All About Eyes

November 2007

Karen Fellows is tired of looking tired. Hardly a surprise, considering the energetic 37-year-old interior decorator is the type of woman who takes regular scouting trips to India and Morocco, hops planes to Capri to visit friends, and spends her downtime jogging in Manhattan’s Central Park. So when she walks into the Upper East Side office of dermatologist Nell Sadick, M.D., one Friday afternoon, she gets right to the point: “I have these fat pockets under my eyes,” she says in her native Texan drawl. Dragging her fingers across her lower lids, she points to her “substantial shadows here and here,” adding plaintively that “as I’ve gotten into my later 30s, I’ve noticed that I look a little more…drawn.” Several years ago, Fellows briefly consulted a plastic surgeon about having the fat pads under her eyes removed entirely, “but the people I know who’ve done that look so hollow,” she says. “Besides, it seemed drastic—and I’m just too young” So she’s contented herself with injections of Botox to get rid of frown lines and a bit of the new filler Sculptra to smooth out the skin beneath her lower lids. Her eyes look more refreshed than they have in years—but she knows they could look better.

Whose couldn’t? In the war against aging, the eyes constitute the battered front lines—the most fragile skin on our entire body and the area on the face that becomes progressively more crinkled, hollow and shadowy with every passing year. No wonder women are willing to go to the ends of the Earth for answers. Today doctors have access to a wealth of line-smoothing injectables, energy sources that tighten skin and tweak pigmentation, and refined surgical techniques that have revolutionized the way we turn back the clock. Because the eyes age in a uniquely 360-degree manner—squinty fine lines at the corners; sagging upper lids; hollow sockets; puffy bags underneath, made worse by bluish veins and blotchy shadows—you need a multipronged, 360-degree approach to treat them.

Until recently, no one in her right mind would allow a laser anywhere near the fragile orbital flesh, but as technology evolves, times change. Sadick’s sleek Park Avenue compound purrs with the sound of devices that, in expert hands, can safely clean up pigmentation, fine lines, and sagging skin surrounding the eyes without any nightmarish side effects. Reclining in an examination chair, Fellows listens to Sadick describe the latest incarnation of Thermage, a deep-heating radio-frequency treatment designed to tighten lax skin by remodeling existing collagen and stimulating new collagen growth. The target: sagging lids and brows, as well as the fat pads that protrude as collagen bundles loosen. While early versions had uneven track records and usually required copious amounts of painkillers, the latest model to roll off the assembly line boasts a smaller tip that penetrates very superficially, causing only minimal pain, barely noticeable swelling, and redness that lasts for a few days. Effects peak six months after treatment and last for up to two years. “Thermage for the eyes has produced pretty dramatic results,” Sadick says as his assistant places a pair of black contact lens—like shields over Fellows’s eyes, making her look like something out of X-Men. “Much better than the results seen on the rest of the face.”

But a single course of action won’t necessarily solve all of your problems. What’s the point of tightening the collagen below the skin, after all, if the surface reflects decades of sun damage? For the little red blotches that plague lower lids, Jeffrey Dover, M.D., associate clinical professor of dermatology at Yale University School of Medicine, calls on the time-tested pulsed-dye and Gemini lasers, along with intense pulsed light (IPL). He wipes out the bluish veins that darken the sockets of fair-skinned women with the long-pulsed Nd:YAG laser. “I did three of these this morning,” he says. “Most of my patients never thought they could treat this problem until they come in for the appointment.”

