A to Z of Periorbital Injectables: Understanding Anatomy & Complications
According to Periocular rejuvenation using hyaluronic acid fillers by Kasra Ziai, Jessyka G. Lighthall (2020) The periocular region is essential for social interactions and conveying emotion. It is one of the first subunits of the face to show facial aging. The youthful periocular region is defined by the fullness of the periorbital area, low or no skin excess, minimal pigmentation or rhytidosis of the skin, and appropriate brow height and shape.
Facial aging is the result of facial fat loss, decrease in skin elasticity, deepening dynamic rhytids, static rhytids, change in bony structure, and muscular changes. With the evolution of medical and surgical knowledge over the past few decades on facial aging, we now have a better understanding of the underlying pathophysiology. This has resulted in a shift from volume reducing interventions for periorbital aging such as blepharoplasty with fat resection to volume replacement techniques.
Since 2004, hyaluronic acid (HA) filler has been used for periorbital rejuvenation. The minimally-invasive, office-based nature of HA filler use without the need for general anesthesia, the low complication rate, and the lack of downtime have resulted in increased popularity, and it has replaced blepharoplasty as the most commonly performed cosmetic procedure for periocular rejuvenation.
Understanding the periorbital anatomy, proper injection techniques and complications that can arise are important for every injector of this delicate area. However, even in the most skilled injectors, complications can arise and education, recognition and early treatment are of utmost importance.
Understanding the underlying soft tissue, vascular and bony anatomy and aging changes is crucial for successful rejuvenation in the periorbital area as it is one of the most dynamic and unforgiving in relation to volume enhancements.
The eyelid skin is the thinnest in the body that lacks subcutaneous fat and is a dynamic structure. Irregularities are more readily apparent in this area than other areas of the face. Understanding the complex anatomy is important to help avoid potential complications and is critical for the assessment of appropriate treatment of patients. This anatomy review includes skin, bony compartment, muscle & fat pads.
The skin of the periorbital area and specifically the tear trough region is thin and closely attached to the underlying orbicularis oculi muscle.
This results in a transparent appearance and a bluish hue at baseline related to the underlying muscular structure and vasculature. Additionally, hyperpigmentation and telangiectasias may occur due to long-term sun damage.
Skin aging varies among different ethnicities with different skin types. These changes are more pronounced in the deep layer of the dermis where the collagen fibers are strongly connected to proteoglycans. With aging, this network becomes loose and less organized, resulting in fine rhytids and crow’s feet lines.
The facial skeleton is believed to grow and expand with aging. Recent studies have shown that certain portions of the facial bones undergo resorption with aging. This age-related bone loss can result in a hollow appearance of the inferolateral subunit.
In males, the supraorbital rim is more prominent and the brow is flatter and located at the level of rim, resulting in a more linear appearance. In females, the aesthetic brow is arched and located above the supraorbital rim. The female brow tapers laterally. In general, the highest peak of the brow should be located at the junction of the middle and lateral third at either the lateral limbus or lateral canthus.
The periorbital muscles include the frontalis that elevates the brow and the depressor muscles which include the orbital portion of orbicularis oculi, corrugator, procerus, and depressor supercilii.
The corrugator muscles result in vertical glabellar rhytids and the procerus results in the horizontal glabellar rhytid. These muscles are of importance when using neuromodulators in conjunction with fillers for deep static rhytids. Additionally, the orbital portion of the orbicularis oculi will contribute to the nasojugal groove due to attachments inferomedially.
The upper periorbital area contains the preaponeurotic fat pad, preseptal fat pad, and galea fat pad or retro-orbicularis oculi fat (ROOF) pad.
In periorbital aging, the preseptal and the ROOF fat descends and may lose volume, facilitating gravitational descent of the unsupported lateral brow, which causes brow ptosis and produces the appearance of a heavy lid with or without dermatochalasis.
This is also attributable to the weakening of the orbital septum and subsequent pseudoherniation of the fat pads. Resulting in the deflation of the upper eyelid as well as hollowing and increased visibility of the supraorbital rim prominence. These changes produce a deep-set, hollow, and skeletonized orbit with tired, sad, or angry appearing eyes.
Adding volume with HA fillers in this region can restore the youthful appearance of the periorbital area with a minimally invasive procedure. However, severe pseudoherniation of fat may limit the amount of correction obtained without surgical intervention.
Hyaluronic Acid (HA) Fillers for Periorbital Injection
Prior to the availability of HA Fillers, autologous fat was predominantly used to restore volume around the eye. Autologous fat requires a donor site, is more invasive, and requires more downtime with a higher rate of complications.
Since the introduction of the first filler, a multitude of synthetic fillers have been introduced to the market. Volume replacement occurs primarily through the hydrophilic biomaterial properties of hyaluronic acids that act as a spacer within the tissue planes.
