Bright Eyes

Introduction

The area around the eyes, known as the periorbital region, is one of the first places to reveal the signs of aging.¹ This delicate zone—comprising the upper and lower eyelids, eyebrows, and surrounding skin—is highly vulnerable to environmental factors, lifestyle habits, and the natural aging process. Over time, fine lines form, skin texture becomes uneven, and volume loss leaves a hollow, tired look. Exposure to UV rays, constant facial expressions, and habits like smoking only speed up these changes, leading to sagging skin and deeper wrinkles.

Because the eyes are central to facial aesthetics, even minor changes in this area can profoundly affect a person’s overall appearance. Rejuvenating the periorbital region requires more than just addressing wrinkles or dark circles. It demands a holistic approach—one that restores lost volume, smooths the skin and maintains harmony with the rest of the face.

In this article, we’ll learn the most effective, minimally invasive techniques for periorbital rejuvenation. By combining treatments like dermal fillers, neuromodulators and skin-boosting strategically, we can achieve results that look natural, enhance the entire face, and help patients feel more vibrant and confident.

Patient Assessment

When evaluating facial aesthetics, it's important to identify the key concerns that patients commonly present. Three main issues often emerge:

Tired Look

A tired appearance is often characterized by sunken eyes and dark circles that are typically accompanied by mild to severe periorbital hollows. In some cases, hyperpigmentation can worsen the tired look and create an appearance of fatigue even when the patient feels well-rested.

Grumpy Look

A grumpy or displeased expression is usually due to a combination of periorbital hollows and the presence of glabellar lines (frown lines between the eyebrows). These lines, caused by repeated corrugator muscle activity, can give the face an unintentionally stern or irritated appearance.

Aging Look

The aging face involves multiple changes, including:

• Periorbital hollows cause a sunken look around the eyes.
• Midface volume loss, which can lead to sagging or flattening of the cheeks.
• Glabellar lines contribute to an aged appearance.
• Loss of the smooth transition from the lower eyelids to the cheeks and nasal wall.

Younger faces have a smooth, seamless line from the eyelids to the cheeks, but as we age, this becomes less even, causing the face to look older or more tired. When assessing, it's key to consider how visible these changes are since they often happen together and vary in degree.

The practitioner can use different scales to evaluate the severity of periorbital issues:

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Galderma FAS (Static Lines and Dynamic Glabellar Lines)

Tear Trough Rating Scale

Infraorbital Hollow Scale:

Tear Through Deformity Scale:

Relevant Anatomy

As the area around the eyes, including the forehead and temples, is often the first to show signs of aging, this region plays a crucial role in our expressions and sense of vitality. A combination of genetic predisposition and environmental factors drives these changes.

With age, our skin gradually loses key components like collagen and elastin, which are essential for maintaining a youthful appearance. While these effects impact the entire face, they are especially noticeable around the eyes. Fine lines appear, and deeper structural shifts begin to affect the eyelids and the surrounding tissues.

Wrinkles, sagging brows, and altered eyelid contours are some of the most common age-related issues in this area. Skin becomes looser, and fat distribution around the eyes shifts, which contributes to a tired or aged look. Additionally, changes in skin tone and texture, including hyperpigmentation or dullness, add to the overall aged appearance.

Addressing these visible changes is a core focus of facial rejuvenation. 

The tables below shows the main anatomical features of the periorbital area^2,3 and associated age changes:¹

Selecting the Right Product in Aesthetics⁸

Choosing the right filler in facial aesthetics is all about understanding how different fillers behave.⁹ The way hyaluronic acid (HA) fillers flow and respond to facial anatomy plays a key role in delivering the best results for different areas of the face.

NASHA™ Technology: Precision and Lift

NASHA™ fillers are all about lift and precision. With a firmer texture due to a higher G', these fillers work best in areas that need more structure and support—like the tear troughs. One example is Restylane Eyelight™, which is specifically designed to restore volume under the eyes.⁵ This addresses hollowing with precision and results in a fresher and rested appearance.

