Clinical Review & Education
Special Communication
Nonsurgical Considerations for Addressing Periocular Aesthetics A Conceptual Dimensional Approach Ronald Mancini, MD
T
he periocular region serves to frame the eyes and provides a focal point of facial aesthetics. Periocular aesthetics can be evaluated by 2-dimensional (2-D) (x,y coordinate) frontal plane considerations or by 3-dimensional (3-D) considerations, in which the z coordinate is significantly affected by volume considerations. Millimeter differences between the right and left periocular regions, particularly when viewed in the 2-D frontal plane, can result in significant asymmetry and periocular disharmony. Nonsurgical modalities in the form of fillers and toxins provide the tools for subtle aesthetic modifications in the second and third dimension in a reversible, modifiable manner.
2-D Aesthetics Two-dimensional aesthetics are a particularly important consideration in the periocular region. Asymmetry in the 2-D frontal view plane of the eyebrow, upper eyelid, and lower eyelid positions has a significant impact on periocular aesthetics. Millimeter differences in the 2-D frontal view position of the eyebrows, upper eyelid position in the form of subtle degrees of blepharoptosis or, conversely, retraction quantitated by the margin reflex distance 1 (MRD1), and lower eyelid position in the form of retraction and scleral show affect periocular symmetry and aesthetics. More complex 2-D periocular parameters can have also have an impact on periocular aesthetics. Goldberg et al1 and Papageorgiou et al2 have eloquently described additional parameters in the form of tarsal platform show
(TPS) and brow fat span (BFS), which convey considerable importance to the judged aesthetic quality of the periocular region. All of these parameters are judged in the 2-D plane, although they are significantly affected by 3-D considerations, particularly volume (Figure 1).
3-D Aesthetics Three-dimensional aesthetics add consideration of the z coordinate, or projection, and rely heavily on volume for their impact. Much emphasis has been placed in recent years on 3-D aesthetics and volume in the literature3-5; however, the impact volume has on 2-D aesthetics in the periocular region is perhaps one of its most important features. Volume plays heavily on 2-D frontal plane eyebrow position with regard to the eyebrow fat pad. A deflated eyebrow fat pad can lead to descent of the skin envelope and brow ptosis and conversely a volumized eyebrow fat pad can lift and fill that skin envelope and elevate a ptotic brow.3,6 Goldberg et al1 and Papageorgiou et al2 suggest TPS and BFS are intimately related to, and highly dependent on, supratarsal volume. The lower eyelid and midface are perhaps the regions of the periocular complex most sensitive to 3-D volumetric changes. Lower eyelid retraction, most accurately defined as inferior displacement of the lower eyelid resulting in scleral show without malposition of the eyelid margin, significantly affects periocular aesthetics. Lower eyelid retraction most commonly occurs secondary to postblepharoplasty middle lamellar
Figure 1. Aesthetic Parameters Viewed in the 2-Dimensional Frontal Plane y
D C B A E F
x
z
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A, Margin reflex distance 1 (MRD1): the distance from the central corneal light reflex to the central upper eyelid margin; B, tarsal platform show: the distance from the eyelid margin to the eyelid fold; C, brow fat span: the distance from the eyelid fold to the eyebrow; D, eyebrow position; E, lower eyelid margin position quantitated as scleral show when eyelid retraction is present; and F, orbital rim hollow.
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Figure 2. Nonsurgical Management of the Eyebrow Region A
C
B
D
E
A, Botulinum toxin A injection pattern for a “chemical brow lift.” Chemodenervation of the corrugator-procerus muscle complex can be achieved with on average 5 injections of 5 units per injection of botulinum toxin A and chemodenervation of the lateral orbital orbicularis muscle with on average 2 injections of 2.5 units of botulinum toxin A per injection site. B, An average of 5 injections of 2.5 units per injection of botulinum toxin A can readily allow for brow lowering by weakening the frontalis muscle. C, A 59-year-old woman with
eyebrow asymmetry, relative ptosis on the left, and relative retraction on the right before and after botulinum toxin A injection to relatively lower the right brow and relatively raise the left brow. D, Titrated injection of hyaluronic acid gel filler along the inferior border of the eyebrow fat pad in the suborbicularis oculi plane can volumize the skin envelope and elevate the brow soft tissues. E, A 58-year-old woman before and after injection of 0.5-mL hyaluronic acid gel to the eyebrow fat pad.
scarring7; however, there is also a relative volume collapse in the middle lamellar plane that notably contributes to the retraction.8,9 The development of the periorbital hollows, particularly the orbital rim hollow, in concert with midface volume loss and descent, has an impact on the aesthetics of the eyelid-cheek junction.3 This volume perturbation is most prominent when viewed in the z coordinate and results in the double convexity deformity. Many of these 2-D and 3-D aesthetic parameters of the periocular region have their effects in the millimeter range, making desired surgical outcomes difficult to achieve. Nonsurgical modalities in the form of fillers and toxins provide the tools for subtle aesthetic modifications in the second and third dimension in a reversible, modifiable manner. Hyaluronic acid gel (HAG) fillers are of particular utility in this area because they allow reversibility with hyaluronidase and fine tuning if the desired outcome is not achieved.10-13
pressors (corrugator-procerus muscle complex and the orbicularis oculi muscle). Three-dimensional considerations including eyebrow fat pad position and volume, in addition to affecting the 3-D contour of the eyebrow, also significantly affect the relative 2-D eyebrow position (Figure 2). Two-dimensional eyebrow position can be modified by adjusting the balance between the brow elevators and depressors. Eyebrow elevation can be achieved with weakening of the brow depressors: chemodenervation of the corrugator-procerus muscle complex can be achieved with, on average, 5 injections of 5 units per injection of botulinum toxin A and chemodenervation of the lateral orbital orbicularis muscle with, on average, 2 injections of 2.5 units of botulinum toxin A per injection site (Figure 2A). The net effect is weakening of the brow depressors and 2-D eyebrow elevation. More focal brow elevation can be achieved by focusing on the medial (corrugator-procerus complex) or lateral (orbital orbicularis) depressors. Brow lowering can be achieved by shifting the balance toward the brow depressors by weakening the only elevator of the eyebrow (the frontalis muscle). An average of 5 injections of 2.5 units per injection of botulinum toxin A can readily allow for brow lowering (Figure 2B). Titrating to lower injection concentrations can allow for more subtle depression.
