Eyelid Treatment’s Effect on Overall Facial Aesthetic Outcome

When we encounter another person, the eyes are typically the first place we look. The eyes convey emotion, as well as health. Therefore, it is no surprise that the periorbital region is the primary focus of rejuvenation and facial aesthetics. As aesthetic surgeons, we do not consider the eyes in isolation, rather we see the face as a continuum that includes the tissues that abut the eyes, like the brows and cheeks.

In the past, our only option to correcting acquired ptosis or low-lying lids was surgery. With the advent of non-surgical products, our available armamentarium now allows us the opportunity to provide periorbital rejuvenation that is safe and effective with very little down time.

Heavy tissue around the eyes gives one a tired or aged appearance. Although we cannot excise extra skin and fat from the upper lids without surgery, we can raise a droopy or tired looking lid. Upneeq (oxymetazoline hydrochloride ophthalmic solution 0.1%; RVL Pharmaceuticals), is the first-ever drug product approved for ptosis. The potent, direct-acting alpha-adrenergic receptor agonist can elevate the lid by up to 2mm with one drop that lasts about 8 hours, creating a more opened eye and more alert appearance without risking an overdone look. A secondary effect I have observed in my practice is patients’ sclera appears whiter.

Upper lid ptosis repair, on the other hand, is one of the more difficult surgical treatments, requiring extreme precision—within millimeters—in the setting of eyelid contour abnormalities that add to the challenge. The muscle of the upper lid is like a window shade and a surgical tightening could cause the lid not to close completely, resulting in dry eye. In fact, dry eye can occur even with a cosmetically perfect result. Ptosis surgery, while successful in most cases, has a high revision rate and side effects.

HOW IT WORKS AND FOR WHOM

Two muscles allow the upper lid to elevate. One is the striated levator palpebrae superioris, the function of which is voluntary lifting; it lifts the lid around 14mm. The second is Muller’s muscle. This smooth muscle is located posterior of the striated muscle, attaching to the upper lid into the tarsus or cartilage-like substance of the upper lid. Muller’s muscle lifts the lid about 2mm involuntarily as part of the sympathetic nervous system. This is where Upneeq works.

I was one of the investigators in the Upneeq clinical trials which also evaluated ocular and systemic metrics, finding the drop to be very safe.¹ In the trial, we measured vision, intraocular pressure, and corneal staining; we found no statistically significant changes in those measures. Only about 1% to 5% of participants experienced keratitis, dryness, or irritation. We saw no systemic effects regarding heart rate and blood pressure.

Upneeq is indicated for age-related ptosis, or involutional, droopy lids. It is not for use in cases of neurogenic ptosis or an autoimmune condition like myasthenia gravis. Practitioners must be aware if patients have any of these other conditions, such as a life-threatening third nerve palsy, signs of which are a droopy lid with the eye turned outward with a dilated pupil.

CLINICAL TRIAL RESULTS

Many older patients can benefit from this product as an alternative to surgery. We know that low-lying lids can impair one’s field of vision. In the clinical trials, Upneeq was shown, statistically to significantly improve patients’ superior visual field defects and drooping upper eyelid positions.² These improvements were observed from the first patient assessment on day 1 and maintained over the 14-day treatment period. Specifically, the primary efficacy endpoint was change from baseline in the number of points seen on the Leicester Peripheral Field Test (LPFT), a test to detect superior visual field deficits due to ptosis, on days 1 (6 hours post-instillation) and 14 (2 hours post-instillation). The secondary endpoint, change from baseline in Marginal Reflex Distance 1 (MRD-1), was assessed at the same time points.

Key trial findings, which were published in JAMA Ophthalmology, include:

• Increase from baseline in mean number of points seen on superior visual field (LPFT)
  • Day 1: 5.9 ± 6.4 (oxymetazoline 0.1%) versus 1.8 ± 4.1 (vehicle), mean difference: 4.07 (95% CI: 2.74, 5.39), P <.001
  • Day 14: 7.1 ± 5.9 (oxymetazoline 0.1%) versus 2.4 ± 5.5 (vehicle), mean difference: 4.74 (95% CI: 3.43, 6.04), P <.001,
• Increase from baseline in upper eyelid elevation (MRD-1)
  • Day 1: 0.96 ± 0.89mm (oxymetazoline, 0.1%) vs 0.50 ± 0.81mm (vehicle), mean difference: 0.47 mm (95% CI: 0.27, 0.67), P <.001
  • Day 14: 1.16 ± 0.87mm (oxymetazoline, 0.1%) vs 0.50 ± 0.80mm (vehicle), mean difference: 0.67mm (95% CI: 0.46, 0.88), P <.001

Upneeq provides a great test for a patient who wants to see what they would look like with their lids more open. If they are not pleased with the result, they can simply discontinue the drop. In my experience and opinion, it can be used chronically with minimal risk of adverse effects, no rebound redness, and no lack of efficacy. It also does not take surgery off the table.