The contraptions that have even the most jaded dermatologists buzzing are the burgeoning class of fractionated lasers, which deliver a checkerboard of energy to the skin, leaving tiny pockets untouched, allowing for faster healing and, appropriately, a fraction of the downtime you get with the bigger guns. The first of these gadgets to make news was the Fraxel, approved by the FDA two years ago and now back with a very small, seven-millimeter tip ideal for tackling the fragile skin around the eyes. While the traditional Fraxel works well but with distinct limitations—by most accounts, it does a good job of diminishing early brown spots and fine lines over a series of three to five moderately painful treatments but hasn’t quite lived up to the hype when it comes to crow’s-feet and deeper wrinkles—the fresh-from-the-factory class of CO2 fractional resurfacing devices, which combine the power of the (historically harsh and much feared) CO, laser with the relative tenderness of fractionalized therapy, may hold even more promise. Jean Carruthers, M.D., clinical professor of ophthalmology at the University of British Columbia, Vancouver, and a facial-cosmetic-surgery specialist, calls the new devices, which offer the appealing combination of potency and minimal healing time, “possibly the most exciting of the procedures currently out there.” She recommends the recently approved ActiveFX from Lumenis for wrinkles, laxity, and discoloration around the eyes. Fraxel’s version, a microablative CO2 laser, uses a slightly different technology, accomplishing in several rounds what ActiveFX does in a single pass.

For severe photoaging around the eyes—deep wrinkles, uneven pigmentation, and loose skin—Dover still hauls out his trusty, almost old-fashioned CO2 laser, admitting its blowtorch-like approach is not for the faint of heart (expect a week or more of blistering). Since the treatment comes with a risk of hyperpigmentation and scarring that could last long after the procedure, “it’s got to be done by a true expert, not by a tech in a medi-spa, that’s for sure,” he says. Meanwhile, Sadick has been tackling deep-set wrinkles with the brand-new Sciton (the latest generation of erbium laser, a class long known and trusted for producing results that approach those of the harrowing CO2) and the Portrait Plasma, a sci-fi device whereby plasma resurfaces the upper and lower lids—aided by a spray of heated nitrogen gas—leaving in its wake some minor bruising and scaling that disappear as new skin regenerates (usually within five to seven days).

Botox is no longer regarded as revolutionary, but the wrinkle-relaxing toxin remains one of the easiest, most reliable ways to either prevent (when started early) or obliterate “the hyperactivity of the muscles around the eyes,” says George Hruza, M.D., clinical associate professor of dermatology at St. Louis University in Missouri, delicately referring to the inevitable squint, smile, and frown lines. What is revolutionary about Botox, notes Hruza, is the way in which the most innovative doctors are wielding their syringes. Many are using minute amounts of it in the delicate, previously off-limits lower lids to smooth stubborn crinkles. The most stunning new use for the injectable, though, mimics the effects of the scalpel, albeit very slightly. Hruza’s calendar is increasingly booked with patients whose upper lids are just beginning to sag at the outer corners, a problem he remedies with a touch of Botox between the eye and brow. “You can achieve a bit of a nonsurgical brow-lift of a couple of millimeters,” he says. “It might seem like very little, but it makes a big difference.”

Of course, a little hit of Botox always works better when you combine it with a little hit of something else. And for growing numbers of women these days, that something else is volume—the word out of every dermatologist’s and plastic surgeon’s mouth when talk turns to the eyes. It’s no wonder, since for many women, the real culprit behind darkened lower lids isn’t veins, freckles, or lack of sleep; it’s the unflattering way the light reflects off their concave under-eyes. Which means that at the end of the day, you can pour your life savings into tightening and depigmenting procedures, but if the area beneath your eyes is left looking skeletal— because of either age-related fat loss or genetics—the entire orbital region will wind up looking tired and old.

New York City dermatologist Lisa Airan, M.D., has written extensively in medical journals about the benefits of injectable fillers in the eye socket and lower lids. Consider an old, withered grape magically restored to its younger, juicier self, complete with the taut, unlined skin of its youth, and you’ll understand her obsession. To remedy overall volume loss, Sculptra (poly-L-lactic acid) is increasingly popular in Airan’s practice because of the way it coaxes the body to make its own collagen. While plumping takes about two months to materialize, results last up to two years after a series of two to three treatments spaced four weeks apart. To minimize shadows and even out fat pads, Airan developed a technique with her husband, Toronto plastic surgeon Trevor Born, M.D., depositing precise micro- injections of fat (harvested from elsewhere in the body) into the deepest part of the under-eye hollow. Pot those with advanced volume loss, “we can also graft fat in the upper lids, along the brow bone, and just beneath it,” says Airan. One caveat: Improperly injected, fat can take unevenly around the eyes—not a happy thought, since the filler lasts indefinitely. Radiesse, a gel infused with calcium microspheres, lasts a year or more and is a popular treatment for deep wrinkles around the eyes. For shallow, early crinkles, Juvederm Ultra and Restylane Fine Lines (thinner, refined versions of their more viscous counterparts) contain particles of hyaluronic acid minute enough to smooth out the most tissue- thin orbital skin.