Nonsurgical Management of the Eyebrow Region Resting frontal plane eyebrow position is the result of the dynamic balance between the brow elevators (frontalis muscle) and brow de452
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Figure 3. Nonsurgical Management of the Upper Eyelid Region A
B
C
D
E
F
A, Botulinum toxin A at low doses (an average of 2 injection sites with 2 units per site) injected into the pretarsal orbicularis muscle can subtly raise a relatively ptotic eyelid. B, A 24-year-old woman with left residual upper eyelid ptosis despite 2 prior surgical procedures with improved left upper eyelid ptosis after injection of botulinum toxin A. C, Conversely, a relatively retracted upper eyelid can be lowered with the use of titrated hyaluronic acid gel (HAG) filler. D, A 48-year-old woman with relative left upper eyelid retraction secondary to thyroid eye disease with improved left upper eyelid position after HAG injection. E, Titrated injection of HAG in the lateral and central subbrow region to improve supratarsal volume loss. F, A 67-year-old Asian patient with superior sulcus volume loss and hollowing before and after HAG injection. G, A 38-year-old Asian patient with supratarsal volume loss and development of multiple eyelid folds before and after HAG injection.
G
Three-dimensionality of the eyebrow relies heavily on the volume and position of the eyebrow fat pad and soft tissues. Although recent studies have failed to show that volume loss occurs in the eyebrow fat pad with aging,14 volumizing this area can improve brow projection and give the illusion of a lifted brow by virtue of filling the skin envelope and lifting the 2-D apparent location of the brow soft tissues and cilia. Titrated injection of HAG filler along the inferior border of the eyebrow fat pad in the suborbicularis oculi plane is performed until the desired effect is achieved. Typical doses are 0.4 to 0.6 mL of HAG, although doses required to achieve the desired outcome are individual to each patient (Figure 2D and E).
Nonsurgical Management of the Upper Eyelid Region Resting 2-D frontal plane upper eyelid position is the result of the dynamic balance between the upper eyelid depressors (the orbicujamafacialplasticsurgery.com
laris oculi muscle) and the upper eyelid elevators (levator and Muellers muscle); in addition, 3-D factors including globe shape and position in the orbit contribute to the 2-D upper eyelid position. Tarsal platform show and brow fat span significantly affect 2-D aesthetics; however, they rely heavily on supratarsal volume.1,2 Threedimensional considerations rely primarily on supratarsal volume, which, beside its influence on TPS and BFS, can affect superior sulcus volume and aesthetics (Figure 3). Two-dimensional upper eyelid margin position, quantitated by the MRD1, can be modified by affecting the balance between the upper eyelid depressors and the upper eyelid elevators: botulinum toxin A at low doses (an average of 2 injection sites with 2 units per site) injected into the pretarsal orbicularis muscle can subtly raise a relatively ptotic eyelid by weakening the orbicularis oculi muscle, shifting the balance toward the eyelid elevators (Figure 3A and B). The average lift is approximately 1 mm, although variability can exist. The injection is subcutaneous, as deeper injection raises the risk of inadvertently worsening the ptosis due to levator weakening.11,15 ConJAMA Facial Plastic Surgery November/December 2014 Volume 16, Number 6
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versely a relatively retracted upper eyelid can be lowered with the use of HAG filler as described previously in the literature.10-12 The conjunctiva is anesthetized with topical agents, and the upper eyelid is everted, exposing the conjunctiva superior to the superior border of the tarsus. A single bolus of HAG (0.1-0.2 mL) is placed centrally in the levator aponeurosis plane, with the end point being adequate lowering with improved symmetry (Figure 3C and D). This can typically be achieved with 1 to 2 injections in a single session. There is a dual mechanism hypothesis for the technique’s immediate effect of eyelid lowering. Hyaluronic acid gel acts as an upper eyelid load, or “HAG goldweight,” mechanically weighting the upper eyelid, and second, the HAG filler physically stents and inhibits the action of the levator muscle, thereby limiting its ability to lift the eyelid.11,12 The technique provides the surgeon the capability to dynamically and precisely fine-tune upper eyelid position in cases where these goals may be difficult to achieve with surgery, such as in the multioperated eyelid.10 Three-dimensional supratarsal volume can affect a variety of upper eyelid aesthetic parameters. Upper blepharoplasty provides a powerful means for addressing supratarsal 3-D aesthetics when skin redundancy (dermatochalasis) and fat prolapse (primarily of the medial fat compartment) are present. Hollowing of the superior sulcus and supratarsal volume loss, however, can have an equal or perhaps greater influence on upper eyelid aesthetics. Postsurgical and/or age-related superior sulcus volume loss can be addressed with HAG injection in the central and lateral subbrow regions.3,6 Titrated injection of HAG in the lateral and central subbrow region is performed until the desired effect is achieved. The injection plane is the suborbicularis oculi, with careful avoidance of deeper injection. This injection is more inferior to that described for eyebrow fat pad inflation. Typical doses are 0.4 to 0.6 mL of HAG, although doses required to achieve the desired outcome are individual to each patient (Figure 3E and F). Asian upper eyelids are particularly prone to volume loss in this subbrow, superior sulcus distribution, often resulting in the secondary formation of multiple eyelid creases. Surgery attempting to remove “redundant” tissue fails to address the underlying problem of volume loss and is often unsuccessful. Hyaluronic acid gel filler can be used to restore a natural single or absent crease configuration (R.M., unpublished data, February 2014). Titrated injection of HAG filler in the suborbicularis oculi plane of the superior sulcus and the suborbicularis oculi plane superior to the primary crease in the eyelid can improve the multiple crease configuration (Figure 3G).
