Skin is the first feature to consider when conducting a cosmetic examination of the face and eyelid areas, according to a speaker.

Tanuj Nakra, MD, said he begins his facial assessment when he first meets the patient.

“I start with the skin,” Nakra said at Oculofacial Plastic Surgery Subspecialty Day preceding the American Academy of Ophthalmology meeting. “The skin, as we all know, can be substantially affected by UV damage that can penetrate through the dermis and cause molecular change to the matrix and collagen structure.”

Whether wrinkles are dynamic or static affects how Nakra considers treatment. He might use botulinum toxin to elevate the brow away from the orbital region in a patient with aging skin and dynamic wrinkles. In a patient with static wrinkles, that is, wrinkles that are present at rest, Nakra suggests using skin care, peel or resurfacing to rejuvenate the skin.

“The paradigm has changed for laser resurfacing,” Nakra said. “We now use fractionated lasers for the majority of our cases. The fractionated laser allows us to treat the eyelid region right to the lashes and really get substantial improvement in both upper and lower skin tone.”

After addressing skin in his assessment, Nakra then considers bone asymmetry, volume loss caused by aging, gravity and contour.