Non-invasive Periocular Rejuvenation with Thermage® FLX for Moderate Eyelid Laxity

INTRODUCTION

The periocular aging process is a common challenge in aesthetic medicine and plastic surgery, with options ranging from surgical procedures like blepharoplasty to non-invasive techniques such as radiofrequency. Thermage ® FLX, an FDA-approved method, offers better tolerability than previous generations, stimulates collagen production, and improves skin laxity within the orbital margin without incisions or prolonged recovery times. It has also proven effective in reducing nasolabial folds and moderate wrinkles on the face and neck.

Thermage® FLX is particularly effective in treating eyelid laxity, with visible results in eyebrow lifting and wrinkle reduction in the orbital region, depending on the number and distribution of shots.

During periocular treatments, the area is marked with grid including vectors for precise application. This process ensures precise skin tightening without overheating, which could cause epidermal injury. Typically performed without anaesthesia, patients usually report mild to moderate but tolerable sensations of heat. Post-treatment follow-ups at 1, 3, 6, and 12 months assess both patient-perceived and physician-observed aesthetic improvements, supported by new collagen production in the skin.

The mechanism involves applying an electric field that switches polarity millions of times per second, generating heat in the deep skin layers and subcutaneous tissue4 due to tissue resistance. This leads to dermal collagen remodelling, enhancing skin firmness and reducing wrinkles, similar to other non-ablative technologies. Cooling mechanisms protect the skin before, during, and after treatment, minimizing risks like pigmentation changes, scarring, or infections, making it safe for all skin types.

This treatment is highly satisfactory, particularly for patients seeking non-invasive periocular rejuvenation without surgery and with shorter recovery times.

CASE PRESENTATION

PATIENT DATA: A 65-year-old female, a regular patient of aesthetic medicine for over 20 years, with multiple treatments involving devices and injectables. She has controlled hypertension and hypercholesterolemia.

REASON FOR CONSULTATION: Progressive development of under eye bags over the past five years, unchanged throughout the day, with eyelid laxity and fine wrinkles around the eyes. She did not wish to undergo surgical treatment.

INITIAL EVALUATION: Pre-treatment photographs and physical examination revealed bilaterally reduced ocular aperture, moderate upper eyelid ptosis, severe upper and lower blepharochalasis, external eye angle droop, bilateral fine eyelid wrinkles, a pronounced inferior orbital groove, and protrusion of the fat pad (4 mm above the orbital

rim). High-resolution ultrasound analysis showed dermis thickness, SLEB (subepidermal low echogenicity band) thickness correlated with photoaging severity, and fat pad protrusion.

TECHNIQUE JUSTIFICATION

Considering the clinical complexity and ultrasound findings, Thermage® FLX was selected due to its focal heat concentration capability and three-dimensional heating. These attributes addressed the patient’s needs in a single session, unlike other devices.

PROCEDURE DESCRIPTION

PROTOCOL: Thermage® FLX was applied to the upper and lower eyelids, periocular region, forehead, and temporal area. A 4.0cm² tip delivered 300 pulses at an energy level of 3-4,5 which lasted approximately one hour, performing multiple passes over the area in order to progressively increase heating.

ANESTHESIA: No anaesthesia was used to avoid any dysesthetic sensations.

DURATION: The entire procedure, including treatment mapping and sunscreen application, lasted 90 minutes. High-resolution ultrasound of the upper and lower eyelids took approximately 10 minutes. Three pauses during treatment assessed symmetry and immediate contraction effects, and a mid-procedure break allowed the patient to evaluate initial results.

COMPLETION: After completing the total shots, high- resolution ultrasound and immediate photography showed subtle changes and ensured patient comfort.

FOLLOW-UP AND RESULTS

IMMEDIATE: The patient described a sensation of “pleasant mild tightness,” with transient erythema that resolved within five minutes. Ultrasound showed slight dermal thickening and reduced echogenicity, interpreted as water attraction, with persistent SLEB.

SHORT AND LONG-TERM RESULTS: Evaluations at 1, 3, and 6 months revealed dermal thickening, preserved echogenicity, SLEB contraction, and reduced laxity and fine wrinkles, as confirmed by follow-up photographs.

QUANTITATIVE RESULTS: Improvements included wrinkle reduction, eyebrow lifting, eyelid skin contraction, infraorbital fat pad herniation reduction (from 4 mm to 2 mm), and enhanced patient-perceived aesthetics.

DISCUSSION

Thermage® FLX has proven effective for eyelid laxity improvement without the risks of surgical procedures. Progressive clinical improvements were evident at 4 and 6 months. The patient avoided complications such as scarring or hyperpigmentation.

The procedure’s success relies on skin cooling, which allows safe deep heating, denaturing proteins and inducing the formation of firmer collagen fibres.

The patient’s Fitzpatrick phototype II and moderate skin sensitivity highlighted the safety of Thermage® FLX, delivering immediate, medium, and long-term results. Monitoring via photography and ultrasound confirmed gradual improvement in SLEB thickness, dermal thickness, subcutaneous echogenicity, and fat pad protrusion reduction.

CONCLUSION

Thermage® FLX treatment of the periocular region in this patient resulted in notable improvements in skin firmness, wrinkle reduction, and suborbital fat pad compression, achieving high patient satisfaction without significant complications.