Cosmetic Ideas and Innovations Nonsurgical Lower

Cosmetic Ideas
and Innovations
Nonsurgical Lower Eyelid Lift
Lisa E. Airan, M.D., and Trevor M. Born, M.D.
New York, N.Y.; and Toronto, Ontario, Canada
placing the filler at the deepest level of the
hollow, the filler is covered by the periosteum,
sub– orbicularis oculi fat, orbicularis oculi muscle, and skin. This multilayer covering conceals
the product, allows for ease of manipulation if
there are irregularities detected, and allows
placement of the material in a large bolus confined to a small area. The large bolus of hyaluronic acid undergoes slow degradation and is
placed at a level where the tissue is immobile
and will therefore last longer. When filler is
placed superficially, it is more readily palpable
and visible, particularly when the patient is
smiling, and can result in the appearance of a
bluish tint to the skin.
Treatment of inherited or age-related hollowing of the lower eyelid has been previously
described with autologous fat but not with injectable hyaluronic acid. We describe a novel
method for improving the appearance of a
hollow periorbital region by injecting hyaluronic acid along the inferior orbital rim and
malar bone.
The soft tissues of the periorbital region
including the lower and upper eyelids, nasojugal groove, and supraorbital rim may lack
volume as an inherited trait or lose volume
with age.1 This gives rise to a hollow area
below the lower eyelid and a tired appearance. This hollow produces a shadow, particularly in vertical light, that is difficult to conceal with makeup. The “natural” dark color
of the skin on the medial aspect of the nasojugal groove and the periorbital hollow
causes patients to appear tired even when
they are well rested. The approach to rejuvenation of the periorbital area continues to
evolve from strictly surgical procedures to
the practice of new techniques that are safer
and allow for greater aesthetic control. The
hollow may be corrected on a permanent
basis with microfat grafting and/or lower
eyelid surgery or temporarily with an injectable hyaluronic acid. The correction is performed in the office under local anesthesia,
with minimal downtime and discomfort. The
correction lasts 5 to 8 months and in some
cases up to 1 year and includes minimal complications.
The principle is to fill the deepest part of the
infraorbital hollow or nasojugal groove, which
extends to the lateral inferior orbital rim. By
MATERIALS
AND
METHODS
The most important aspect of this treatment
is to adequately mark the patient in a seated
position before infiltration of anesthetic. Using
a semipermanent marker, the depth of the
hollow should be marked first. Then, the perimeter of the region to be filled is marked
(Fig. 1).
To preserve anatomy and avoid distortion of
the soft-tissue covering, a minimal amount of
anesthetic is infiltrated into the periosteum.
After infiltration with local anesthetic, the tissues are compressed to eliminate distortion
(Fig. 2). To achieve maximum vasoconstriction
and limit treatment ecchymosis, hyaluronic
acid should be injected at least 20 minutes
after infiltration of the anesthetic.
For this procedure, only the nonanimal stabilized hyaluronic acid products (Restylane
and Perlane; Medicis Pharmaceutical Corp.,
Scottsdale, Ariz.) have been used.2 The tech-
Received for publication October 4, 2004; revised April 19, 2005.
The authors are consultants to Medicis Pharmaceutical Corp., Scottsdale, Arizona.
DOI: 10.1097/01.prs.0000185624.54613.31
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PLASTIC AND RECONSTRUCTIVE SURGERY,
FIG. 1. (1) The deepest part of the hollow is corrected
first. (2) The surrounding hollow is then corrected and the
malar projection is enhanced.
nique for injection is started at the lateral orbital rim hollow. The needle is placed through
the skin down to the bone surface with the
bevel down. A small amount of hyaluronic acid
is injected while it is palpated with the index
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finger of the other hand. The needle is then
marched along the bone, focusing on the
depth of the hollow. Small amounts (⬍0.1 ml)
are injected. The filler should be palpated for
location and possible irregularity and may be
assessed by distraction of the soft tissues of the
cheek in a downward direction. The needle is
then advanced along the rim until the entire
region is filled. The most medial aspect of the
nasojugal groove is filled by “pushing” the hyaluronic acid with a finger into the area to
avoid puncture of the prominent infratrochlear vessels adjacent to the nasal bone. Care
must be taken near the infraorbital nerve, as
direct injection with either local anesthetic or
filler may cause injury. Small amounts of filler
under low pressure must be placed to avoid
retrograde embolus into a periorbital artery. If
resistance to the flow of filler is detected, the
needle should be removed and repositioned.
