Abstract
Aging in the infraorbital area and upper eyelid can be improved using hyaluronic acid. In order to achieve the best results for your patient it is important to have a good knowledge of the anatomy and do a comprehensive patient assessment, and choose the correct technique and product. Here we discuss how to assess your patient’s anatomy, and the best technique to use, in order to address a lack of volume in the tear trough, palpebromalar groove, and upper eyelid. When using fillers in this area it is important to ensure that you are injecting into the correct layer and that you are not using too much product.
56 Filler Finesse: Tear Trough and Upper Eyelid
Key Points
The aging process in the infraorbital area and upper eyelid causes a tired and sad appearance and can be improved by the injection of filler.
The only useful and long-lasting filler is hyaluronic acid (the injection of fat is not described in this chapter).
For filler injections, whatever the location, we follow our ATP protocol, which means:
First, A: knowledge of the Anatomy and Assess the patient
Second, T: choose the right Technique, and
Third, P: use the right Product
Make sure you’re in the right plane, do not overfill, and do not overpromise results.
56.1 Assessment and Anatomy
56.1.1 Assessment
Discuss patient’s expectations and conduct a patient assessment using historic photos.
Consider previous treatments or medical diseases that could contraindicate fillers (follow the instructions for use on the leaflet).
Conduct a clinical examination to determine any other contraindications: eyelid laxity (positive pinch test), malar mounds, positive or neutral vectors, very thin skin, or skin infection.
If the patient has midcheek depression with a midcheek fold, this needs to be addressed before treating the tear trough and palpebromalar groove.
56.1.2 Anatomy
Infraorbital Rim
Why do we have a tear trough? The tear tough depression is caused where the orbicularis oculi muscle attaches to the bone. The skin here can have a darker appearance (creating dark circles) and can also be overshadowed by palpebral bags, further causing a tired appearance.
Why do we have a palpebromalar groove? This is due to the loss of the top of infraorbital fat compartment, creating excessive thinness of the infraorbital lateral orbit.
What happens during the aging process? Several factors contribute to aging under the eyes: loss of superficial fat (creating and increasing the palpebromalar groove); receding bone at the infraorbital margin deepens the tear trough depression; and increased volume of the palpebral fat pad.
Where are the anatomical dangers (Fig. 56.1)? There are none close to the tear trough and palpebromalar groove:
The angular artery is superficial in the nasojugal groove, then goes up on the lateral side of the nose.
The infraorbital nerve is 3 mm below the orbital margin.
Upper Eyelid: A-Frame Deformity, Sunken or Hollow Eyes
Why do we age? A-frame deformity or sunken eyes:
It could be congenital due to a lack of intraorbital fat or large eye sockets but commonly, post blepharoplasty, it is because the surgeon has removed too much fat. It can also be associated with weakness of the levator palpebrae superioris.
During the aging process the depression of hollow eyes is relatively stable with time, but skin laxity increases.
Where are the anatomical dangers (Fig. 56.1)?
Anatomical vascular dangers are further away as the deep supraorbital and supratrochlear arteries emerge from the bone foramen.
The only theoretical danger is when entering in a retroseptal plane, which can be avoided using a rigid 25-gauge cannula and an entrance point on the orbital rim in the right plane between the bone and the orbicularis oculi.
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