| FACIAL AESTHETICS | PEER-REVIEW
Figure 3 Illustration of periorbital and mid-facial ageing. This artistic filtered
illustration clearly shows the ageing changes that occurs in the inferior orbital and mid-face region owing to the descent and atrophy of the fat pads
Table 1 Treatments to the periorbital area according to depth and layer
However, it is essential to treat patients with a Fitzpatrick
skin type IV–VI with caution when undertaking resurfacing procedures. Rather, it is recommended to opt for non- ablative fractional lasers than ablative; and more superficial peels rather than deep, to reduce the risk of possible postinflammatory hyperpigmentation. Periorbital hyperpigmentation is very common in
patients with a Fitzpatrick skin type IV–VI, and especially in patients of South Asian origin. Treatment options may include multiple superficial peelings, pigmentation focused laser treatment options, such as non-ablative fractional laser, IPL and/ or depigmenting creams applied daily. The use of superficially placed fillers may be useful in
thin or wrinkled periorbital skin periorbital, but the product may be visible for a few days to a few weeks owing to the very thin epidermal, dermal and subcutaneous fat aspects. Therefore, the amount of product placed per injection
point should be the absolute minimal to ensure that the nodules are not visible. Low viscosity, low cross-linked hyaluronic acid fillers are recommended and the technique used is mostly multi-puncture with micro-droplets of the product. The patient can massage the area regularly after the procedure with a post-injection cream to help diffuse the droplets for an even result. This technique can be very useful in most lateral eye wrinkles, which form over the zygomatic arch and run down towards the cheek. Muscular periorbital treatment is usually carried out for
the overactive contraction of the orbicularis oculi muscle. The use of botulinum toxin in this muscle is off-label. The most lateral aspect of the orbital part of the orbicularis oculi is treated to reduce so-called ‘crow’s feet’, or smile wrinkles (Figure 4). Figure 4 shows the injection points and amount of units
of onabotulinum toxin A recommended for the patient shown, with a typically hyperactive orbicularis oculi muscle contraction. Between 6 and 10 units of onabotulinum toxin A distributed over 3–5 points per side of the orbicularis oculi muscle is sufficient to achieve successful results. The treatment will improve lateral eye wrinkles and further enhance an opening of the eye area, as the orbicularis oculi muscle closes the eye area in a sphincteric action. In some patients the palpebral part of orbicularis oculi muscle may also be hyperactive, as seen in the patient in Figure 4. This results in the eye closing almost completely when smiling. Injection of 0.5–1 units of
onabotulinum toxin A will reduce the closing of the eye during the mimical action of smiling. The injection point is placed centrally in the palpebral part. The treatment of the fat pads and subcutaneous tissue
around the eye region requires excellent analysis, an artistic eye, and an expert anatomical knowledge of both the fat pads and vascular structures. Injection of dermal fillers into vascular vessels can result in disastrous complications that may include skin necrosis, hyperpigmentation and even reports of blindness1, 2 The use of cannulae for the injection of dermal fillers
.
reduces the risk of intravascular placement significantly. In the opinion of the author, the use of hyaluronic acid fillers remains the safest and most reliable treatment option for the periorbital region. A variety of hyaluronic acid fillers with different viscosity and concentration can be used according to the area injected and the depth of injection. Low viscosity hyaluronic acid fillers are ideally used for
skin restructuring in this area, as well as for the treatment of fine lines. It can also be used as a safer and softer option for tear trough filling, though more treatment sessions may be required. Medium viscosity hyaluronic acid fillers in the periorbital area are used for medium folds such as tear trough filling and supraorbital volume replacement, while high viscosity hyaluronic acid fillers are typically used for large volume replacement such as cheek augmentation and malar enhancement. The type of filler and its indication should be respected and chosen correctly at all times.
Supraorbital dermal filler injections The skin of the supraorbital area loses elasticity and structure, resulting in excess skin folding over the eye. This article has discussed the treatment options for the skin, but will now look at the options for dermal fillers in this area. The supraorbital area is prone to hollowness owing to ageing of the preaponeurotic fat pads. This gives a very aged and skeletal facade to the eyes. This area is quite a dangerous area for injection owing to
the vascular structures. There are a huge number of fine vessels surrounding the area owing to the complex vascular supply. This vascular supply arises from a range of pedicles of the trochlear artery, suborbital, superficial temporal and lachrymal arteries, which anastomose with themselves and the contralateral networks. Furthermore, the supratrochlear and suborbital nerves are also located in this region. Consequently, treatment with a cannula rather than a needle is highly recommended to reduce the risk of
Skin ■ Peelings
■ Fractional laser: ablative or non-ablative radiofrequency
■ Infrared ■ Mesotherapy
■ Low cross-linked, low viscosity hyaluronic acid
Muscle
■ Botulinum toxin treatment for overactive orbicularis oculi muscle. Most lateral orbital part of orbicularis oculi muscle
Fat
■ Supraorbital fat pads: hyaluronic acid (using a cannula)
■ Infraorbital enhancement: hyaluronic acid for tear trough, or lift from below over the malar fat pad
The skin of
the supraorbital area loses elasticity and structure, resulting in excess skin folding over the eye.
prime-journal.com | March 2013 ❚ 65
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