Finally, from the weird-but-true file: carboxy therapy, a tightening treatment popular in Brazil that infuses carbon- dioxide bubbles under the skin using a microneedle. “It’s been shown to increase blood flow and lymphatic drainage and stimulate new collagen synthesis,” says Sadick, adding that it may be an excellent way to maintain results between Thermage, Portrait Plasma, or Sciton treatments. His office is performing early clinical studies that will likely go to the FDA for review in the near future, but it’s still too soon to know how long results last.

When we have all of these nonsurgical options at our fingertips—when even plastic surgeon Trevor Born is trumpeting his “nonsurgical eyelid lift”—you’ve got to wonder whether surgery is passé. Especially if, as Karen Fellows points out, far too many women roll out of the operating room looking ironically older, more severe—let’s call it the Mr. Spock problem—than when they rolled in.

Thankfully, the old-school blepharoplasty has undergone a much-needed makeover. Once again, the watchword is volume. Boca Raton oculoplastic surgeon Steven Fagien, M.D., was nearly laughed out of a convention hall some fifteen years ago when he gave a presentation on volume-enhancing upper blepharoplasty. “People looked at me like I had three heads,” he recalls. At a time when surgeons were attempting to re-create a caricature of the deep-set Hollywood bedroom eye by “removing skin, muscle, and fat,” he was leaving the surrounding upper-lid muscle in place. As he pulled the skin tighter, the muscle would fold like an accordion, replacing hollowness just below the brow bone with youthful plumpness. His approach to the lower lids is similar: With a delicate incision beneath the skin, he removes just a fraction of the fat pad, leaving the muscle intact so that he can tighten it together with the skin, using it to recompartmentalize under-eye bags so that they blend seamlessly into the rest of the face—and stay that way for a decade or more.

It’s hard to know whether to feel comforted by this wealth of new options or utterly overwhelmed. At the end of the day, one wonders whether slapping on an eye cream isn’t easier.

And now, whatever your gripe, there’s a cream purporting to treat it. Chronic dark circles? Hylexin—brought to you by the makers of StriVectin—promises to break down the pigment responsible for purple shadows. Fine lines? Estee Lauder’s Perfectionist Power Correcting Patch contains a slim, computer chip—like battery that emits a tiny current of energy, drawing water to the skin’s surface, where it plumps up offending wrinkles, and enhances the effect of the Perfectionist [CP+] Correcting Serum you’re supposed to apply after removing the patch. And Olay Regenerist Eye Derma-Pods—individual space-age sponge applicators that also exfoliate—build collagen with pentapeptides and temporarily erase lines with a silicone-based surface filler. Crow’s-feet? Peter Thomas Roth’s new Un-Wrinkle Eye contains a cocktail of peptides, some of which build collagen over time and others that—literally—mimic the paralyzing venom of a Brazilian viper, blocking muscle receptors ordinarily responsible for expression lines. General sagginess? Lancôme’s Rénergie Microlift RARE. for eyes aims to firm skin—by “rebundling” collagen—and deliver an instant lifting effect, thanks to a silica-and-soy-protein “micro-mesh network.”

“I’m in love with Capture Totale,” says Fellows, referring to an eye cream Neil Sadick helped develop with Dior. She doesn’t know how it works (it shores up and revitalizes collagen with longoza-plant extract), only that “it keeps my skin tone looking the same. It moisturizes, and I feel like my skin looks firm and plump.” And for now, that’s all she can say about the miracle cream. She’s too busy marveling that, mere seconds after finishing her Thermage and Sculptra treatments, her eyes look noticeably wider and, yes, well rested. Sadick has suggested she return in eighteen months to repeat the combination therapy, but she has other plans: “I think, Why not go back every twelve months and not stress about it?”