The volume required ranges from 0.35 to 1.40
ml of Restylane or Perlane per side. The very
hollow eye, with or without the support of the
malar bone (negative, neutral, or positive vector) can be corrected by using a larger amount
of filler. An initial maximum volume of 1.40 ml
per lower eyelid should be used, and the patient should be evaluated for more filler 2 to 4
weeks after the first treatment. If fat pads are
sizable, removal of a portion of the fat pad
through a transconjunctival approach is recommended followed by the addition of filler to
the lower rim, as described above. The addition of filler can be administered immediately
FIG. 2. After infiltration with local anesthetic, the tissues are compressed
to eliminate distortion.
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NONSURGICAL LOWER EYELID LIFT
FIG. 3. Note the correction on the right eye of the patient with 0.7 cc of
Perlane compared with no correction on the left.
FIG. 4. Preinjection with Perlane. A 48-year-old woman
with marked periorbital hollowing and a “polar bear” anatomy of the cheek and lower eyelid.
FIG. 5. Preinjection. Note the marked periorbital hollowing.
postoperatively or after any length of time after
the surgical intervention. Postinjection treatment includes gentle placement of cool packs
so as not to distort or displace the product.
Patients should minimize strenuous activity for
48 hours after treatment. If patients can tolerate them, oral antihistamines are prescribed
for swelling. Pain medication may be required.
Patients should be informed that they will have
swelling for 72 hours and bruising for up to 2
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weeks. The patient should be assessed for contour irregularity at 1 week. If present, the irregularity can be massaged down or the addition of strategically placed filler should be
administered. Occasional ecchymosis may
cause early distortion; manipulation should be
held off until it resolves.
RESULTS
Excellent contour was achieved in all patients. The improved contour of the lower lid
gives patients the appearance of being better
rested and more youthful by eliminating the
infraorbital hollow and its shadows (Fig. 3).
The lower eyelid appears shorter in the vertical axis. The procedure gives the appearance of having lower eyelid surgery or a
“nonsurgical” eyelid lift. A dramatic difference is seen before (Figs. 4 and 5) and after
(Fig. 6) the procedure. Patients have reported that the look of being tired was completely corrected through the use of this
technique. In addition, the darkened appearance of the lower lid is improved. The average length of correction is 8 months, with
correction in some cases of up to 1 year (Fig.
7). The product is not visible. Repeated injections with Perlane and Restylane improve
FIG. 6. Postinjection. Note the rested appearance.
FIG. 7. Postinjection image at 6 months with 1.4 cc of
Perlane per side showing correction of the hollow and increased malar projection.
the longevity of the results. A number of
patient types benefit from this procedure.
Figure 8, left shows a young woman who had
lower blepharoplasty 3 years previously; she
was unhappy with the hollow appearance and
scleral show. Seven months after her second
injection with 0.7 cc of Perlane per side, the
patient remained pleased with the result
(Fig. 8, right). Figure 9, left shows a male
patient with extreme facial hollowing. He has
very thin skin/tissues over the malar region,
and it is technically very difficult to get an
even contour. This patient experienced
bruising for 3 weeks and required follow-up
manipulation to achieve an even contour. At
3 months after injection, the patient remained very pleased with the result (Fig. 9,
right). Figure 10, left shows a 45-year-old
woman with periorbital hollowing following
lower lid blepharoplasty. At 1 month postinjection, the patient was concerned with persisting fold at the area inferior to the tarsal
plate of the lower lid (Fig. 10, above, right).
