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It is often said that the eyes are the windows to the soul. What would an aged periorbital appearance imply? It is no wonder that rejuvenation of the periorbital region is one of the commonest aesthetic requests. A youthful and aesthetically pleasing upper eyelid region consists of well-positioned eyebrows, appropriate eyebrow-to-upper eyelid crease distances, crisp upper eyelid creases, appropriate degree of eye opening, and taut skin without wrinkles or pigmentary blemishes. There should be minimal expression lines at the outer eye region when smiling or laughing. These findings impart the image of an individual who is energetic and attentive.
Crow’s feet are one of the first signs of ageing and are visible in many individuals in their early- to mid-thirties. This is most easily observed when individual smiles or laughs and manifests as wrinkles radiating out from the outside (lateral) of the eye socket. Crow’s feet may be dynamic (intermittent) or static (permanent).
The orbicularis oculi is a muscle that surrounds the entire eye socket and is responsible for the blinking and closure of the eyelids. With increasing age, the skin around the lateral (outer) portion of the eye becomes thinner as a result of loss of elastin and collagen fibers and ground substance.
The subcutaneous fat layer also becomes increasingly thin due to age-related loss of the subcutaneous fat volume. The result is increasing prominence of the orbicularis muscle contraction as a person ages and manifests as crow’s feet, which appear as wrinkles radiating outward from the eye.
There are three treatment options for crow’s feet: botulinum toxin injection, nanofat injection, and surgical crow’s feet correction. The optimal treatment for crow’s feet depends on their severity, the individual anatomy and treatment goals.
Botulinum toxin is commonly used to treat crow’s feet and attains a high level of satisfaction in most cases. The popularity of botulinum toxin injection has grown rapidly since the 1990s, and it is now one of the most commonly administered procedures in the world.
Individuals with shallow, dynamic wrinkles with minimal skin loosening respond best to botulinum toxin injection.
We frequently see or hear of people who look unnatural following aesthetic treatments. This is often due to practitioners who attempt to reverse all the signs of aging by using botulinum toxin alone, resulting in stiff and unnatural results.
Botulinum toxin effaces wrinkles by partial weakening of the frontalis muscle but does not reverse skin and muscle laxity or fat atrophy. Attaining bespoke and attractive results that retain an individual’s expressivity is frequently possible and requires accurate assessment, appropriate product choice, precise administration by an experienced practitioner.
The orbicularis muscle contracts in a circular manner during blinking and facial animation and causes crow’s feet. Botulinum toxin reduces signs of aging by partial weakening of the orbicularis oculi muscles that cause formation of crow’s feet. Males generally require higher doses of botulinum toxin for optimal result.
The effects of botulinum toxin generally take 1 to 3 days to be observed, and will last for 4 to 6 months. Repeat treatments are necessary for maintenance of the result.
Individuals are advised to avoid vigorous massage to the treatment area for 2 hours following the injection. This is to prevent spread of the botulinum toxin, which may result in potential unintended adjacent muscle paralysis. Individuals may resume their usual activities immediately following the procedure.
Nanofat injection involves harvesting fat graft from areas of excess. This fat is purified and emulsified using proprietary techniques, then injecting this fine mixture containing adipose-derived stem cells (ADSCs) into the crow’s feet. Nanofat injection provides natural-looking results and long-term improvement as compared with botulinum toxin injection.
It exerts regenerative effects on the overlying skin. Nanofat injection is a minimally-invasive ambulatory procedure performed under local anesthesia, with optional intravenous sedation if requested.
Individuals with any degree of crow’s feet and seeking long-term improvement may consider nanofat injection. Individuals with other areas of hollowing and volume loss may undergo concurrent structural fat grafting to the face, neck, or hands and achieve simultaneous benefit in multiple sites. Those with severe hollowing will benefit from significant cost saving in the long term as compared with recurrent treatment using large volume filler injection.
Common sites for fat harvest include the inner thighs, hips, flanks and lower abdomen. Small incisions are made near the areas of intended liposuction, and local anesthetic is infused for optimal intra- and post- operative pain relief.
The fat is broken up and aspirated under negative pressure. It is purified and emulsified using proprietary techniques. The fat particles are reduced in size until a liquid-like mixture is obtained. This mixture behaves like a natural biological filler.
During the emulsification process, the larger adipocytes (fat storage cells) are destroyed, leaving the smaller adipose-derived stem cells (ADSCs) within the mixture. These are injected into the crow’s feet, and it is thought that the ADSCs exert regenerative effect on the skin in addition to filling the deficient volume.
Nanofat injection improves the quality and pigmentation of the overlying skin and is its unique advantage over synthetic fillers.
Many individuals are able to return to work on the day after the surgery. Depending on the extent of fat harvesting performed, most of the swelling and bruising will resolve by the 7th postoperative day. Stitch removal is usually performed on the 5th postoperative day.
Individuals are advised to avoid pressure on the injected areas to optimize the final result. Postoperative swelling is reduced by remaining upright during the daytime and by elevating the head of the bed with extra pillows when asleep at night. Individuals may return to their original exercise and gym routines after 2 weeks.
The orbicularis oculi muscle is routinely exposed during face lift surgery and presents as an opportunity to partially weaken the muscle surgically and deliver sustained improvement of the crow’s feet.
The following are good candidates for surgical crow’s feet correction:
A complete description of face lift (rhytidectomy) may be found here.