Eye contact is a decisive factor in human interactions. As our eyes are a primary indicator for youthfulness, health and mental alertness, the periorbital region is one of the main targets for cosmetic procedures. In fact, the periorbital area is one of the first facial regions to show signs of ageing, and even little changes in its structure and volume can influence the emotions and confidence-levels of patients.
A series of morphological and clinical studies have shown that ageing of the periorbital region not only implies a deterioration in skin elasticity, but also a volume loss which leads to changes in the 3-dimensional topography of the face, and to soft tissue skin sagging. The use of hyaluronic acid (HA) fillers in the periorbital region can never be a substitution for plastic surgical procedures. However, in some cases — and only in experienced doctors’ hands — HA fillers can be a useful and effective tool to improve the signs of ageing in the upper third of the face and the periorbital region. It is often helpful to emphasise the differences between a more fundamental and permanent plastic surgical correction and the softer, impermanent filler treatment.
HA fillers are often used in combination with botulinum toxin for different areas and indications:
To correct wrinkles such as crow’s feet, glabellar lines, or mild cases of tear trough deformity
To elevate, reshape and augment the eyebrows
To restore the fullness of the orbital cavity
To improve the shape and volume in the periorbital region as a result of ageing, such as hollow eyes or other deformities after trauma or cosmetic procedures.
Aesthetic treatments in the periorbital region constitute an advanced technique and therefore require much practical experience and a profound knowledge of the facial anatomy for minimising the risk of adverse reactions. Complications in the orbital area could be disastrous. Nonetheless, in experienced hands, HA fillers provide a safe, fast, easy and cost-efficient method of beautification. Patients appreciate this kind of treatment owing to the negligible down-time and minimal complications.
As a result of the rapidly growing number of HA fillers on the aesthetic market, it is vital to use only high quality products that are manufactured by reliable and well-known companies. Subtle differences between the range of products can be identified: the particle size and concentration of HA, the degree of cross-linking, and the level of elasticity and viscosity determine the properties of the product decisively. I have performed hundreds of periorbital injections and tested a high number of different dermal fillers. For the correction of the nasojugal fold and tear trough deformities I often use the HA filler range Princess, manufactured by Croma (Austria). In such cases, I can rely on a safe product and like the consistency and homogeneity of the gel, as well as the ease of handling. The product has a very smooth and even flow, which facilitates the injection and distribution in the tissue. I also find it advantageous that the product does not migrate within the tissue, which means that the product positioning can be well controlled.
For volume substitutions and reshaping of the periorbital region, I recommend the use of highly cross-linked HA fillers such as Princess Volume. I usually inject into the periosteal plane, using a retrograde linear threading technique. It is possible to use both blunt-tip cannulae and sharp needles. I prefer blunt tip cannulae (sizes 25 G and 27 G) as the number of percutaneous insertions can be reduced significantly compared with sharp needles. It has been proven that injections with blunt-tip cannulae minimise swelling, bruising and pain. Nerve blocks are typically not needed in that area and would obscure the deformity. Approximately 15–20 minutes before the injection, a topical anaesthetic cream containing lidocaine can be applied for minimising the patients’ discomfort during the treatment.
A very important consideration with any HA filler is not to overcorrect. For the majority of patients, a 1 ml syringe of Princess Filler or Volume in the periorbital region is sufficient.
For treating the tear trough deformities in Patients 1 and 2, I injected approximately 0.3 ml of Princess Volume on each side. For augmenting and reshaping the eyebrows in Patient 2, I injected 0.25 ml of Princess Volume per side deep to the periosteum, above the orbital rim, using a 27 G blunt-tip cannula. Despite the relatively small amount of dermal filler required, the upper periorbital aesthetics of the two patients could be successfully transformed.
For the rehydration of the skin, improvement in elasticity and treatment of crow’s feet, the use of a non-cross-linked HA product such as Princess Rich is a good choice. The combination of HA and glycerol as in Princess Rich has been proven to increase the hydration of the skin, improve its tone, and act as a rejuvenation booster. For treating crow’s feet successfully, a nappage or multi-puncture technique is advisable. Typically, small papules and reddening will occur after the injections, which is nothing to worry about and completely normal. Within 6–24 hours the skin has usually eased and the aesthetic improvement will be visible.
Periorbital rejuvenation is a frequently demanded cosmetic procedure, for which the use of HA-based fillers is a safe, easy and fast technique with short down-time and few complications.
For optimal results, the following aspects are paramount to bear in mind and respect:
Extensive training and experience, as well as a thorough understanding of the facial anatomy
Correct patient selection
Analysis of patients’ motivation, needs and expectations
Careful analysis and examination of the problem and the facial individuality
Choice of an appropriate dermal filler.