Infraorbital / upper and lower eyelids

16 Infraorbital / upper and lower eyelids







Anatomy of the eye


Complete knowledge and understanding of both dynamic and volumetric changes in the face, as well as the interaction between and function of various facial musculature and the surrounding soft tissue, are critical to ensuring successful outcomes with the use of BoNT in the periorbital region. Although in-depth examinations of facial anatomy have been published elsewhere, this chapter focuses on the anatomy of the eye relevant to the use of BoNT in the upper and lower eyelids (Fig. 16.1).




The upper eyelid extends from the eyelid margin to the eyebrow superiorly, with the superior palpebral sulcus (associated with the upper eyelid skin crease) located lengthwise between the medial canthus and the lateral orbital rim, approximately in the range of 8–11 mm superior to the eyelid margin. The lower eyelid extends below the inferior orbital rim to join the cheek. In youth, the inferior palpebral sulcus (lower eyelid fold) is located 3–5 mm from the lower lid margin.


The orbicularis oculi – the sphincter muscle of the eyelids – is a wide, concentric band of muscle comprising the palpebral component, which can be further divided into pretarsal and preseptal portions and is responsible for blinking and gentle eyelid closure, and the orbital component, responsible for forceful lid closure and the production of lateral canthal and lower eyelid rhytides. Superiorly, the orbital component interdigitates with other superficial muscles of facial expression, including the frontalis, corrugator, and the depressor supercilii muscles, laterally it comes into proximity of the overlying fascia of the temporalis muscles, and the muscles of the inferior quadratus labii superioris and zygomaticus complex. Inferiorly, the orbicularis lies flat across the cheek and is considered a part of the superficial musculoaponeurotic system (SMAS), which translates muscle movement into movement of the skin. At the junction of the lower lid with the cheek, the orbicularis oculi muscle forms a direct attachment with the orbital rim at the junction of the palpebral and orbital portions.




Patient assessment and selection


Because successful use of BoNT in the periorbital region demands close attention to anatomical variations and individualized treatment, a thorough evaluation of every patient is mandatory. Comprehensive assessment will include patient education and counseling, medical history, and physical examination of the periorbital region and area to be treated.


Communication between patient and clinician builds trust and ensures that expectations do not exceed realistic outcomes. Evaluation of periorbital concerns in discussion as well as physical examination will avoid post-injection problems. Interviews should address the patient’s current ophthalmic status including the presence of dry eye symptoms as well as the transient nature of BoNT injections, the need for frequent touch-ups, common injection-related side effects, and potential complications. Informed consent is essential.


A complete medical and ophthalmic history is necessary, including previous experiences with rejuvenation procedures, surgery, and any other conditions that might influence treatment plans or outcome. The degree of rhytides and their potential response to treatment can be assessed via the Glogau photoaging scale (Table 16.1). Moreover, the quality of skin around the eye will also determine a treatment plan: patients with excessive skin above the eye, prominent fat pads in the lower lid, septal fat herniation, or severe elastosis (identified by a positive snap test), may require additional rejuvenating procedures such as laser or light-based therapies or even surgery prior to augmentation. All findings (including any sign of ptosis or asymmetry) should be noted and discussed with the patient, and standard digital photographs taken both before and after any treatments. Photographs should display the face in repose and at maximal expression to document changes on animation.


Table 16.1 Wrinkle severity and rejuvenation requirements



















Group severity* Description Rejuvenation modalities
II Moderate; wrinkles in motion Responds well to BoNT alone
III Advanced; wrinkles at rest BoNT plus additional correction, such as soft tissue augmentation
IV Severe; only wrinkles BoNT plus deeper skin resurfacing for maximal improvement

* Based on the Glogau classification of photoaging.




Not everyone is a candidate for BoNT therapy. Aside from general contraindications (Box 16.1), caution should prevail in patients with a history and especially complications related to previous lower eyelid blepharoplasty and injections avoided in patients with lower lid laxity, due to the risk of scleral show, pre-existing conditions that could be worsened by treatment, such as mid-facial paresis or symptomatic dry eyes, stable or progressive muscular dystrophic conditions causing blepharoptosis, or anyone with already-compromised function of the orbicularis oculi.



Box 16.1


Contraindications and precautions to periocular BoNT treatment










Contraindications Precautions

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