The periorbital area is a vital facial feature with psychological, functional and aesthetic significance. This area has always been a focus for rejuvenation by physicians and surgeons involved in practising plastic surgery, dermatology and aesthetic medicine. A number of important aspects have to be taken into consideration to ensure successful rejuvenation of this area. The timeworn rationale of merely treating wrinkles or filling folds will certainly not complement a naturally and aesthetically pleasing result. An artistic, anatomically expert, and functionally considerate approach will be more ideal to ensure maximum patient and physician satisfaction.

The periorbital area is a core feature on the human face, an area by which people are recognised, emotion portrayed, and character displayed and predicted by others. Changing or enhancing this area can further complement the person, or it could be unfavourable to their appearance and character. Therefore, when considering a treatment plan to successfully enhance the periorbital area, there are a number of vital facets that the aesthetic practitioner should take into consideration.

It is imperative to understand and respect true natural beauty that is also age-appropriate. Secondly, a full understanding of the anatomy of the periorbital area, eyelid and the mid-face is essential, as well as a strong grasp of the pathology involved in the ageing of the periorbital area. Finally, and perhaps most importantly, the aesthetic practitioner must understand his/her patients, their needs, and their preferences.

Anatomy and ageing pathology of the periorbital and mid-facial areas

The anatomical and pathological qualities of the periorbital area clearly define the treatment protocols needed to enhance this region. The delicate and unique anatomy should be perfectly understood in order to comprehend the pathology of ageing. The mid-face should also be considered when evaluating the periorbital area, as it will contribute to the ageing pathology and undesirable appearance of the periorbital region.

The important structures to understand in this region include the skin, subcutaneous structures, fat pads, muscles, the venolymphatic and nervous structures, and the skeletal aspects.

The skin around the eyes is delicate and thin; therefore, it is inclined to ageing. The ageing changes evident in this region include loose skin, fine wrinkles, loss of elasticity and hyperpigmentation. These changes cause an unattractive appearance in the upper and/or lower eyelid regions.

Loose skin on the upper eyelid results in either a hooding or crepe paper (i.e. fragile, wrinkled) appearance of this orbital region. The lower eyelid region is more prone to hyperpigmentation, but also suffers from loose skin, fine wrinkles and thinning of subcutaneous fat, and the dermis reveals the dark hue of the muscular and vascular aspects beneath.

Just below the skin and just above the orbicularis oculi muscle, lies the superficial subcutaneous fat pad. This thin layer of fat disguises the dark vascular appearance of muscle; therefore, atrophy of this fat would contribute to the aforementioned hue of dark skin around the eye.


Figure 1 Lateral cross sectional illustration of periorbital area

The muscles involved in the periorbital area include the orbicularis oculi muscle, which has both a palpebral and orbital part. It is a very thin muscle with a dark red (vascular) colour. The orbital part also contributes to lifting the superficial malar and cheek fat pads. The orbicularis oculi muscle is a concentric muscle with a sphincteric action to close the eye. The other muscles surrounding the periorbital region have an impact with vectors pulling on the area. These include the corrugator muscles, which have a medial and inferior pulling action on the skin of the upper eyelid, and also on the eyebrows. The frontalis muscle is the only elevator of the upper face and has a superior lifting on the upper eyelid skin.

The lifting action of the frontalis muscle is used more often in a person with excess upper eyelid skin. This muscle should therefore be spared from muscle relaxing injections in these patients, as the mimetic action of the frontalis is crucial to lift this excess skin.

The fat pads in the periorbital and surrounding regions are very important in maintaining a youthful and aesthetically pleasing appearance. Unfortunately, these fat pads atrophy quite rapidly with age. The fat pads that should be clearly identified by doctors wanting to enhance the periorbital region include, inferiorly, the superficial fat above the orbicularis oculi muscles, the superficial cheek fat, infraorbital fat pads, the suborbicularis oculi fat (SOOF), the malar fat pad, and superiorly, the preaponeurotic and nasal fat pads.

The fat pads not only atrophy with ageing, but also move inferiorly with gravitation, and the muscles and septae keeping them in place thin and stretch, resulting in an inferior and anterior descent and projection of the orbital fat pads. It is vital to understand the pathology with regard to ageing around the eyes in order to successfully rejuvenate and enhance this region.

The orbital septum becomes lax and the infraorbital fat pad moves anteriorly and inferiorly, resulting in ‘bags’ under the eyes. At the same time, the malar fat pad atrophies and descends, exacerbating the tear trough (lid–cheek junction) and the nasojugal groove. The decline of periorbital fat results in hollowness above and below the eye, as well as sagging skin over the lost volumes and unnatural shadows.