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Nonsurgical Rejuvenation of the Periorbital Region

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Christine L Bokman, MD
Sandy Zhang-Nunes, MD
Christopher I Zoumalan, MD

Introduction

The eyes are the aesthetic centerpiece of the face. As prominent facial features, the eyes and periorbital region reveal early changes associated with aging, fatigue, and stress.[1] Rejuvenation of the periorbital region, therefore, requires astute, three-dimensional evaluation and a comprehensive treatment plan.

Minimally invasive rejuvenation has gained immense popularity over the last fifteen years.[2] Nonsurgical rejuvenation is advantageous when primarily addressing concavities or hollowness while preserving youthful volume, as a subtractive surgical appearance characterized by volume loss is less attractive. The periorbital region is no exception. When evaluating patients for periorbital rejuvenation, emphasis must be made on volume preservation as well as the region’s relationship with the rest of the face – the eyes are geographically confluent with the upper and lower face.

This chapter presents a thematic and anatomical approach to both the upper and lower periorbital regions. Candidate considerations for nonsurgical versus surgical rejuvenation are delineated. Filler techniques are described in detail as well as indications for filler removal and safety considerations. The chapter also includes videos on advanced periorbital filler techniques.

Upper Periorbital Region

Anatomy and Aging

Management of the aging periorbital region in nonsurgical rejuvenation begins with an understanding of anatomy. The upper periorbital region not only includes the upper eyelid and superior sulcus, but also the eyebrow, requiring simultaneous evaluation. The upper eyelid contains two muscles that lift the eyelid, the levator palpebrae superioris and Muller’s muscle, while the more superficial orbicularis oculi muscle closes the eyelid and depresses the brow. The two fat pads of the upper eyelid are the central and medial fat pads.[3],[4]  

With age, vertical descent of the brow leads to redundant skin, or dermatochalasis. Skin redundancy of the upper eyelid is also driven by increasing skin laxity over time. Even in the absence of brow ptosis, skin redundancy is accentuated by subcutaneous brow fat volume loss. The central fat pad of the eyelid may enlarge or become atrophic over time.[5] Atrophy of central fat results in hollowing of the superior sulcus. In some cases, superior sulcus hollowing is exaggerated when the frontalis is chronically elevated in cases of eyelid ptosis, raising the brow and adding to a hollowed sulcus. Concurrent tissue loss in the temple region adds to a deflated look.

Within the lateral upper lid, the lacrimal gland may also prolapse with time, resulting in an overly volumized upper eyelid. To evaluate for lacrimal gland prolapse, the upper eyelid is everted and careful examination of the lateral fornix identifies a prolapsed gland. Medially, the medial fat pad enlarges over time and prolapses anteriorly due to weakening of the septum and orbicularis oculi muscle anterior to the fat.5 Overall, an aging upper eyelid is characterized by medial fat pad prolapse, fat atrophy centrally, and brow ptosis with deflation, all factors that should be addressed when rejuvenation the upper eyelid.

Patient Selection

Evaluation of the upper eyelid and periorbita requires eyelid, brow, and temple consideration. The ideal candidate for upper eyelid filler presents with true volume loss of the superior sulcus due to involutional changes in the absence of significant excess skin or brow ptosis.[6] Patients may also present post-operatively after an overly aggressive eyelid blepharoplasty that resulted in hollowing. Brow lifting surgery may also unveil underlying upper eyelid fat pad atrophy.  These patients are also good candidates for superior sulcus filler.[7]

In terms of eyebrows, patients with brow deflation without brow ptosis benefit from filler to the brow fat pad region to restore volume without weighting down the brow. In cases of brow ptosis with concurrent deflation, surgery is a better choice. Similarly, patients who present with lacrimal gland prolapse also benefit from surgical lacrimal gland repositioning. At the time of surgery, brow volume loss may be addressed with concurrent fat grafting. An alternative to surgery in milder cases of brow ptosis is a chemical brow lift with botulinum toxin, targeting the brow depressors: the sub-brow orbicularis oculi muscle and corrugators.

Temple atrophy is more noticeable and less acceptable cosmetically in women than in men. Atrophy within the temples is also present in cases of fat wasting due to excessive exercise, weight loss, or lipodystrophy. Although usually not recognized as the main complaint from a patient perspective in periorbital rejuvenation, it becomes more evident when the midface and brow region is re-volumized.[8] Generally, patients with concavity in this region are excellent candidates for volume restoration with filler.