Nonsurgical Management of the Lower Eyelid Region and Eyelid-Cheek Junction Resting lower eyelid position in the 2-D frontal plane is the result of a complex relationship between a number of variables. As mentioned, a key contributor to lower eyelid 2-D position relies heavily on the status of the middle lamella, where volume collapse can result in lower eyelid retraction and scleral show.8,9 Additional contributors include the tone of the lower eyelid orbicularis muscle and the horizontal tension of the lateral canthal tendon. The relative globe-to-orbital rim and subrim projection, 454
Nonsurgical Care Addressing Periocular Aesthetics
defined by z coordinate 3-D projection, can result in a negative vector configuration and scleral show when viewed in the 2-D frontal plane.16-19 Additional 3-D considerations include development of the periorbital hollows, particularly the orbital rim hollow, which in concert with midface volume loss and descent have a significant impact on the aesthetics of the eyelid-cheek junction and can result in a “long lower eyelid appearance” and the double convexity deformity.20 Lower eyelid retraction and scleral show can be improved nonsurgically using HAG fillers.9,10 The mechanism of improvement in lower eyelid position is dual in nature: vertical augmentation and stenting the lower eyelid and volumetric expansion the collapsed middle lamellar plane. Hyaluronic acid gel is injected in small aliquots through multiple injection sites across the length of the lower eyelid. A layered approach is used with multiple, fine, threadlike injections (10-20 per eyelid) placed deep to the orbicularis oculi muscle within the middle lamellar plane. The vertical extent of the injections is from the inferior border of the tarsus to the region of the orbital rim. The injections are titrated until the desired degree of lower eyelid elevation is achieved, on average 0.3 to 0.5 mL are used per eyelid depending on the degree of retraction.10 The technique can often afford 1 to 2 mm of lower eyelid elevation (Figure 4A and B). Management of the periorbital hollows, particularly the lower orbital rim hollow, is particularly amenable to nonsurgical modalities.3 In the 2-D frontal plane, volume loss of the orbital rim hollow interrupts the smooth transition from eyelid to cheek. Three-dimensionally, the impact of the development of the orbital rim hollow can be appreciated by its impact in the z coordinate. The development of the double convexity deformity results from the contrast between the relative volume projection of the lower eyelid fat compartments to the volume deficient orbital rim hollow and back to the volume projection of the upper cheek. This results in a “valley between two hills” configuration. Volumizing the orbital rim hollow softens this transition and helps to reestablish a more youthful single convexity configuration.3,20-22 Titrated injection of HAG as thin strands perpendicular to the orbital rim hollow is performed until the desired outcome of softening the orbital rim hollow is achieved. The injection plane is suborbicularis oculi and the injection initiated beyond the fibers of the orbital orbicularis to minimize the chances of bruising by avoiding passing the needle through the highly vascular orbicularis muscle. The quantity injected can vary depending on individual patient anatomy; however, 0.5 to 1 mL per side can often notably improve the orbital rim hollow (Figure 4C and D). Three-dimensional volume loss and midface descent can have a significant impact on the eyelid-check junction aesthetic unit.4,20,23 Three-dimensional volumization of the malar region can improve the 3-D aesthetics of the midface by filling the skin envelope, restoring a more youthful fullness to the upper cheek, result in a more youthful shortened lower eyelid appearance and secondarily soften the nasolabial fold as well. The upper cheek can sometimes require considerable volume to restore youthful fullness. Deep plane injection in the preperiosteal location allows for natural filling and minimizes the concern for contour irregularities. Titrated injection of filler is performed until desired volume is achieved (Figure 4E and F). Volumes of filler are variable in this region and dependent on individual patient anatomy.
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Figure 4. Nonsurgical Management of the Lower Eyelid Region and Eyelid-Cheek Junction A
B
C
D
E
F
A, Lower eyelid retraction addressed with hyaluronic acid gel (HAG) injected in small aliquots through multiple injection sites across the length of the lower eyelid. B, A 67-year-old patient with right greater than left lower eyelid retraction before and after HAG injection to improve the lower eyelid position and lessen scleral show. C and D, Orbital rim hollow in a 44-year-old woman before and after 0.5 mL per side of HAG filler. E, Titrated injection of HAG in the
Discussion The periocular region is the focal point of facial aesthetics. Millimeter increments of change required to achieve periocular symmetry and harmony can often be difficult to achieve surgically, and the sequelae of a surgical complication in this area cannot only entail aesthetic ramifications but visual complications as well. Nonsurgical aesthetic modifications offer a number of advantages compared with traditional surgical approaches. These advantages include the convenience of an in-office procedure with minimal down time; the ability to perform the procedures with local anesthesia; a less invasive alternative for patients who are not dissuaded by the concept of outpatient maintenance procedures; the injections can be repeated in a stepwise manner, jamafacialplasticsurgery.com
malar region can improve the 3-dimensional aesthetics of the entire midface and eyelid cheek junction. F, A 53-year-old woman before and after HAG injection, 1 mL, to the right malar region. Note upper cheek/malar fullness, natural softening of the nasolabial fold, and relative shortening of the lower eyelid appearance.
providing the surgeon with the ability to fine-tune injections to achieve an optimal result; the ability to temporarily adjust eyelid position, allowing for a flexible approach in patients whose underlying problem may be evolving over time such as those in the postoperative period; and avoidance of surgery in patients with multioperated eyelids reducing the risk of worsening their status, particularly in cases where a significant degree of preexisting orbicularis or zygomatic branch weakness is present from prior surgery.10-12 Botulinum toxin A and HAG injections are not without potential complication. Complications after botulinum toxin injection in the periocular area tend to be minimal and when they do occur, transient in nature owing to the physiologic mechanism of botulinum toxin’s affect. The most pertinent, relating specifically to periocular injections as described herein, include injectionJAMA Facial Plastic Surgery November/December 2014 Volume 16, Number 6
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related ecchymosis, inadvertent eyelid or eyebrow ptosis, lower eyelid retraction, diplopia, dry eye, and lagophthalmos.24-26 Hyaluronic acid gel injection is also not without risk, and the body of literature describing complications continues to grow. The majority of complications from periocular injections are minor and include temporary erythema, edema, and ecchymosis at the injection site; contour irregularities; fluid accumulation; and bluish discoloration secondary to light scattering. When the latter occur they can necessitate enzymatic dissolution with hyaluronidase. More severe complications, including cutaneous hypersensitivity reactions,27 vascular occlusions28,29 including branch retinal artery occlusion and vision loss,30 and infections including biofilm-type processes,31 have been described in the literature but are considered rare. The risks of more severe complications, particularly vascular occlusion, can be minimized by familiarizing oneself thoroughly with the anatomy (particu-
9. Goldberg RA, Lee S, Jayasundera T, Tsirbas A, Douglas RS, McCann JD. Treatment of lower eyelid retraction by expansion of the lower eyelid with hyaluronic acid gel. Ophthal Plast Reconstr Surg. 2007;23(5):343-348.
21. Lambros VS. Discussion: quantitative evaluation of volume augmentation in the tear trough with a hyaluronic acid-based filler: a three-dimensional analysis. Plast Reconstr Surg. 2010;125(5):1523-1524.
10. Mancini R. Managing eyelid malpositions with hyaluronic acid gel injections. Int Ophthalmol Clin. 2013;53(3):11-20.
22. Lambros VS. Hyaluronic acid injections for correction of the tear trough deformity. Plast Reconstr Surg. 2007;120(6)(suppl):74S-80S.
11. Mancini R, Khadavi NM, Goldberg RA. Nonsurgical management of upper eyelid margin asymmetry using hyaluronic acid gel filler. Ophthal Plast Reconstr Surg. 2011;27(1):1-3.
