Periocular rejuvenation: current concepts and evidence-based management

The periocular region shows early visible ageing because thin skin, repetitive orbicularis oculi activity, retaining ligaments, orbital fat, and the bony framework change together. Clinical manifestations include rhytids, dermatochalasis, eyelid laxity, tear trough deformity, edema, and dark circles, with potential cosmetic, ocular-surface, and functional consequences. Assessment should distinguish pigmentary, vascular, structural, and volume-related findings and should include eyelid position and laxity, brow position, ocular-surface status, relevant medication use, and visual-field testing when functional symptoms are present. Management is anatomy driven. Botulinum toxin type A, hyaluronic acid fillers, light- and energy-based procedures, and selected regenerative or collagen-biostimulatory injectables may benefit appropriately selected patients, whereas blepharoplasty and fat repositioning remain the reference treatments for substantial tissue laxity, fat prolapse, or functional impairment. Evidence is strongest for established indications but remains heterogeneous across devices, injection techniques, and emerging products. Early positive clinical, objective, mechanistic, and safety data for polynucleotides and collagen biostimulators indicate insufficient evidence to determine comparative efficacy rather than evidence of absent effect. Procedure-specific recommendations should therefore be interpreted according to whether they arise from comparative studies, consensus, anatomical principles, or expert practice.