However, 9 months after injection, the patient was more satisfied but wanted more
filling of the lower lid skin itself to obliterate
this fold (Fig. 10, below, right). She was offered a repeated injection of Perlane or mi-
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NONSURGICAL LOWER EYELID LIFT
FIG. 8. (Left) Two views of a 35-year-old woman before the procedure. (Right) Images obtained
7 months after the procedure during which 0.7 cc of Perlane per side was administered.
crofat grafting to restore the lower eyelid and
malar region volume.
As a caveat, irregularities may be seen in the
first week after injection. These irregularities can
be corrected by light massage within 1 to 2 weeks
of the initial injection. With massage or the addition of strategically placed filler, all irregularities can be corrected. Eyes with a shallow hollow
and taut skin respond best to this procedure. Patients with slack lower eyelid skin, broad flat orbital
rims, and very thin periorbital tissue can provide
more of a challenge for the physician that is not
familiar with this technique. This type of eyelid is
difficult to inject; any irregularity of filler in the
lower eyelid will be seen more easily. Physicians who
are unfamiliar with this procedure should begin
with a younger patient with tighter lower eyelid skin
and a shallow hollow.
In most patients, bruising and swelling are
seen up to 2 weeks after the injections. Ecchymosis can be significant; however, even the more
significant bruising should completely resolve
within a 3-week period. It should be noted that
permanent skin staining has not been observed
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FIG. 9. (Left) Preinjection image of a 54-year-old man with marked facial hollowing. Note the
scleral show and very flat malar region with a “polar bear” appearance. (Right) Postinjection with
2.1 cc of Perlane per side.
with the use of this procedure. Side effects, such
as bruising and swelling, can be lessened by infiltration of the periosteum with local anesthetic
with epinephrine (1:200,000). Patients experience mild discomfort that may be treated with
ibuprofen or acetaminophen. No major complications have been noted. Blindness has been reported when fat is injected in the periorbital
area3,4; however, there have been no cases of
blindness or central nervous system emboli reported by the authors with the use of the presented technique.
DISCUSSION
The appearance of the eye changes with age
because of orbital remodeling.1 Techniques currently available to patients for correction of a
hollow lower lid area include midface lift, microfat grafting, cheek implants, and lower lid blepharoplasty with fat transposition.5– 8 All of these
techniques are invasive and require a prescribed
amount of patient downtime; bruising and swelling can last up to several weeks in the case of
blepharoplasty. Traditionally, patients seeking
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NONSURGICAL LOWER EYELID LIFT
FIG. 10. (Left) Preinjection image of a 45-year-old woman with periorbital hollowing following
lower lid blepharoplasty. (Above, right) One month postinjection with 0.7 cc per side. (Below, right)
Nine months postinjection. Note the volume maintenance.
treatment for a hollow lower lid had few nonsurgical options. Lower lid resurfacing with carbon
dioxide or erbium:yttrium-aluminum-garnet laser has become popular and can improve dark
pigmentation but does not resolve the appearance of the lower lid area completely.9,10
We propose a novel technique with which to
address the concern of patients regarding a
dark recessed lower lid appearance with a single in-office procedure with minimal downtime. This technique has produced highly aesthetic results that rival surgical alternatives.
This method also preserves the lower orbital fat
and prevents the “operated” appearance that
may follow conventional blepharoplasty.11 The
authors have successfully used this technique
in over 400 patients.
CONCLUSIONS
We have presented a novel method that improves the contour of the periorbital area. This
method has been shown to be reproducible in
over 400 patients. The advantages of this tech-
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nique include minimal downtime, ease of procedure, and safety.
Lisa Airan, M.D.
910 Fifth Avenue
New York, N.Y. 10021
[email protected]
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4. Dreizen, N. G., and Framm, L. Sudden unilateral visual
loss after autologous fat injection into the glabellar
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