OBT™ Technology: Contouring and Expression

In contrast, OBT™ fillers (Optimal Balance Technology) are more flexible and softer. With a lower G', they’re perfect for areas like the midface that require smooth contouring and volume. Restylane Volyme™ is a great example that adds natural-looking volume to the cheeks while adapting easily to facial expressions.⁶

How NASHA™ and OBT™ Work Together

These two technologies complement each other perfectly. NASHA™ is great for areas that need structure and lift, while OBT™ works best in places where softer volume and movement are required. Together, they give practitioners the flexibility to treat different parts of the face with precision and make sure each area gets exactly what it needs.

Peptide-Based Skin Boosters: Enhancing Skin Quality

Cellbooster products add another layer to treatment by focusing on skin quality. Cellbooster Glow™ and Cellbooster Lift™ are great for tackling issues like hyperpigmentation and improving skin texture. They work well in delicate areas like the tear troughs, where both filler and skin quality improvements are needed. Clinical studies show results within 2–3 days, with effects lasting up to six months, and patients often report high satisfaction after just one session.

Neuromodulators: BoNTA (Botulinum Toxin Type A)

BoNTA (Botulinum Toxin Type A) works by temporarily blocking acetylcholine release, which stops muscle contractions. This makes it perfect for treating dynamic wrinkles like frown lines between the eyebrows. 

While the effect wears off as the nerve terminals heal, treatments like Alluzience™can provide effective wrinkle reduction without giving the face a rigid, “frozen” look.⁴

Treatments for a Holistic Outcome⁷

Instead of treating concerns individually, a holistic approach to rejuvenating the eye area works best. Combining fillers for volume, neuromodulators to smooth wrinkles, and peptides to improve skin quality adds a personal touch to your treatment and create a more complete and natural look.

How to Sequence Treatments

The order in which treatments are applied is key to maximizing results:

• Start with Fillers: Begin by restoring volume in the tear troughs, midface, temples, and jawline to reestablish facial structure and lift.
• Follow with Neuromodulators: Next, smooth dynamic wrinkles like glabellar lines using botulinum toxin to relax overactive muscles.
• Finish with Skin Treatments: End with skin boosters or peptides to improve texture, hydration, and skin quality.

Tailored Treatment Plans

Tailor each treatment to the patient’s individual facial features, age, gender, and goals. Adjust the products and dosages to match the patient's goals and create the most natural-looking results.

Synergistic Effects

Maximize results by combining treatments that target different concerns. For instance, use Restylane Eyelight™ for tear trough volume and Cellbooster Glow™ for skin quality. This combined approach addresses both structural and surface issues.

Continuous Evaluation

Facial aesthetics is a dynamic process. Start with conservative treatments, monitor results, and refine the approach as needed. Regular assessments ensure patient satisfaction and allow for adjustments that enhance outcomes over time.

The Power of Blending Treatments

The process of combining treatments involves understanding how different products work together to address issues like volume loss, dynamic wrinkles, skin quality, and pigmentation. The success of these treatments depends on customizing the sequence and dosage based on the patient’s anatomy and desired outcomes.

Tear Troughs (Periorbital Hollows) and Dark Circles

The tear troughs are often hollow and shadowed, which lends the eyes a tired appearance. Combining fillers and skin-boosting treatments is an effective way to correct both volume loss and dark circles.

Combination:

Here are the core factors to consider in treating tear troughs and their corresponding treatment options:

