Treating the Periorbital Region

Miss Rachna Murthy presents her approach to rejuvenation using the Juvéderm range following her presentation at CCR

The eyes are the most important part of the face when it comes to expressed emotion, communication and recognition. Gaze tracking studies from the 60s show that this is the area we focus on when communicating with others.1 Even subtle changes to skin tone or wrinkles in this area can change the look of our entire face and age us prematurely.

Respecting the anatomy With the thinnest skin on the body at less that 1mm thick, the periocular area is often the first facial area to show visible signs of ageing.2 Consequently, there is a high patient demand for periocular rejuvenation. Adding to this is seven muscle groups acting on each side simultaneously with every expression and blink, bone resorption around the orbital rim, collagen loss in the skin, laxity in the ligaments, thinning of the orbital septum, prolapse of fat in various places and hollowing in others.3 Practitioners should be aware, most importantly, of the purpose of the eyelids and periorbita. These serve the most important function of protecting the eyes, and any treatments should consider maintaining the function of the eyelids, the eyes, the eye surface, and the vision as well as improving cosmesis, without risking complications.4 When considering restoration of the ageing changes or rejuvenation/alteration of anatomy, it is important to be aware of the gender differences in normal anatomy, and the changes with ageing as patients should not be treated in the same way. A masculine brow tends to be flatter, while a more feminine brow will tend to be arched and higher above the orbital rim, for example.5 Normal ageing occurs in all layers of the periocular area from the bone up and these considerations are important when deciding upon a treatment approach.6 Prior to any Before After treatment, whether surgical or nonsurgical, an in-depth consultation is essential.7 It’s my approach to cover the treatment details, post-treatment outcomes, and full medical history including any underlying autoimmune conditions that might contribute to periorbital swelling. In my view, examination should include looking at skin 52-year-old patient before and after treatment using 1ml of Juvéderm Voluma into the mid-face and 0.5ml of laxity, muscle function, eyelid laxity, Volbella into the tear trough position of the eyelids (if there is a pre-existing ptosis), positions of hollowing and of fat prolapse (suggestive of a deficient septum), and pre-existing oedema. Your treatments should aim to improve the anatomical integrity of the periorbital area and maintain function as well as improve cosmetic outcome.8 Treating successfully With good patient selection for dermal filler treatment – excluding patients that have preexisting malar oedema and managing expectations in those that would profit more from surgery – there can be improvement in skin hydration, volume loss and integrity.9 The majority of problems occur with the use of the wrong products in the wrong area or excessive volume.10 This area is also extremely vascular, the skin is thin, and there are vessels supplying the vision from the internal carotid as well as anastomoses with branches of the external carotid, that all can risk emboli with intra vascular injection.11 Also disrupting normal anatomy, like the septum, can result in fat prolapse and worsening cosmesis later, as well as intraorbital filler placement.12 Much of tear trough improvement can be achieved by starting with treatment to the midface to improve the lid-cheek junction and support to the eyelid. In my experience, starting treatments laterally over the zygomatic arch, which is part of the lateral line of fixed ligaments, can improve lift and support and reduce the volume required in the medial cheek.13 My personal practice protocol for the cheek is Juvéderm Voluma14 (0.5ml per side laterally and 0.3-0.5ml medially to the deep cheek fat pad and SOOF). For the tear trough, tiny micro-aliquots of Juvéderm Volbella can be placed, aiming to underfill (no more than 0.3ml per side in total).15 Repeat treatment to the tear trough can be performed after three weeks, allowing time for the initial treatment to integrate and review the residual contour abnormality and volume deficiency.

REFERENCES

1. Yarbus, eye movements and vision. I-Perception 2010; 1(1):7-27. 2. Michael A C Kane, Nonsurgical Periorbital and Brow

Rejuvenation, Plast Reconstr Surg. 2015 Jan;135(1):63-71. 3. CL. Shumway; et al. Anatomy, Head and Neck, Eye Extraocular

Muscles. 2021. Statpearls. 4. Christoph Hintschich. Periocular Plastic Surgery. Deutsches

Ärzteblatt International, Dtsch Arztebl Int 2010; 107(9): 141–6. 5. MH. Hohman, et al. Transgender, Surgery of the Head and

Neck. 2021.Statpearls. 6. Kapoor et al (2021). Treating Aging Changes of Facial

Anatomical Layers with Hyaluronic Acid Fillers Clinical, Cosmetic and Investigational, Dermatology 2021:14 1105–1118. 7. Kashkouli et al (2017). Periorbital facial rejuvenation; applied anatomy and pre-operative assessment Journal of Current

Ophthalmology 29 (2017) 154e168. 8. Bruna Souza Felix Bravo et al., Comprehensive Treatment of

Periorbital Region with Hyaluronic Acid, J Clin Aesthet Dermatol. 2015 Jun; 8(6): 30–35. 9. Jonathan Hoenig and Danya Hoenig (2013). Minimally Invasive

Periorbital Rejuvenation. Facial Plast Surg 2013;29:295–309. 10. Eckart Haneke (2015). Managing Complications of Fillers: Rare and Not-So- Rare. Journal Cutan Aesthet Surg. 8(4), pp. 198–210. 11. Jaishree Sharad, ‘Dermal Fillers for the Treatment of Tear Trough

Deformity: A Review of Anatomy, Treatment Techniques, and their Outcomes’, Journal of Cutaneous and Aesthetic Surgery, 2012, V5, I4. 12. Kasra Ziai et al., Periocular rejuvenation using hyaluronic acid fillers, The Role of Hyaluronic Acid in Modern Plastic and

Aesthetic Surgery, Oct 2020. 13. Myomodulation with Injectable Fillers: An Innovative Approach to Addressing Facial Muscle Movement (v1.0). 14. Karina Colossi Furlan, Hyaluronic Acid for Malar Area and

Zygomatic Arch, A. Da Costa (ed.), Minimally Invasive Aesthetic

Procedures, Springer Nature Switzerland AG 2020. 15. Mr Dalvi Humzah & Dr Raj Acquilla, Peri-orbital rejuvenation using HA fillers, pmfa news, 201 5,VOL 2 NO 4.

Miss Rachna Murthy is a consultant oculoplastic and aesthetic surgeon and co-owns FaceRestoration. She is regarded as an authority on aesthetic eyelid surgery, skin cancer and thyroid eye disease and is a consultant to Allergan. Qual: BSc(Hons), MB, BS, FRCOphth

This article is produced and funded by Allergan Aesthetics, an AbbVie Company

For more information go to: www.juvederm.co.uk

UK-JUV-210649 October 2021