23. Rohrich RJ, Pessa JE. The retaining system of the face: histologic evaluation of the septal boundaries of the subcutaneous fat compartments. Plast Reconstr Surg. 2008;121(5):1804-1809.
REFERENCES
12. Mancini R, Taban M, Lowinger A, et al. Use of hyaluronic acid gel in the management of paralytic lagophthalmos: the hyaluronic acid gel “gold weight.” Ophthal Plast Reconstr Surg. 2009;25(1): 23-26.
1. Goldberg RA, Lew H. Cosmetic outcome of posterior approach ptosis surgery (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2011;109:157-167.
13. Taban M, Mancini R, Nakra T, et al. Nonsurgical management of congenital eyelid malpositions using hyaluronic acid gel. Ophthal Plast Reconstr Surg. 2009;25(4):259-263.
24. Kaltreider SA, Kennedy RH, Woog JJ, Bradley EA, Custer PL, Meyer DR; American Academy of Ophthalmology; Ophthalmic Technology Assessment Committee Oculoplastics Panel. Cosmetic oculofacial applications of botulinum toxin: a report by the American Academy of Ophthalmology. Ophthalmology. 2005;112(6):11591167.
2. Papageorgiou KI, Ang M, Chang SH, Kohn J, Martinez S, Goldberg RA. Aesthetic considerations in upper eyelid retraction surgery. Ophthal Plast Reconstr Surg. 2012;28(6):419-423.
14. Papageorgiou KI, Mancini R, Garneau HC, et al. A three-dimensional construct of the aging eyebrow: the illusion of volume loss. Aesthet Surg J. 2012;32(1):46-57.
3. Goldberg RA, Fiaschetti D. Filling the periorbital hollows with hyaluronic acid gel: initial experience with 244 injections. Ophthal Plast Reconstr Surg. 2006;22(5):335-343.
15. McElhinny ER, Reich I, Burt B, et al. Treatment of pseudoptosis secondary to aberrant regeneration of the facial nerve with botulinum toxin type A. Ophthal Plast Reconstr Surg. 2013;29 (3):175-178.
ARTICLE INFORMATION Author Affiliation: Section of Oculoplastic and Orbit Surgery, Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas. Corresponding Author: Ronald Mancini, MD, Section of Oculoplastic and Orbit Surgery, Department of Ophthalmology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390 ([email protected]). Accepted for Publication: May 20, 2014. Published Online: August 21, 2014. doi:10.1001/jamafacial.2014.498. Conflict of Interest Disclosures: None reported.
4. Lambros V. Models of facial aging and implications for treatment. Clin Plast Surg. 2008;35 (3):319-327. 5. Glasgold MJ, Glasgold RA, Lam SM. Volume restoration and facial aesthetics. Facial Plast Surg Clin North Am. 2008;16(4):435-442. 6. Lambros V. Volumizing the brow with hyaluronic acid fillers. Aesthet Surg J. 2009;29(3):174-179. 7. Shorr N, Fallor MK. “Madame Butterfly” procedure: combined cheek and lateral canthal suspension procedure for post-blepharoplasty, “round eye,” and lower eyelid retraction. Ophthal Plast Reconstr Surg. 1985;1(4):229-235. 8. Chang HS, Lee D, Taban M, Douglas RS, Goldberg RA. “En-glove” lysis of lower eyelid retractors with AlloDerm and dermis-fat grafts in lower eyelid retraction surgery. Ophthal Plast Reconstr Surg. 2011;27(2):137-141.
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larly the vascular supply of the region to be injected), avoiding areas with considerably higher risks of complications (eg, the glabellar region) due to unfavorable anatomic vascular distribution, prompt recognition, and ensuring ready availability of hyaluronidase should reversalbeneeded.Additionalmeasuressuchasnitropasteandmassage are controversial because theoretically they may allow further propagation of the material down the vascular tree, potentially affecting the blood supply of more critical structures such as the eye in the case of periocular injections. The arena of periocular aesthetics plays out in the second and third dimension with little room for error, where millimeter differences can differentiate success from failure. Nonsurgical modalities in the form of HAG reversible fillers and botulinum toxin provide the tools for subtle aesthetic modifications in the second and third dimension in a reversible, modifiable manner.
16. Pessa JE, Desvigne LD, Lambros VS, Nimerick J, Sugunan B, Zadoo VP. Changes in ocular globe-to-orbital rim position with age: implications for aesthetic blepharoplasty of the lower eyelids. Aesthetic Plast Surg. 1999;23(5):337-342. 17. Yaremchuk MJ. Improving periorbital appearance in the “morphologically prone.” Plast Reconstr Surg. 2004;114(4):980-987. 18. Goldstein SA, Goldstein SM. Anatomic and aesthetic considerations in midfacial rejuvenation. Facial Plast Surg. 2006;22(2):105-111. 19. Jelks GW, Jelks EB. Preoperative evaluation of the blepharoplasty patient: bypassing the pitfalls. Clin Plast Surg. 1993;20(2):213-224. 20. Goldberg RA, Edelstein C, Balch K, Shorr N. Fat repositioning in lower eyelid blepharoplasty. Semin Ophthalmol. 1998;13(3):103-106.
25. Coté TR, Mohan AK, Polder JA, Walton MK, Braun MM. Botulinum toxin type A injections: adverse events reported to the US Food and Drug Administration in therapeutic and cosmetic cases. J Am Acad Dermatol. 2005;53(3):407-415. 26. Levy LL, Emer JJ. Complications of minimally invasive cosmetic procedures: prevention and management. J Cutan Aesthet Surg. 2012;5(2):121132. 27. Lupton JR, Alster TS. Cutaneous hypersensitivity reaction to injectable hyaluronic acid gel. Dermatol Surg. 2000;26(2):135-137. 28. DeLorenzi C. Complications of injectable fillers, part 2: vascular complications. Aesthet Surg J. 2014; 34(4):584-600. 29. Schanz S, Schippert W, Ulmer A, Rassner G, Fierlbeck G. Arterial embolization caused by injection of hyaluronic acid (Restylane). Br J Dermatol. 2002;146(5):928-929. 30. Peter S, Mennel S. Retinal branch artery occlusion following injection of hyaluronic acid (Restylane). Clin Experiment Ophthalmol. 2006;34 (4):363-364. 31. Narins RS, Jewell M, Rubin M, Cohen J, Strobos J. Clinical conference: management of rare events following dermal fillers—focal necrosis and angry red bumps. Dermatol Surg. 2006;32(3):426-434.
