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 dangerous intravascular placement. This area can be enhanced with hyaluronic acid fillers to reduce upper eyelid hollowness and enhance brow lifting. Figure 3 illustrates the recommended lines of injection with a cannula to enhance the supraorbital and brow areas.
Infraorbital dermal filler injections
The infraorbital region can be enhanced at a few different points, including the tear trough, lateral cheek and especially by lifting the mid-face that significantly enhances the infraorbital area.
The upper lateral cheek area can appear aged and unattractive owing to the loss of zygomatic projection and wrinkles as a result of hyperactivity of the orbicularis oculi contracting underneath and progressively thinning the skin. The lateral eye wrinkles soften quite easily with botulinum toxin injections over the lateral aspect of the orbicularis oculi muscle; however, some wrinkles often remain over the zygomatic arch as a result of the contraction of the zygomaticus major and minor muscles, which cannot be treated using botulinum toxin. This area can be successfully enhanced with a two-layer approach, by placing a low viscosity hyaluronic acid filler as micro-droplets into the superficial wrinkles, and a high viscosity hyaluronic acid filler over the lateral cheek area. These techniques are illustrated in Figure 4, with the blue circles showing the micro-droplets of the low viscosity hyaluronic acid filler that is injected with a multi-puncture technique into the deep dermis. The white circular line shows the area in which the high viscosity dermal filler is placed in the subcutaneous tissue. This can be performed using either a needle or a cannula, followed by liberal massaging to blend the filler into the tissue. This technique will not only remove lateral smile wrinkles, but also enhance the facial contour to allow the light to fall on the lateral cheek area. This gives a very attractive appearance, especially in female patients.
The tear trough area can be quite challenging to treat. Few patients need only tear trough filling exclusively, while the majority will need enhancement of the malar fat pad area. As discussed, the descent and decline of the malar fat pad betrays the tear trough area. Therefore, if the patient does not have sufficient volume over the medial malar area, then exclusive tear trough treatment will result in increased heaviness and worsened shadows under the eyes.
In younger patients, exclusive tear trough treatment with a medium reticulated hyaluronic acid filler can be injected using either a needle or cannula. Placing the filler with a cannula will reduce the risk of bruising, but will not eliminate this risk. An article by the Carruthers’ recommends the preferred needle technique to be injecting the filler at the base of the tear trough and then manually pushing the filler with a finger into the tear trough area.
The older patient will often require malar enhancement to lift the tear trough by replacing the lost volume. This treatment is performed using either the cannula or needle technique, with a high viscosity filler to replace a rather large volume loss. There are a number of approaches to enhance the malar and cheek areas, which may include placing the filler with three bolus injections in a line 1–2 cm below the inferior orbital rim, or by performing a fanning technique with either a needle or cannula injection.