Techniques

Technique considerations include filler choice, delivery method, zones of placement, and layers of placement. Although technique vary between practicing physicians, basic principles are used in achieving optimal results. Safety is also a key component of injection technique since injections around the eyes pose an increased risk for vision loss, and knowledge of periorbital anatomy is paramount to minimizing these risks.

When selecting the appropriate type of filler for a particular area in periorbital rejuvenation, hyaluronic acid G’ is a valuable measure indicative of product stiffness or resistance to deformation.[9] In general, a high G’ is generally more suitable for a deeper fill to be placed in tissue layers closer to or directly on top of periosteum. In contrast, a lower G’ is more appropriate for placement in superficial tissue layers and muscle. Uses of high and low G’ fillers and where to place them in the periorbital region will become more apparent in the following sections.

Another key consideration to consider is the use of a cannula versus a needle for product delivery. A cannula has been reasoned as safer than a needle because, in theory, a blunt-tipped cannula may be less likely to pierce and canalize a blood vessel compared to a needle. However, even in the hands of the most skilled injectors, a cannula has been shown to penetrate arterial walls[10] and blindness has been reported.[11],[12]

Recent studies show that a cannula is more precise than a needle in terms of filler placement in facial aesthetics.[13] [14] [15] Most common cannulas used in the periorbital area are 1.5 inch 25 gauge but some also use 27 gauge. The authors prefer the 25 gauge due to a theoretically lower risk of intravascular penetration. If using a needle, the authors prefer using a 32 gauge ½ inch needle around the periocular area, although more viscous fillers may require a larger gauge. Overall, injectors should be facile and safe with both cannula and needle, and have a detailed understanding of facial anatomy.

In upper periorbital rejuvenation, an individualized approach is advised after detailed assessment of the brow, temple, superior sulcus, upper eyelid. Basic principles of technique are used to maximize safety. When filling a hollow superior sulcus, the brow should be lifted, and the filler should be placed just below the brow allowing it to settle in the superior sulcus, avoiding the supraorbital, supratrochlear neurovascular bundles, and the levator and superior rectus muscles. This technique is usually performed with a cannula at two points, one at the lateral canthus and another in the superior sulcus above the lateral limbus of the eye to fill the medial sulcus.  In this region, a shorter 27 gauge can be considered, with clear understanding of the vascular structures that need to be avoided.  Filler in the eyelid can result in ptosis, and because the eyelid skin is the thinnest in the body, product may be more visible. A deflated brow can also be filled from the lateral access point in the sulcus.

In terms of the layer of placement, filler placed just anterior to the periosteum, in the pre-periosteal space, yields better outcomes.[16] Placement in the superficial layers is more likely to result in blue-gray dyschromia, also called the Tyndall effect erroneously, edema, and contour irregularities.[17] Because placement is within deeper tissue layers, use of a stiffer filler represented by a higher G’ allows for a more complete filling of the hollow.  Lower G’ filler can be used if less volumization is required and the overlying tissue is very thin.  Lower G’ filler can also be used superficially for ingrained lines not responsive to neurotoxin (such as sleep lines usually found more laterally over the brow).  Glabellar lines, however, which are in close proximity to the supraorbital and supratrochlear vascular bundles are best treated with means other than filler, as that is a region with much higher incidence of blindness.[18]

Lower Periorbital Region

Anatomy and Aging

The closely integrated relationship between the lower eyelid, periorbital region, and midface may be understood anatomically as an inverted triangle that contains the lower eyelid-midface complex: the lateral border is defined by a line from the lateral canthus to the oral commissure, while the medial border runs from the medial canthus through the nasolabial fold.[19]

Significant landmarks within the inverted triangle are fat pads within the cheek and lower orbit as well as two key ligaments of the lower eyelid-midface complex. The malar fat pad, divided into the deep medial, middle, and lateral compartments, is the fat pad of the anterior cheek and sits at the inferior border of the orbicularis oculi muscle.4, [20] Under the orbicularis muscle lies the suborbicularis oculi fat (SOOF), which is separated from the orbital fat by the orbital septum. The orbital fat is further divided into the medial, middle, and lateral fat pads.[21] The two key ligaments include the orbicularis retaining ligament and the zygomaticocutaneous ligament. These are important because they become more visible with age as soft tissue including fat prolapses around them.[22]

