58 Filler Finesse: Upper Eyelid Sulcus

Val Lambros

Abstract

In many patients the superior orbital rim and brow deflate with age, and it makes sense to fill the area to regain the sense of a young eye. To show the patient the effect of the procedure, the area is filled with local anesthetic before injection.

Orbit hollowing – HA fillers – orbital and brow injections – aging eyes – local anesthetic preview – facial harmony – eye lifts

58 Filler Finesse: Upper Eyelid Sulcus

Key Points

In youth the periorbital area is characterized by abundant subcutaneous tissue with elastic overlying skin. Young upper eyelids are long and full. With time, the soft tissues of the eyebrow and orbit may thin and hollow, the orbital rim becomes apparent, and the eye looks shorter, rounder, and gaunt.
This latter contour is often seen after upper eyelid surgery. Though orbits like these can appear highly defined and dramatic with considerable acreage for makeup, they can also make the eye and face look older in general.
In some people, reinflation of the brow and superior orbit looks better.
This is a visual concept, which is not intuitive for many patients; simply describing it does not let a patient understand how treatment will appear.
My practice for decades has been to “preview” the effect of the treatment by injecting the brows with dilute local anesthetic to duplicate the effect of the filler.
Patients uniformly like this idea. Just like trying clothes on before buying, patients can see and understand the desired result before actually doing a potentially expensive procedure, which they might not like. It lets the patient make the most informed decision possible. In addition, the injector can look at the preview and decide whether and where to modify the injection for maximum benefit. The patient is now numb from the anesthetic and vasoconstricted as well.
Placing the local anesthetic precisely is more difficult than the injection of the product. It is easy to make blobs in the skin. Doing the previews makes the clinician a better injector.

58.1 Injection

As can be seen in Fig. 58.1, the brow region contains numerous large arteries. As can also be seen, the arteries course deep to the orbicularis and frontalis at the level of the brow. The key to filling the brow safely is to inject precisely into the subcutaneous brow fat pad, an area clearly absent of vessels as pictured.
This is analogous to other parts of the face such as the lips, nose, or glabellar frown lines, where the location of the arteries is known and avoided. The “local preview” not only vasoconstricts the area, but by expanding the volume of the brow region, gives the injector a larger target volume for needle placement adding to safety. I believe (but cannot prove) that injecting HA filler into an area which has been expanded with saline leads to better diffusion of product and more even distribution. This injection has been remarkable smooth perhaps because of this effect.
This is not an injection for beginners; the injector needs to have the ability to confine the depth of the needle to the subcutaneous plane. It is probably not suited for bolus injection and finger smoothing. I believe that linear injections work best. The injection should be as smooth as possible before using some finger pressure to finalize the distribution evenly.
For cost reasons, the typical injection is usually ½ cc of product per side. This amount may underdo some brows, but will improve all the correctly chosen patients. I prefer particulate HA products.
The injection of product is done immediately after the patients approves the preview.
- Product placement is partly visual, which is apparent through the local anesthetic and partly tactile. I prefer to use a 30g ½ inch needle to inject across the brow.
Cannulas may be used, but they are whippier than needles. In some orbits the globe sits immediately adjacent to the superior orbital rim and could be injured. The curvature of the brow is difficult to follow with a cannula.
With this technique the amount of filler per pass is tiny, about 3 hundredths of a cc per pass. Perhaps most importantly the needle is always kept moving.
- Starting laterally, for each entrance of the needle, superiorly, neutral, and inferiorly slanted passes are made. The injections then march across the brow in the subcutaneous plane. The injections are kept at or above the inferior margin of the superior orbital rim except for a small amount medially.
In the soft tissue of the medial orbit, tiny injections are made to fill the delicate curves there. A needle offers considerably more precision in this location than a cannula. Tiny passes of product are used in the subcutaneous space.
Intra-arterial injection of product, though very rare, should always in the back of one’s mind.
As would be expected a needle produces more bruising in the brow than a cannula would be expected to. This is discussed with the patients beforehand. For this procedure, I think more precision is worth the bruising.
In some patients, a small amount of lax eyelid skin may be filled and expanded. There may be some real or apparent elevation of the brow. Since the primary function of brow filling is expansion of the skin, if the injector attempts to elevate the brows or fill in a large amount of extra upper lid skin, the brows will likely appear unnaturally large.
There are many patients who, from age or excisional eyelid surgery look quite hollow (the “nursing home eye”) and are not candidates for further traditional surgery. Also, there are patients who exhibit flat non-projecting negative vector superior orbital rims. Both these groups have the potential for very attractive improvement from brow filling and consequent visual shrinking of a large depleted orbit.
Some of the best lid results I have seen have been in patients who had some brow fill and a small removal of eyelid fat and skin.