Synthetic fillers such as calcium hydroxyapatite (CHA: Radiesse; MerzAesthetics), polymethyl methacrylate (PMMA; Artefill; Suneva Medical), and poly-l-lactic acid (PLLA: Sculptra Aesthetic) have additional biostimulatory effect in addition to spacer effect.
Each HA filler is unique and ideal for a specific region of the face that is aligned with the patient’s goal. In general, fillers with smaller particle size, lower concentration, and lower G’ are more appropriate for fine lines and wrinkles that require more superficial injection, while fillers with higher particle size and elastic modulus are more appropriate for deeper injections.
In the periorbital area, the reversible and temporary hyaluronic acid (HA) fillers are preferred. Proper selection and placement of product can help avoid some complications. The use of permanent, non-reversible fillers are discouraged in the periorbital area as this area is constantly changing and complications with these fillers can be difficult to address. Complications accosiated with HA fillers are non-ischaemic and ischaemic.
Ischemia is a condition in which the blood flow (and thus oxygen) is restricted or reduced in a part of the body. Such complications related to filler injections, such as soft tissue necrosis and visual compromise, can occur and should be discussed with patients receiving any filler injection.
The mechanism of action of filler-associated ischaemia is due to direct intra-arterial injection of product. With injection, it is proposed that the filer product enters the artery initially in a retrograde fashion then once the plunger is released, anterograde embolisation of filler product occurs. Because of this, a larger area than the injection site along a vascular distribution is affected. In the periorbital area, the vascular structures to be aware of include the supraorbital, supratrochlear, infraorbital and angular arteries. In cases of filler induced ischaemia, early recognition and treatment is a key in treating patients.
For HA injections, the incidence of vascular occlusion is at 3–9/10,000 injections. The most high-risk areas include the glabellae and nasal area, but can also occur anywhere arteries run including the lip, nasolabial fold and temple.
There are tips to help prevent accidental intra-arterial injection of product but no technique is 100% effective in avoiding ischaemic complications. Some techniques that can be useful are using local anaesthetics with epinephrine to vasoconstrict vessels prior to injection, injecting small volumes per pass, aspiration prior to injection, using low injection pressure, avoiding scarred areas and considering the use of blunt cannulas.
However, remember cannulas can also act similarly to needles, especially those with smaller calibre and those used in scarred areas where the vessels are more likely to be tethered.
Non-ischaemic complications include contour irregularities, bluish-discoloration or Tyndall effect, inflammatory reactions, and infection/biofilm formation.
Transient oedema and bruising are expected after any periorbital injection and can be minimised by avoiding blood thinners 2 weeks prior to injection, applying numbing cream with a vasoconstrictor such as epinephrine prior to injection and the use of cool compresses after injection.
To help avoid contour irregularities, injections below the orbicularis or in the pre-periosteal plane will help to allow more coverage of the filler product. In addition, placement of small amounts of filler product, in a cross-hatched pattern or small amounts on the periosteum may be helpful.
To help avoid persistent oedema after HA fillers, it is important to note those patients that are prone to retaining fluid. Patients with fluid around their eyes prior to injection may not be ideal candidates for HA fillers and this should be discussed with the patient prior to treatment. If the contour irregularities or oedema does not resolve over time, dissolving the HA filler with hyaluronidase can be performed. In these cases, small amounts of hyaluronidase can be injected to the desired effect, usually around 15–50 IU.
Periorbital rejuvenation with injectables, primarily HA fillers, can be effective in addressing periorbital aging. Because of the increasing use of periorbital fillers, more complications, both non-ischaemic and ischaemic, will be encountered.
In patients presenting with inflammatory signs after periorbital filler injection, infection should be highly suspected. True allergic reactions can occur but are less common. To minimise infection, thorough sterilisation of the treatment site should be performed prior to injection. Fillers should be treated as implants as that is what their use is approved as in the United States by the Food and Drug Administration.
Understanding the complex periorbital anatomy and proper injection techniques can help avoid complications, but are no guarantee. Only injectors with the understanding of the periorbital anatomy and its complications should inject this complex region.
Therefore, education of both patients and injectors of these potential complications is critical to achieving the best result.
Periorbital Injectables: Understanding and Avoiding Complications by Catherine J Hwang (2016)
Periocular rejuvenation using hyaluronic acid fillers by Kasra Ziai, Jessyka G. Lighthall (2020)
Anatomical Study and Clinical Observation of Retro-orbicularis Oculi Fat (ROOF) by Xian Wang & Haiping Wang
Man with Unilateral Periorbital Edema by Gabriela Espinoza MD, Sam N Kuchinka, MD (2018)
Learn orbital ageing/ periodical anatomy - neuromuscular architecture/ suitable vs. unsuitable candidates/ pre-treatment assessment (skin quality/hollowness/orbital fat pad/cutaneous colour)/ upper eyelid and tear-trough landmarks: needle vs. cannula technique/ after-care & complication management in our upcoming Aesthetic Injection Hand-On Master Classes/Mini Fellowship happening globally:
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