Similar to the upper periorbital region, signs of aging in the lower are due to gravity and vertical descent. As the malar fat pad of the midface descends and separates from the lower eyelid, it creates lower eyelid hollowness and midface volume loss3,[23] in addition to nasolabial fold accentuation.[24] Meanwhile, the orbicular oculi muscle tone decreases along with elasticity of the orbital septum, leading to orbital fat prolapse. In some patients, the medial, middle, and lateral orbital fat pads can clearly be distinguished. Further, the SOOF atrophies and descends vertically similar to the malar fat pad, leading to additional hollowing. The tension of the superiorly located orbicularis retaining ligament and more inferior zygomaticocutaneous ligament accentuates the prolapsed orbital fat, resulting in a superior depression laterally and an inferior depression that is more noticeable in the presence of malar edema. The strong attachment of both ligaments medially further defines the tear trough, also known as the nasojugal groove.[25]

Patient Selection

In lower periorbital rejuvenation, candidates are treated with either filler or surgical lower eyelid blepharoplasty.  The first main consideration is the presence of herniated orbital fat.[26] The ideal candidate for lower eyelid filler has true infraorbital rim hollowing but little to no herniation of orbital fat and no excess skin. In these cases, filler may be used to address volume loss and fill in concavities. Of note, in younger patients, infraorbital rim hollowing may be congenital in nature, and these patients are excellent candidates for filler.[27] A moderate to severe amount of herniated orbital fat is more amenable to surgery with either fat debulking or fat repositioning.24

One should consider hollowing and concavities across the entire lid as regions in the form of medial (also termed tear trough deformity) central, and lateral infraorbital hollowing.  Further, atrophy of the malar fat pad and volume loss along the cheek and zygomatic arch must also be considered, and should be addressed for complete rejuvenation.

Other factors to consider in selecting the proper candidate for filler is the amount of excess lower eyelid skin, malar edema, and Fitzpatrick score. In cases of no excess to a mild amount of excess skin, patients may be good candidates for either a chemical peel or laser resurfacing. However, when patients present with moderate to severe amounts of excess skin, surgery is a better option since filler and other nonsurgical interventions do not address excess skin.

Another important factor that cannot be overlooked is the presence of malar edema since filler may significantly worsen edema in this region. Malar edema can be considered a relative contraindication for filler. Patients with malar edema must be educated on this key point before even considering filler or not given the option of filler. If a patient desires to proceed despite the risks of worsening malar edema, even after dissolution, then techniques targeted at minimizing malar edema should be used. Limiting filler volume, and the placement of filler deep at the preperiosteal layer may limit the incidence of malar edema.[28] More hydrophilic filler will significantly worsen the malar edema, and any compression of the tissues even from less hydrophilic or even non-HA filler can reduce lymphatic drainage in this area and worsen malar edema. This is further discussed in the following section.

Finally, a higher Fitzpatrick score, representing a darker complexion, generally demonstrates excellent outcomes with filler.[29] Blue-gray dyschromia, also previously called the Tyndall effect, is typically the result of filler placed too superficially in the dermis.[30] In fact, it has also been posited that this blue-gray dyschromia is secondary to superficial blue veins anteriorized by HA placement.[31] Patients with lower Fitzpatrick scores have less melanin to block blue vein discoloration in periocular skin. Nonetheless, even in patients with lower Fitzpatrick scores, filler in the periocular region may still demonstrate good outcomes.27

Techniques

When a patient presents with infraorbital rim hollowing, a three-dimensional approach should be utilized: analysis should include the lower lid, including the medial, central, and lateral lower eyelid, the lateral cheek, and midface region. Malar fat pad descent and atrophy is one of the first changes of aging that unmasks a tear trough hollow as the cheek separates from the periorbital region.[32] Neglecting the midface in rejuvenation of the lower eyelid is synonymous to filling nasolabial folds without restoring volume to the lateral cheek at the zygomatic arch.  In cases of lower eyelid hollowing that also presents with midface volume loss, beginning with volumizing the midface and cheek is advised.