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Special Communication
Nonsurgical Considerations for Addressing Periocular Aesthetics A Conceptual Dimensional Approach Ronald Mancini, MD
T
he periocular region serves to frame the eyes and provides a focal point of facial aesthetics. Periocular aesthetics can be evaluated by 2-dimensional (2-D) (x,y coordinate) frontal plane considerations or by 3-dimensional (3-D) considerations, in which the z coordinate is significantly affected by volume considerations. Millimeter differences between the right and left periocular regions, particularly when viewed in the 2-D frontal plane, can result in significant asymmetry and periocular disharmony. Nonsurgical modalities in the form of fillers and toxins provide the tools for subtle aesthetic modifications in the second and third dimension in a reversible, modifiable manner.
2-D Aesthetics Two-dimensional aesthetics are a particularly important consideration in the periocular region. Asymmetry in the 2-D frontal view plane of the eyebrow, upper eyelid, and lower eyelid positions has a significant impact on periocular aesthetics. Millimeter differences in the 2-D frontal view position of the eyebrows, upper eyelid position in the form of subtle degrees of blepharoptosis or, conversely, retraction quantitated by the margin reflex distance 1 (MRD1), and lower eyelid position in the form of retraction and scleral show affect periocular symmetry and aesthetics. More complex 2-D periocular parameters can have also have an impact on periocular aesthetics. Goldberg et al1 and Papageorgiou et al2 have eloquently described additional parameters in the form of tarsal platform show
(TPS) and brow fat span (BFS), which convey considerable importance to the judged aesthetic quality of the periocular region. All of these parameters are judged in the 2-D plane, although they are significantly affected by 3-D considerations, particularly volume (Figure 1).
3-D Aesthetics Three-dimensional aesthetics add consideration of the z coordinate, or projection, and rely heavily on volume for their impact. Much emphasis has been placed in recent years on 3-D aesthetics and volume in the literature3-5; however, the impact volume has on 2-D aesthetics in the periocular region is perhaps one of its most important features. Volume plays heavily on 2-D frontal plane eyebrow position with regard to the eyebrow fat pad. A deflated eyebrow fat pad can lead to descent of the skin envelope and brow ptosis and conversely a volumized eyebrow fat pad can lift and fill that skin envelope and elevate a ptotic brow.3,6 Goldberg et al1 and Papageorgiou et al2 suggest TPS and BFS are intimately related to, and highly dependent on, supratarsal volume. The lower eyelid and midface are perhaps the regions of the periocular complex most sensitive to 3-D volumetric changes. Lower eyelid retraction, most accurately defined as inferior displacement of the lower eyelid resulting in scleral show without malposition of the eyelid margin, significantly affects periocular aesthetics. Lower eyelid retraction most commonly occurs secondary to postblepharoplasty middle lamellar
Figure 1. Aesthetic Parameters Viewed in the 2-Dimensional Frontal Plane y
D C B A E F
x
z
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A, Margin reflex distance 1 (MRD1): the distance from the central corneal light reflex to the central upper eyelid margin; B, tarsal platform show: the distance from the eyelid margin to the eyelid fold; C, brow fat span: the distance from the eyelid fold to the eyebrow; D, eyebrow position; E, lower eyelid margin position quantitated as scleral show when eyelid retraction is present; and F, orbital rim hollow.
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Figure 2. Nonsurgical Management of the Eyebrow Region A
C
B
D
E
A, Botulinum toxin A injection pattern for a “chemical brow lift.” Chemodenervation of the corrugator-procerus muscle complex can be achieved with on average 5 injections of 5 units per injection of botulinum toxin A and chemodenervation of the lateral orbital orbicularis muscle with on average 2 injections of 2.5 units of botulinum toxin A per injection site. B, An average of 5 injections of 2.5 units per injection of botulinum toxin A can readily allow for brow lowering by weakening the frontalis muscle. C, A 59-year-old woman with
eyebrow asymmetry, relative ptosis on the left, and relative retraction on the right before and after botulinum toxin A injection to relatively lower the right brow and relatively raise the left brow. D, Titrated injection of hyaluronic acid gel filler along the inferior border of the eyebrow fat pad in the suborbicularis oculi plane can volumize the skin envelope and elevate the brow soft tissues. E, A 58-year-old woman before and after injection of 0.5-mL hyaluronic acid gel to the eyebrow fat pad.
scarring7; however, there is also a relative volume collapse in the middle lamellar plane that notably contributes to the retraction.8,9 The development of the periorbital hollows, particularly the orbital rim hollow, in concert with midface volume loss and descent, has an impact on the aesthetics of the eyelid-cheek junction.3 This volume perturbation is most prominent when viewed in the z coordinate and results in the double convexity deformity. Many of these 2-D and 3-D aesthetic parameters of the periocular region have their effects in the millimeter range, making desired surgical outcomes difficult to achieve. Nonsurgical modalities in the form of fillers and toxins provide the tools for subtle aesthetic modifications in the second and third dimension in a reversible, modifiable manner. Hyaluronic acid gel (HAG) fillers are of particular utility in this area because they allow reversibility with hyaluronidase and fine tuning if the desired outcome is not achieved.10-13
pressors (corrugator-procerus muscle complex and the orbicularis oculi muscle). Three-dimensional considerations including eyebrow fat pad position and volume, in addition to affecting the 3-D contour of the eyebrow, also significantly affect the relative 2-D eyebrow position (Figure 2). Two-dimensional eyebrow position can be modified by adjusting the balance between the brow elevators and depressors. Eyebrow elevation can be achieved with weakening of the brow depressors: chemodenervation of the corrugator-procerus muscle complex can be achieved with, on average, 5 injections of 5 units per injection of botulinum toxin A and chemodenervation of the lateral orbital orbicularis muscle with, on average, 2 injections of 2.5 units of botulinum toxin A per injection site (Figure 2A). The net effect is weakening of the brow depressors and 2-D eyebrow elevation. More focal brow elevation can be achieved by focusing on the medial (corrugator-procerus complex) or lateral (orbital orbicularis) depressors. Brow lowering can be achieved by shifting the balance toward the brow depressors by weakening the only elevator of the eyebrow (the frontalis muscle). An average of 5 injections of 2.5 units per injection of botulinum toxin A can readily allow for brow lowering (Figure 2B). Titrating to lower injection concentrations can allow for more subtle depression.