• Trough Depth: The distance between the anterior lacrimal crest and the deepest point of the trough plays a key role in determining treatment. Volume restoration can be achieved using dermal fillers such as Restylane Eyelight™. For additional lift, Cellbooster Lift™ and Glow™ may also be applied to create a fuller, more youthful appearance.
• Hyperpigmentation: Although discoloration doesn’t affect the depth of the trough, it often makes the area appear more hollow. To reduce this, treatments like Cellbooster Glow™, Cellbooster Lift™, or Ultraformer III (a skin tightening device) can be used to brighten and rejuvenate the under-eye area.
• Prolapse of Nasal Fat Pads: When fat pads in the nasal area shift downward, it can worsen the appearance of tear trough hollows. In these cases, Cellbooster Shape™ is useful in improving contour and reducing the prominence of the prolapse.
• Lower Eyelid Skin Laxity (Rhytidosis): Loose skin in the lower eyelid can enhance the visibility of hollows. To address this, a combination of treatments, including BoNTA (botulinum toxin), dermal fillers, Cellbooster Lift™, and Glow™, or even Ultraformer III, can help tighten the skin, soften wrinkles, and smooth the area.

Step-by-Step:

1. First, use 0.25–0.75 ml of Restylane Eyelight™ to fill the hollows in the tear trough.
2. Once the volume is restored, follow up with Cellbooster Glow to address pigmentation and improve skin texture.

This two-step process treats both the structural hollowing and the darkness under the eyes. 

Glabella (Frown Lines) and Crow’s Feet

Dynamic wrinkles in the glabella (frown lines) and crow’s feet are caused by muscle activity. Combining neuromodulators and skin boosters can soften these wrinkles without freezing natural facial expressions.

Combination:

• Alluzience™ (botulinum toxin type A) can be injected into the corrugator and procerus muscles to relax frown lines.
• For crow’s feet, inject botulinum toxin into the orbicularis oculi muscles to reduce dynamic wrinkles.
• To improve skin texture around the eyes, a skin booster like Cellbooster Glow can enhance hydration and elasticity.

Step-by-Step:

1. Administer 50 Speywood units of Alluzience™ into the glabella (corrugator and procerus muscles).
2. Inject botulinum toxin into the orbicularis oculi muscle to soften the crow’s feet.
3. After addressing the dynamic wrinkles, follow up with Cellbooster Glow to improve the skin’s texture and smoothness around the eyes.

This combination smooths out dynamic wrinkles while improving the overall quality of the skin around the eyes.

Temples and Anterior Cheek (Midface)

Losing volume in the temples and midface can make the face look older and hollow. Treating these areas together ensures that the upper face and midface remain balanced.

Combination:

• Restylane Volyme™ (OBT technology) is ideal for adding volume to the temples and midface. This filler is designed to provide lift while maintaining flexibility for natural facial expressions.

Step-by-Step:

1. Inject 1 ml of Restylane Volyme™ into each temple to restore volume and support the upper face.
2. In the same session, inject Restylane Volyme™ into the anterior cheek (1 ml per side) to lift the midface and smooth the transition from the lower eyelids to the cheeks.

By treating both the temples and midface together, you restore balance and volume to the entire upper and middle part of the face.

Tear Troughs and Midface 

For patients with both tear trough hollowing and midface volume loss, combining Restylane Eyelight™ for the tear troughs and Restylane Volyme™ for the midface can significantly improve the overall look.

Combination:

• Treat the tear troughs with Restylane Eyelight™ to restore volume directly under the eyes.
• Use Restylane Volyme™ to lift the cheeks, which indirectly reduces the appearance of tear trough hollowing by supporting the midface.

Step-by-Step:

1. Start by injecting Restylane Eyelight™ (0.5 ml) into the tear troughs to restore volume under the eyes.
2. Follow this by injecting Restylane Volyme™ (1 ml) into the cheeks to lift the midface and create a smooth contour.

This dual approach creates a seamless transition between the under-eye area and the cheeks.

Lower Face and Crow’s Feet 

Combining fillers, neuromodulators, and skin boosters can provide natural-looking enhancement of the lower face and periorbital region.

Combination:

• Use Restylane Volyme™ to restore volume in the lower face (jawline or chin) and improve structural support.
• Treat crow’s feet with Dysport™ or Alluzience™ to relax dynamic wrinkles around the eyes.
• Use Restylane Skinboosters™ to improve skin texture and hydration across the face, particularly in areas with fine lines.

