| Lower eyelid hollows without skin laxity or festoons |
| Use of anticoagulants |
| Prior fillers and neurotoxin use |
| Assessment for lower eyelid malposition and dermatochalasis |
| History of prior facial surgery |
Introduction
Injection of hyaluronic acid gel (HAG) filler to the infraorbital area is a common treatment patients seek for non-surgical rejuvenation of the lower eyelids. The infraorbital region is a non-forgiving area, as the thin eyelid skin overlying bone cannot mask contour irregularities and lumps and predisposes to blue discoloration, hydrophilic reaction, and excessive bruising and swelling. In addition, while treatment of the infraorbital hollows is generally safe, intravascular complications can occur, and care should always be taken during injections.
Each class of HAG filler has a different biochemical composition (concentration, percent cross-linking, etc.) and unique flow characteristics (viscosity, G’, etc.) yielding specific and distinct clinical manifestations. As such, the appropriate selection of HAG product for different facial areas is essential for success. This is especially true for the very delicate area of the eyelids and associated periorbita. In the infraorbital area, the single injection technique, the use of a cannula versus a needle, and a multidirectional entry point, can be important features for successful application of filler and avoidance of injection-related complications. The use of HAGs is ideal for the infraorbital region as they are readily reversed with hyaluronidase should complications arise.
For deeper, infraorbital injections, a stiffer (higher G’) and more viscous product such as Restylane (Galderma) can provide a three-dimensional tissue expansion (lift and fill), while a less robust and viscous product such as Belotero Balance (Merz) can better efface more superficial irregularities. In my experience, deep injection of Belotero, has less capacity three dimensionally to fill and a shorter clinical duration compared to Restylane. Postoperative oral antibiotics are not routinely given unless a tapering course of oral steroids (Medrol dose pack) is added for swelling. After completion of injection, patients are observed for 15 minutes to assure the absence of skin blanching or mottling which may signify an intravascular injection of the gel. A slow and low pressure injection technique, aspiration on the plunger of the syringe prior to injection, and retrograde delivery of the gel can minimize intravascular complications that can lead to skin necrosis or blindness. Every office should have hyaluronidase, nitropaste (controversial), heat packs and aspirin on hand in case complications arise.
Surgical Technique