Nonsurgical Management of the Eyebrow Region Resting frontal plane eyebrow position is the result of the dynamic balance between the brow elevators (frontalis muscle) and brow de452
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Figure 3. Nonsurgical Management of the Upper Eyelid Region A
B
C
D
E
F
A, Botulinum toxin A at low doses (an average of 2 injection sites with 2 units per site) injected into the pretarsal orbicularis muscle can subtly raise a relatively ptotic eyelid. B, A 24-year-old woman with left residual upper eyelid ptosis despite 2 prior surgical procedures with improved left upper eyelid ptosis after injection of botulinum toxin A. C, Conversely, a relatively retracted upper eyelid can be lowered with the use of titrated hyaluronic acid gel (HAG) filler. D, A 48-year-old woman with relative left upper eyelid retraction secondary to thyroid eye disease with improved left upper eyelid position after HAG injection. E, Titrated injection of HAG in the lateral and central subbrow region to improve supratarsal volume loss. F, A 67-year-old Asian patient with superior sulcus volume loss and hollowing before and after HAG injection. G, A 38-year-old Asian patient with supratarsal volume loss and development of multiple eyelid folds before and after HAG injection.
G
Three-dimensionality of the eyebrow relies heavily on the volume and position of the eyebrow fat pad and soft tissues. Although recent studies have failed to show that volume loss occurs in the eyebrow fat pad with aging,14 volumizing this area can improve brow projection and give the illusion of a lifted brow by virtue of filling the skin envelope and lifting the 2-D apparent location of the brow soft tissues and cilia. Titrated injection of HAG filler along the inferior border of the eyebrow fat pad in the suborbicularis oculi plane is performed until the desired effect is achieved. Typical doses are 0.4 to 0.6 mL of HAG, although doses required to achieve the desired outcome are individual to each patient (Figure 2D and E).
Nonsurgical Management of the Upper Eyelid Region Resting 2-D frontal plane upper eyelid position is the result of the dynamic balance between the upper eyelid depressors (the orbicujamafacialplasticsurgery.com
laris oculi muscle) and the upper eyelid elevators (levator and Muellers muscle); in addition, 3-D factors including globe shape and position in the orbit contribute to the 2-D upper eyelid position. Tarsal platform show and brow fat span significantly affect 2-D aesthetics; however, they rely heavily on supratarsal volume.1,2 Threedimensional considerations rely primarily on supratarsal volume, which, beside its influence on TPS and BFS, can affect superior sulcus volume and aesthetics (Figure 3). Two-dimensional upper eyelid margin position, quantitated by the MRD1, can be modified by affecting the balance between the upper eyelid depressors and the upper eyelid elevators: botulinum toxin A at low doses (an average of 2 injection sites with 2 units per site) injected into the pretarsal orbicularis muscle can subtly raise a relatively ptotic eyelid by weakening the orbicularis oculi muscle, shifting the balance toward the eyelid elevators (Figure 3A and B). The average lift is approximately 1 mm, although variability can exist. The injection is subcutaneous, as deeper injection raises the risk of inadvertently worsening the ptosis due to levator weakening.11,15 ConJAMA Facial Plastic Surgery November/December 2014 Volume 16, Number 6
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versely a relatively retracted upper eyelid can be lowered with the use of HAG filler as described previously in the literature.10-12 The conjunctiva is anesthetized with topical agents, and the upper eyelid is everted, exposing the conjunctiva superior to the superior border of the tarsus. A single bolus of HAG (0.1-0.2 mL) is placed centrally in the levator aponeurosis plane, with the end point being adequate lowering with improved symmetry (Figure 3C and D). This can typically be achieved with 1 to 2 injections in a single session. There is a dual mechanism hypothesis for the technique’s immediate effect of eyelid lowering. Hyaluronic acid gel acts as an upper eyelid load, or “HAG goldweight,” mechanically weighting the upper eyelid, and second, the HAG filler physically stents and inhibits the action of the levator muscle, thereby limiting its ability to lift the eyelid.11,12 The technique provides the surgeon the capability to dynamically and precisely fine-tune upper eyelid position in cases where these goals may be difficult to achieve with surgery, such as in the multioperated eyelid.10 Three-dimensional supratarsal volume can affect a variety of upper eyelid aesthetic parameters. Upper blepharoplasty provides a powerful means for addressing supratarsal 3-D aesthetics when skin redundancy (dermatochalasis) and fat prolapse (primarily of the medial fat compartment) are present. Hollowing of the superior sulcus and supratarsal volume loss, however, can have an equal or perhaps greater influence on upper eyelid aesthetics. Postsurgical and/or age-related superior sulcus volume loss can be addressed with HAG injection in the central and lateral subbrow regions.3,6 Titrated injection of HAG in the lateral and central subbrow region is performed until the desired effect is achieved. The injection plane is the suborbicularis oculi, with careful avoidance of deeper injection. This injection is more inferior to that described for eyebrow fat pad inflation. Typical doses are 0.4 to 0.6 mL of HAG, although doses required to achieve the desired outcome are individual to each patient (Figure 3E and F). Asian upper eyelids are particularly prone to volume loss in this subbrow, superior sulcus distribution, often resulting in the secondary formation of multiple eyelid creases. Surgery attempting to remove “redundant” tissue fails to address the underlying problem of volume loss and is often unsuccessful. Hyaluronic acid gel filler can be used to restore a natural single or absent crease configuration (R.M., unpublished data, February 2014). Titrated injection of HAG filler in the suborbicularis oculi plane of the superior sulcus and the suborbicularis oculi plane superior to the primary crease in the eyelid can improve the multiple crease configuration (Figure 3G).