SYNERGY, SYNERGY, SYNERGY

As a surgeon, I love its synergistic effects with other procedures. Some aesthetic specialists have felt this product could cannibalize their surgery, but the opposite is true. Similar to what happened when the toxins such as Botox (OnabotulinumtoxinA injection; Allergan Aesthetics, an Abbvie Company) were introduced, the product creates more awareness and therefore more patients coming to our practices and the opportunity for additional procedures.

It is no surprise that most patients who appreciate Upneeq are those who are more cosmetically minded. In my experience, these are typically 30- to 50-year-olds—mostly women, but some men. A 40-year-old female patient who receives toxin injections, filler, and uses Latisse (bimatoprost ophthalmic solution 0.03%; Allergan Aesthetics, an Abbvie Company) for example, is a great candidate. In other words, Upneeq is not used in isolation. Aesthetic patients may be interested in elevating the brow, reducing lines between the brows, and crow’s feet. A chemical brow lift with Botox is really synergistic with Upneeq.

PATIENT CONVERSATIONS

Patients tell me that want to look better so that they will feel better. I have them look in a mirror or better yet, I take a picture with their cell phone. I ask them the main areas on their face and neck that they would like to improve. Often, they say, “I don’t like my droopy lids,” or “my lids look heavy.” Sometimes they say, “I feel tired, and people tell me I look tired.” Then they ask for my opinion.

If I observe droopy lids during a patient’s visit for a different concern, such as brown spots or wrinkles, I make sure they are aware of it. It is our duty as aesthetic providers to let our patients know about the available options, and they appreciate the information. We should give an assessment that’s very logical and algorithmic. If the upper lids are low, they can be improved with Upneeq or perhaps the patients is a surgical candidate. I show them what their eyes look like front on and from the side. I have them instill the drop and take another picture in about 20 to 30 minutes when the eyelids are lifted.

When I talk to patients about synergy, I let them know that one thing is not likely going to address all their concerns. They are not in my office only to have their eyes look more open--what they want is to look younger. The upper lid doesn’t live in isolation: We need to consider the continuum with the brows and forehead. We talk about reducing wrinkles and dynamic lines with Botox. The lower lid and the cheek are a continuum. For example, I will educate them that the cheeks lose volume with age making them flatter. The fat pads tend to recede to and sink down in certain areas which is why we like to add volume to the cheeks.

My preferred cheek augmenter is Juvederm Voluma (Allergan Aesthetics, an Abbvie Company) and I may add a light filler into the tear trough, like Juvederm Volbella. As I published in Plastic and Reconstructive Surgery Journal, the lower lid lengthens as we age.³ This can be another area for improvement. The orbit expands superomedially toward the nose and also inferolaterally. As that socket cavity enlarges, the eye sinks back into the socket giving the stigmata of a hollow, aged appearance. The receding bone and sagging ligaments along with fat compartment atrophy accounts for a lengthened the lower lid with age. Therefore, if we could shorten the lower lid, from the lid margin to the first lid groove, it creates a more youthful appearance.

No part of the face exists on its own. Just as we take into consideration the entire face and not a single feature when considering aesthetic improvements, we also do not use a single product by itself (Figures 1-6). These products’ synergistic effects are a key advantage we leverage for attaining excellent outcomes. I always tell my patients, when achieving their desired, natural result, it is a marathon and not a sprint.

Figures 1 and 2: Patient front and side views. Before and after Upneeq, Botox in three zones, and Volbella in the tear trough.
Photos courtesy John Fezza, MD, taken by Tyler Fezza.

Figures 3 and 4: Patient front and side views. Before and after Upneeq, Botox in three zones, and Volbella in the tear trough.
Photos courtesy John Fezza, MD, taken by Tyler Fezza

Figures 5 and 6: Patient front and side views. Before and after Upneeq, Botox in three zones, and Volbella in the tear trough.
Photos courtesy John Fezza, MD, taken by Tyler Fezza

Disclosure: Dr. Fezza is a consultant to and investigator for RVL Pharmaceuticals and a consultant to Allergan Aesthetics, an Abbvie Company. He may be reached at jfezza@centerforsight.net

1. Wirta DL, Korenfeld MS, Foster S, et al. Safety of once-daily oxymetazoline HCl ophthalmic solution, 0.1% in patients with acquired blepharoptosis: results from four randomized, double-masked clinical trials. Clin Ophthalmol. 2021;15:4035-4048. doi: 10.2147/OPTH.S322326

2. Slonim CB, Foster S, Jaros M, et al. Association of oxymetazoline hydrochloride, 0.1%, solution administration with visual field in acquired ptosis: a pooled analysis of 2 randomized clinical trials. JAMA Ophthalmol. 2020;138(11):1168-1175. doi: 10.1001/jamaophthalmol.2020.3812

3. Fezza JP, Massry G. Lower eyelid length. Plast Reconstr Surg. 2015;136(2):152e-159e. doi: 10.1097/PRS.0000000000001415