The hollow or sunken upper eyelid can be unattractive and an aging sign on the face. Genetics, aging, illness, and overly aggressive surgical fat resection can all contribute to a skeletonized, bony appearance of the medial third to half of the superior orbital rim as it blends into the nasal bridge. Restoring the look of lost soft tissue fullness in this area can greatly improve the youthful aesthetic of a hollow orbit.
1) Anatomic Considerations
The upper lid skin is usually quite thin in most individuals; there are sensory nerves of the supraorbital and supratrochlear nerve branches, as well as vascular bundles to avoid during the injection of this area. This is an area that requires advanced knowledge and experience; it should be approached only by the confident injector who is experienced and comfortable with the pertinent anatomy and the management of all aspects of complicated filler patient care.
2) Injection Technique
We prefer hyaluronic acid (HA) for these injections. The best injection plane is directly onto the periosteum on the lower to inferior aspect of the superior orbital rim. Whether performed as a series of depot pearl-like injections massaged together or with a long retrograde injection, the goal is to coat the bone with a uniform layer of product so as to cushion and fill the space between the bone and the skin/muscle complex. The area is most safely approached from a lateral to medial direction, keeping the injections lateral to the medial aspect of the brow. The safest technique is to use a 30- to 32-gauge, half-inch (1.25 cm) to 1-inch (2.5 cm) needle; place the tip of the needle firmly on the bone and perform retrograde injections. Careful observation will reveal where extra sculpting is necessary to augment the deepest concavities of the upper eyelid complex and improve the upper lid contour. This is one area where use of a cannula may be the best choice for product placement and avoidance of vascular injury.
3) Precautions & Risks
Injecting higher along the face of the frontal bone away from the free edge of the orbit will create two potential problems. The first would be a risk of injury to or injection into one of the neurovascular bundles as it exits the bone or orbit. The second possible problem would be the potential for creating the appearance of frontal bossing if filler is placed along the bone rather than in the orbital hollow. Risks for swelling and bruising are real, but the catastrophic intravascular, periocular accidents that could arise are enough to deter most novice and even experienced injectors from trying this new area of volumetric correction.
4) Post-Injection Instructions
Immediate pressure and then ice are helpful to minimize bruises. The eyelid will swell and may need to be iced for several days.
5) Pearls of Injection
Keep the injection volume low at first. Inject from the lateral toward the medial upper eyelid, staying low and keeping the needle moving while introducing product. Often there is not a true foramen for the supraorbital nerve, so it can be expected to exit from the orbit and course superiorly over the bony rim.
Consider dilution of the HA with Xylocaine.
Consider using a cannula technique when treating this region.
Reference: Filler Injection for Sunken Upper Eyelids. In: Kontis T, Lacombe V, ed. Cosmetic Injection Techniques: A Text and Video Guide to Neurotoxins and Fillers. 2nd Edition. Thieme; 2019. doi:10.1055/b-006-160134
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