Nonsurgical Management of the Lower Eyelid Region and Eyelid-Cheek Junction Resting lower eyelid position in the 2-D frontal plane is the result of a complex relationship between a number of variables. As mentioned, a key contributor to lower eyelid 2-D position relies heavily on the status of the middle lamella, where volume collapse can result in lower eyelid retraction and scleral show.8,9 Additional contributors include the tone of the lower eyelid orbicularis muscle and the horizontal tension of the lateral canthal tendon. The relative globe-to-orbital rim and subrim projection, 454
Nonsurgical Care Addressing Periocular Aesthetics
defined by z coordinate 3-D projection, can result in a negative vector configuration and scleral show when viewed in the 2-D frontal plane.16-19 Additional 3-D considerations include development of the periorbital hollows, particularly the orbital rim hollow, which in concert with midface volume loss and descent have a significant impact on the aesthetics of the eyelid-cheek junction and can result in a “long lower eyelid appearance” and the double convexity deformity.20 Lower eyelid retraction and scleral show can be improved nonsurgically using HAG fillers.9,10 The mechanism of improvement in lower eyelid position is dual in nature: vertical augmentation and stenting the lower eyelid and volumetric expansion the collapsed middle lamellar plane. Hyaluronic acid gel is injected in small aliquots through multiple injection sites across the length of the lower eyelid. A layered approach is used with multiple, fine, threadlike injections (10-20 per eyelid) placed deep to the orbicularis oculi muscle within the middle lamellar plane. The vertical extent of the injections is from the inferior border of the tarsus to the region of the orbital rim. The injections are titrated until the desired degree of lower eyelid elevation is achieved, on average 0.3 to 0.5 mL are used per eyelid depending on the degree of retraction.10 The technique can often afford 1 to 2 mm of lower eyelid elevation (Figure 4A and B). Management of the periorbital hollows, particularly the lower orbital rim hollow, is particularly amenable to nonsurgical modalities.3 In the 2-D frontal plane, volume loss of the orbital rim hollow interrupts the smooth transition from eyelid to cheek. Three-dimensionally, the impact of the development of the orbital rim hollow can be appreciated by its impact in the z coordinate. The development of the double convexity deformity results from the contrast between the relative volume projection of the lower eyelid fat compartments to the volume deficient orbital rim hollow and back to the volume projection of the upper cheek. This results in a “valley between two hills” configuration. Volumizing the orbital rim hollow softens this transition and helps to reestablish a more youthful single convexity configuration.3,20-22 Titrated injection of HAG as thin strands perpendicular to the orbital rim hollow is performed until the desired outcome of softening the orbital rim hollow is achieved. The injection plane is suborbicularis oculi and the injection initiated beyond the fibers of the orbital orbicularis to minimize the chances of bruising by avoiding passing the needle through the highly vascular orbicularis muscle. The quantity injected can vary depending on individual patient anatomy; however, 0.5 to 1 mL per side can often notably improve the orbital rim hollow (Figure 4C and D). Three-dimensional volume loss and midface descent can have a significant impact on the eyelid-check junction aesthetic unit.4,20,23 Three-dimensional volumization of the malar region can improve the 3-D aesthetics of the midface by filling the skin envelope, restoring a more youthful fullness to the upper cheek, result in a more youthful shortened lower eyelid appearance and secondarily soften the nasolabial fold as well. The upper cheek can sometimes require considerable volume to restore youthful fullness. Deep plane injection in the preperiosteal location allows for natural filling and minimizes the concern for contour irregularities. Titrated injection of filler is performed until desired volume is achieved (Figure 4E and F). Volumes of filler are variable in this region and dependent on individual patient anatomy.
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Figure 4. Nonsurgical Management of the Lower Eyelid Region and Eyelid-Cheek Junction A
B
C
D
E
F
A, Lower eyelid retraction addressed with hyaluronic acid gel (HAG) injected in small aliquots through multiple injection sites across the length of the lower eyelid. B, A 67-year-old patient with right greater than left lower eyelid retraction before and after HAG injection to improve the lower eyelid position and lessen scleral show. C and D, Orbital rim hollow in a 44-year-old woman before and after 0.5 mL per side of HAG filler. E, Titrated injection of HAG in the
Discussion The periocular region is the focal point of facial aesthetics. Millimeter increments of change required to achieve periocular symmetry and harmony can often be difficult to achieve surgically, and the sequelae of a surgical complication in this area cannot only entail aesthetic ramifications but visual complications as well. Nonsurgical aesthetic modifications offer a number of advantages compared with traditional surgical approaches. These advantages include the convenience of an in-office procedure with minimal down time; the ability to perform the procedures with local anesthesia; a less invasive alternative for patients who are not dissuaded by the concept of outpatient maintenance procedures; the injections can be repeated in a stepwise manner, jamafacialplasticsurgery.com
malar region can improve the 3-dimensional aesthetics of the entire midface and eyelid cheek junction. F, A 53-year-old woman before and after HAG injection, 1 mL, to the right malar region. Note upper cheek/malar fullness, natural softening of the nasolabial fold, and relative shortening of the lower eyelid appearance.
providing the surgeon with the ability to fine-tune injections to achieve an optimal result; the ability to temporarily adjust eyelid position, allowing for a flexible approach in patients whose underlying problem may be evolving over time such as those in the postoperative period; and avoidance of surgery in patients with multioperated eyelids reducing the risk of worsening their status, particularly in cases where a significant degree of preexisting orbicularis or zygomatic branch weakness is present from prior surgery.10-12 Botulinum toxin A and HAG injections are not without potential complication. Complications after botulinum toxin injection in the periocular area tend to be minimal and when they do occur, transient in nature owing to the physiologic mechanism of botulinum toxin’s affect. The most pertinent, relating specifically to periocular injections as described herein, include injectionJAMA Facial Plastic Surgery November/December 2014 Volume 16, Number 6
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related ecchymosis, inadvertent eyelid or eyebrow ptosis, lower eyelid retraction, diplopia, dry eye, and lagophthalmos.24-26 Hyaluronic acid gel injection is also not without risk, and the body of literature describing complications continues to grow. The majority of complications from periocular injections are minor and include temporary erythema, edema, and ecchymosis at the injection site; contour irregularities; fluid accumulation; and bluish discoloration secondary to light scattering. When the latter occur they can necessitate enzymatic dissolution with hyaluronidase. More severe complications, including cutaneous hypersensitivity reactions,27 vascular occlusions28,29 including branch retinal artery occlusion and vision loss,30 and infections including biofilm-type processes,31 have been described in the literature but are considered rare. The risks of more severe complications, particularly vascular occlusion, can be minimized by familiarizing oneself thoroughly with the anatomy (particu-
9. Goldberg RA, Lee S, Jayasundera T, Tsirbas A, Douglas RS, McCann JD. Treatment of lower eyelid retraction by expansion of the lower eyelid with hyaluronic acid gel. Ophthal Plast Reconstr Surg. 2007;23(5):343-348.
21. Lambros VS. Discussion: quantitative evaluation of volume augmentation in the tear trough with a hyaluronic acid-based filler: a three-dimensional analysis. Plast Reconstr Surg. 2010;125(5):1523-1524.
10. Mancini R. Managing eyelid malpositions with hyaluronic acid gel injections. Int Ophthalmol Clin. 2013;53(3):11-20.
22. Lambros VS. Hyaluronic acid injections for correction of the tear trough deformity. Plast Reconstr Surg. 2007;120(6)(suppl):74S-80S.
11. Mancini R, Khadavi NM, Goldberg RA. Nonsurgical management of upper eyelid margin asymmetry using hyaluronic acid gel filler. Ophthal Plast Reconstr Surg. 2011;27(1):1-3.
