was noted in both sexes and is thought to be one hallmark of the aging periorbital region. In addition to the profound changes that are seen within the bony structures of the periorbital region, there are other significant changes in the soft tissue, as well as in the fat and hair of these areas. A comparison of aging in the periorbital area soft tissue using CT scanning demonstrated that the soft tissue muscle volume in the periorbital area decreased in women but increased in men.7 These same authors found an increase of periorbital fat volume in women as they age. Another change that occurs with the aging brow is a decrease of the den-