Similar to the upper eyelid and brow, lower eyelid and midface filler should be placed in deeper planes, within the pre-periosteal space in order to achieve a smooth contour and transition between the lower eyelid and midface. In the medial tear trough, there is less soft tissue between skin and bone, so building up the other parts of the face is crucial. Then, when placing filler medially, care should be taken to place in deeper tissue layers, pre-periosteally, as reports show that the blue-gray dyschromia is most common in this region.17 Similarly, when filling the concavities formed by the orbital retaining and zygomaticocutaneous ligaments, filler should be placed deep because this region is more prone to malar edema. Filler placed in superficial layers may compress the lymphatics and serve as an additional risk factor for malar edema.[33]

Indications for Removal

Rejuvenation of the periorbital region with hyaluronic acid (HA) is the gold standard for soft tissue filler.[34] Although hyaluronic acid is biodegradable and non-species specific, with limited potential for an immunological response, it is not without limitations. Some of the indications for removal include contour irregularities or nodules, product migration, blue-gray dyschromia, persistent edema, inflammatory reactions, infection, tissue expansion, future surgery, and vascular complications.   

While ischemia and infection with biofilm require complete dissolution, contour irregularities may be best treated with partial dissolution. Contour irregularities are commonly the result of both excess volume and filler placement in superficial layers.[35],11 This tends to occur early after injection, though late-onset nodules and orbital ridges have been reported.17 Instead of injecting additional filler around a contour abnormality, filler dissolution is advised. Filler is capable of migrating into several tissue layers and adding filler may exacerbate contour irregularities and bumps. In addition, a biofilm or granuloma may be the underlying cause, more common in late-onset nodules, and filler removal is strongly advised in this situation.[36]

Blue-gray dyschromia is another indication for filler removal with hyaluronidase. Again, this tends to be more of an issue in the tear trough area and lower eyelid where there is less soft tissue and the skin is thinner. Interestingly, dyschromia can form weeks to years after filler placement.31 As such, it is important to always obtain a complete patient history as previous filler injections from years ago may be overlooked by patients.  Fillers in this area have been found to persist for up to nine years.[37]

Similarly, persistent edema particular of the malar region may also occur days to years status post injection, though hours to days after injection is more common. In cases of persistent edema that is bothersome to patients, filler removal is indicated. Despite dissolution with hyaluronidase, patients should be counseled that edema may still persist even after. Skin may also appear more “wrinkled” after filler removal due to filler’s effect as a tissue expander.  Those with preexisting allergies, rosacea, and pre-injection edema are at increased risk for persistent edema even after filler removal.[38]

Patients who have undergone HA injections for lower eyelid periorbital hollowing may present with contour irregularities, especially in the presence of orbital fat prolapse. These patients may be better served by a surgical lower eyelid blepharoplasty with dissolution of filler using hyaluronidase at least two weeks prior to surgery. Hyaluronidase is used to dissolve hyaluronic acid. Overall, patients have excellent surgical outcomes with hyaluronidase injections used to dissolve filler prior to lower eyelid blepharoplasty.[39]

Depending on the rheologic properties of the filler, its chronicity, and the amount that was injected, hyaluronidase can be titrated, from 30 units per square centimeter to higher levels.39 Filler-specific doses of hyaluronidase for dissolution have been investigated both ex and in vivo.[40] The specific dosing of hyaluronidase does not necessarily correlate with the properties of filler such as G’ or viscosity, but rather correlates with the individual type of filler injected. Recent in vivo and in vitro studies of hyaluronidase explore the dosing of hyaluronidase for different HA fillers.  Particularly for when partial dissolution is indicated, such as contour irregularities, a titration of hyaluronidase dosing is proposed depending on filler type (such as more than 20 units per 0.2 mL of Voluma, approximately 10 units for 0.2 mL Juvederm Ultra, and 2.5-5 units for 0.2 mL of Restylane-L and Lyft).  Dose response curves demonstrate that Voluma in particular requires higher doses of hyaluronidase for dissolution, while Restylane requires very little.38, [41]  In general, however, fillers with higher degrees of cross-linking require larger doses of hyaluronidase and often require multiple sessions of injection.

By far the most feared consequence of HA filler, requiring immediate treatment with hyaluronidase, among others therapeutic agents, is a vascular occlusion. Signs of an occlusion include pain, immediate blanching of tissue, and mottled skin changes. If a patient complains of vision loss, emergency consult with an ophthalmologist is mandatory. Nonetheless, it is possible to maximize safety and minimize the risk of this devastating consequence. For vascular occlusions, hyaluronidase is used in conjunction with NSAIDs and/or aspirin. Patients may be placed on a short course of steroids and antibiotics, and in more severe cases, hyperbaric oxygen therapy should be considered.

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