Step-by-Step:

1. Inject Restylane Volyme™ (1 ml per side) to add volume and definition to the lower face.
2. Administer Dysport™ or Alluzience™ to the crow’s feet area to soften fine lines around the eyes.
3. Follow up with Restylane Skinboosters™ to enhance skin texture and hydration, and ensure the entire face looks refreshed.

Some Precautions and Safety Measures

Preventing and managing complications in periorbital treatments is crucial due to the delicate anatomy of the region, particularly the proximity of the eyes and major facial arteries. One of the most serious risks is vascular occlusion, especially when treating areas like the tear troughs and glabellar region. To prevent this, avoid direct injections into the infraorbital artery, use a cannula where appropriate, and always aspirate before injecting to ensure you’re not in a blood vessel. Signs of occlusion—such as blanching, pain, or mottling—must be identified immediately. If they appear, immediate treatment with hyaluronidase to dissolve the filler is essential, along with warming the area and potentially administering aspirin to promote blood flow.

Infection control is another key factor in preventing complications. Strict adherence to sterile techniques during injections is non-negotiable. While prophylactic antibiotics are not typically necessary, they can be considered for high-risk patients. Should an infection occur, swift action is required—appropriate antibiotics should be prescribed, and in more severe cases, abscess drainage may be needed.

Minor complications like bruising and swelling are common in the periorbital area due to its rich vascular network. These can be minimized by using a cannula, applying ice before and after the procedure, and advising patients to avoid blood-thinning medications like aspirin or ibuprofen before treatment. If bruising occurs, treatments like topical arnica, bromelain, or pulsed dye lasers can help speed up healing.

Even with meticulous planning, asymmetry can occur, particularly in patients with pre-existing facial asymmetries. The best course of action is to wait for any initial swelling to subside before addressing asymmetry with touch-up treatments. Small adjustments using filler or neurotoxin can usually correct the imbalance.

Ensuring informed consent and managing patient expectations are critical components of a successful treatment. Before beginning any procedure, make sure your patient fully understands the potential risks, realistic outcomes, and possible complications. Using visual aids, such as before-and-after photos or case studies, can be very helpful. For more anxious patients, it’s a good idea to explain how complications, such as vascular occlusions, are managed—reassuring them that treatments like hyaluronidase are available if needed.

Here are some product-specific contraindications and precautions to note:

Botulinum Toxin (Alluzience and Dysport)

Botulinum toxin, including Alluzience and Dysport, is effective for treating dynamic facial wrinkles but requires careful patient screening.

Contraindications:

• Allergies: Avoid use in patients with known allergies to botulinum toxin or excipients like L-histidine, sucrose, or polysorbate 80.
• Neuromuscular Disorders: Patients with myasthenia gravis, Eaton-Lambert syndrome, or ALS should avoid treatment due to the risk of worsening muscle weakness.
• Infection: Avoid injecting into areas with active infections.

Warnings and Precautions:

• Avoid Vascular Injection: Intravascular injections can cause serious complications like necrosis or ischemia.
• Neuromuscular Concerns: Use caution in patients with dysphagia or aspiration, as botulinum toxin may worsen these conditions.
• Pregnancy/Breastfeeding: Not recommended during pregnancy or breastfeeding.

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Restylane Eyelight

Restylane Eyelight is ideal for periorbital rejuvenation but requires careful patient selection.

Contraindications:

• Allergies: Avoid in patients with hypersensitivity to hyaluronic acid, lidocaine, or streptococcal proteins.
• Severe Allergies: Patients with a history of anaphylaxis may not be suitable for treatment.
• Porphyria: Avoid in patients with porphyria.

Warnings and Precautions:

• Avoid Intravascular Injection: Injection into blood vessels can lead to vascular occlusion, ischemia, or blindness.
• Active Disease: Postpone treatment if there’s any infection or inflammation near the injection site.
• Bleeding Risk: Patients on anticoagulants may experience more bruising.

