Is the palpebromalar junction stable?

In his observations of the periorbital area and the mid‑face, Lambros5 wrote, ‘the lid–cheek junction is very stable because it sits on tissues which are fixed’. A number of authors concur with Lambros in this regard;  however, the authors of the present article are not of the same opinion. As already described, the bony rim of the orbital rim, which tends to recede with age, is fixed, as is the deep malar fat, which is fixed to the bony rim for protection. The skin, superficial malar fat and orbicularis muscle are not fixed: they are mobile.

It is obvious that the inferior eyelid lengthens during the age-related sagging and the palpebromalar junction becomes lower. This is evidenced by rejuvenation and embellishment with volumising products (such as hyaluronic acid or autologous fat, in the authors’ experience), which raise the level of the palpebromalar junction and shortens the lower eyelid.

Where and how to inject

There are two major considerations: the hydrophilic nature of hyaluronic acid and the thinness of the palpebral skin. A placement of hyaluronic acid that is too superficial and injected just under this fine skin can give an unaesthetic blue appearance (Tyndall effect), caused by light diffraction. Therefore, the injection must be deep.

The following technique is proposed:

  • The injection must be deep at the level of the palpebromalar groove, in front of the bony orbital rim, and just behind the orbicularis muscle
  • Inject slowly with a very gentle pressure on the plunger of the syringe to avoid uncontrolled superficial spreading of the product. Do not crack under pressure
  • Inject small quantities to avoid over-correction, which is unaesthetic and difficult to rectify correctly, even with hyaluronidase.

Cannula or needle?

This is generally based on the personal preference of the physician, depending on the technique he/she is most comfortable using. Using a needle is certainly easier; however, a fine blunt cannula easily penetrates owing to the fineness of the skin at the level of the lid–cheek junction.

[pull_quote align=”left” ]Using a needle is certainly easier; however, a fine blunt cannula easily penetrates owing to the fineness of the skin at the level of the lid–cheek junction.[/pull_quote]Although the cannula is considered to be less traumatic, the needle causes no extra bruising if the physician understands how to avoid the trunk of the facial artery and vein (i.e. medially). In the authors’ opinion, the relative risk of trauma on the small vessels and capillaries, both small branches of the facial artery and facial vein, is the same when using either device. However, the impact on larger vessels, such as the trunks of the facial artery and the facial vein, is riskier with a needle, which can pierce these large vessels, whereas a cannula will avoid them.

Despite this, using a cannula requires a greater amount of force, giving less control, especially in the denser and more fibrous deep malar fat. Physicians should be wary of using a flexible cannula because of its ability to bend, making it more difficult to control its route and end cannula position. Care must be taken to ensure the flexible cannula does not slide into the orbit and the ocular globe.

Bolus or fanning techniques

Again, it is advised that physicians use the technique most comfortable for them, either fan or bolus. Product deposition can be placed using a fanning technique to create a fine and narrow sheet, or using a few small bolus, which can be gently moulded to remove any irregularity.

A very gentle pressure can reduce the risk of bruising, but caution needs to be observed as excessive pressure or massage can provoke a superficial spreading of the product, despite an initially correct placement.