23. Rohrich RJ, Pessa JE. The retaining system of the face: histologic evaluation of the septal boundaries of the subcutaneous fat compartments. Plast Reconstr Surg. 2008;121(5):1804-1809.
REFERENCES
12. Mancini R, Taban M, Lowinger A, et al. Use of hyaluronic acid gel in the management of paralytic lagophthalmos: the hyaluronic acid gel “gold weight.” Ophthal Plast Reconstr Surg. 2009;25(1): 23-26.
1. Goldberg RA, Lew H. Cosmetic outcome of posterior approach ptosis surgery (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2011;109:157-167.
13. Taban M, Mancini R, Nakra T, et al. Nonsurgical management of congenital eyelid malpositions using hyaluronic acid gel. Ophthal Plast Reconstr Surg. 2009;25(4):259-263.
24. Kaltreider SA, Kennedy RH, Woog JJ, Bradley EA, Custer PL, Meyer DR; American Academy of Ophthalmology; Ophthalmic Technology Assessment Committee Oculoplastics Panel. Cosmetic oculofacial applications of botulinum toxin: a report by the American Academy of Ophthalmology. Ophthalmology. 2005;112(6):11591167.
2. Papageorgiou KI, Ang M, Chang SH, Kohn J, Martinez S, Goldberg RA. Aesthetic considerations in upper eyelid retraction surgery. Ophthal Plast Reconstr Surg. 2012;28(6):419-423.
14. Papageorgiou KI, Mancini R, Garneau HC, et al. A three-dimensional construct of the aging eyebrow: the illusion of volume loss. Aesthet Surg J. 2012;32(1):46-57.
3. Goldberg RA, Fiaschetti D. Filling the periorbital hollows with hyaluronic acid gel: initial experience with 244 injections. Ophthal Plast Reconstr Surg. 2006;22(5):335-343.
15. McElhinny ER, Reich I, Burt B, et al. Treatment of pseudoptosis secondary to aberrant regeneration of the facial nerve with botulinum toxin type A. Ophthal Plast Reconstr Surg. 2013;29 (3):175-178.
ARTICLE INFORMATION Author Affiliation: Section of Oculoplastic and Orbit Surgery, Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas. Corresponding Author: Ronald Mancini, MD, Section of Oculoplastic and Orbit Surgery, Department of Ophthalmology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390 ([email protected]). Accepted for Publication: May 20, 2014. Published Online: August 21, 2014. doi:10.1001/jamafacial.2014.498. Conflict of Interest Disclosures: None reported.
4. Lambros V. Models of facial aging and implications for treatment. Clin Plast Surg. 2008;35 (3):319-327. 5. Glasgold MJ, Glasgold RA, Lam SM. Volume restoration and facial aesthetics. Facial Plast Surg Clin North Am. 2008;16(4):435-442. 6. Lambros V. Volumizing the brow with hyaluronic acid fillers. Aesthet Surg J. 2009;29(3):174-179. 7. Shorr N, Fallor MK. “Madame Butterfly” procedure: combined cheek and lateral canthal suspension procedure for post-blepharoplasty, “round eye,” and lower eyelid retraction. Ophthal Plast Reconstr Surg. 1985;1(4):229-235. 8. Chang HS, Lee D, Taban M, Douglas RS, Goldberg RA. “En-glove” lysis of lower eyelid retractors with AlloDerm and dermis-fat grafts in lower eyelid retraction surgery. Ophthal Plast Reconstr Surg. 2011;27(2):137-141.
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larly the vascular supply of the region to be injected), avoiding areas with considerably higher risks of complications (eg, the glabellar region) due to unfavorable anatomic vascular distribution, prompt recognition, and ensuring ready availability of hyaluronidase should reversalbeneeded.Additionalmeasuressuchasnitropasteandmassage are controversial because theoretically they may allow further propagation of the material down the vascular tree, potentially affecting the blood supply of more critical structures such as the eye in the case of periocular injections. The arena of periocular aesthetics plays out in the second and third dimension with little room for error, where millimeter differences can differentiate success from failure. Nonsurgical modalities in the form of HAG reversible fillers and botulinum toxin provide the tools for subtle aesthetic modifications in the second and third dimension in a reversible, modifiable manner.
16. Pessa JE, Desvigne LD, Lambros VS, Nimerick J, Sugunan B, Zadoo VP. Changes in ocular globe-to-orbital rim position with age: implications for aesthetic blepharoplasty of the lower eyelids. Aesthetic Plast Surg. 1999;23(5):337-342. 17. Yaremchuk MJ. Improving periorbital appearance in the “morphologically prone.” Plast Reconstr Surg. 2004;114(4):980-987. 18. Goldstein SA, Goldstein SM. Anatomic and aesthetic considerations in midfacial rejuvenation. Facial Plast Surg. 2006;22(2):105-111. 19. Jelks GW, Jelks EB. Preoperative evaluation of the blepharoplasty patient: bypassing the pitfalls. Clin Plast Surg. 1993;20(2):213-224. 20. Goldberg RA, Edelstein C, Balch K, Shorr N. Fat repositioning in lower eyelid blepharoplasty. Semin Ophthalmol. 1998;13(3):103-106.
25. Coté TR, Mohan AK, Polder JA, Walton MK, Braun MM. Botulinum toxin type A injections: adverse events reported to the US Food and Drug Administration in therapeutic and cosmetic cases. J Am Acad Dermatol. 2005;53(3):407-415. 26. Levy LL, Emer JJ. Complications of minimally invasive cosmetic procedures: prevention and management. J Cutan Aesthet Surg. 2012;5(2):121132. 27. Lupton JR, Alster TS. Cutaneous hypersensitivity reaction to injectable hyaluronic acid gel. Dermatol Surg. 2000;26(2):135-137. 28. DeLorenzi C. Complications of injectable fillers, part 2: vascular complications. Aesthet Surg J. 2014; 34(4):584-600. 29. Schanz S, Schippert W, Ulmer A, Rassner G, Fierlbeck G. Arterial embolization caused by injection of hyaluronic acid (Restylane). Br J Dermatol. 2002;146(5):928-929. 30. Peter S, Mennel S. Retinal branch artery occlusion following injection of hyaluronic acid (Restylane). Clin Experiment Ophthalmol. 2006;34 (4):363-364. 31. Narins RS, Jewell M, Rubin M, Cohen J, Strobos J. Clinical conference: management of rare events following dermal fillers—focal necrosis and angry red bumps. Dermatol Surg. 2006;32(3):426-434.
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