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Restylane Volyme

Restylane Volyme, used for midface and temple volume restoration, has specific contraindications and precautions.

Contraindications:

• Allergies: Patients allergic to hyaluronic acid, lidocaine, or streptococcal proteins should avoid treatment.
• Severe Allergies: Caution is advised in those with a history of anaphylaxis.
• Active Infections: Avoid treating areas with infections.

Warnings and Precautions:

• Intravascular Injection: Always avoid injecting into blood vessels, as this can cause necrosis or ischemia.
• Bleeding Disorders: Patients with bleeding issues or on anticoagulants may bruise more easily post-treatment.

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After the procedure, it’s important to provide clear post-treatment care instructions. Educate patients on what activities to avoid, such as strenuous exercise or massaging the treated area. Also, they should be provided with emergency contact information and clear guidelines on when to seek medical advice if any issues arise.

Every aesthetic practice must be equipped with essential emergency tools. Always have hyaluronidase on hand to treat vascular occlusions. Stock topical antibiotics and steroids to manage minor infections or post-treatment inflammation, and ensure you have sterile saline and gauze available for immediate wound care if needed.

In the case of a suspected vascular occlusion, stop injections immediately, massage the area, and apply warm compresses to improve blood flow. Administer hyaluronidase as soon as possible. If the situation worsens or doesn’t resolve quickly, the patient should be referred to an ophthalmologist or plastic surgeon for further evaluation.

Lastly, while rare, adverse reactions to neuromodulators like ptosis (drooping eyelid) or diplopia (double vision) can occur after botulinum toxin injections. Fortunately, these issues are usually resolved over time. In some cases, they can be managed with prescription eye drops that help stimulate muscle contraction and improve the condition.

By following these protocols, you can ensure patient safety while delivering high-quality treatments.

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Conclusion

Periorbital rejuvenation is both an art and a science. It requires a deep understanding of facial anatomy and the skill to customize treatments for each individual. The aim is to restore a youthful, refreshed look while keeping the patient’s natural beauty intact, all with safety and precision at the forefront.

Emerging technologies are transforming aesthetics. Ultrasound-guided injections offer greater precision and reduce risks like vascular occlusion. New dermal fillers provide longer-lasting effects while encouraging collagen production for more natural results. Biostimulatory injectables such as PLLA and CaHA stimulate the body’s repair processes, adding a regenerative touch.

Innovations like nanotechnology-based fillers, radiofrequency (RF), HIFU, and next-generation neurotoxins are expanding treatment options while offering subtle, long-lasting improvements.

Ultimately, the aesthetic practitioner’s role is about boosting confidence and well-being. By staying ahead of technological advancements and focusing on personalized care, practitioners can help their patients look and feel their best.

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References

1. Swift, A., Liew, S., Weinkle, S., Garcia, J. K., & Silberberg, M. B. (2021). The Facial Aging Process From the “Inside Out”. Aesthetic Surgery Journal, 41(10), 1107-1119. https://doi.org/10.1093/asj/sjaa339
2. Codner MA, McCord CD Jr., eds. Eyelid & Periorbital Surgery. 2nd ed. New York, NY: Thieme Medical Publishers; 2016.
3. Kashkouli, M. B., Abdolalizadeh, P., Abolfathzadeh, N., Sianati, H., Sharepour, M., & Hadi, Y. (2017). Periorbital facial rejuvenation; applied anatomy and pre-operative assessment. Journal of Current Ophthalmology, 29(3), 154-168. https://doi.org/10.1016/j.joco.2017.04.001
4. Alluzience™ product information 
5. Restylane Eyelight™ product information
6. Restylane Volyme™ product information
7. Content from Source PPT by Hubmed (Dr. Maya Sinai)
8. Öhrlund A. J Cosmet Dermatol Sci Applic 2018;8(2):47–54.
9. Choi, M. S. (2020). Basic rheology of dermal filler. Archives of Plastic Surgery, 47(4), 301-304. https://doi.org/10.5999/aps.2020.00731

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