Injection plastic surgery of the periorbital area

Philippe Berros , ophthalmic surgeon, MD, Department of Surgical Ophthalmology, Princess Grace Clinic (Monaco)

Yulia Dyachenko, dermatovenerologist, cosmetologist, international trainer of the Q-Med company, scientific director of the Vallex M educational center ( Russia )

Elena Rumyantseva, Candidate of Medical Sciences, dermatovenerologist, cosmetologist, Vallex M ( Russia )

In youth, the look is usually “open”, the eyebrow area protrudes slightly forward, and the fold of the upper eyelid is located at a distance of approximately 8–10 mm from the eyelash edge. With age, factors such as a significant decrease in skin elasticity, atrophy and displacement of subcutaneous fatty tissue, atrophy of the underlying bone structures (with a change in the shape of the bony edge of the orbit), weakening of ligaments lead to the formation of a clinical picture of a “tired” face, one of the main characteristics of which is the presence of a pronounced depression in the form of a palpebromal groove in the infraorbital region.

There has been an increase in the popularity of minimally invasive methods in the correction of furrows under the eyes. According to many experts, both foreign and Russian [1–5], injection plastic surgery of this zone is a safe and effective method.

TOPOGRAPHIC ANATOMY

Aging of the periorbital region is multifactorial in nature and is largely determined by the anatomical features of this area. The skin around the eyes is thin and practically devoid of underlying fatty tissue. The upper edge of the cheek fat pad is separated from the lower edge of the orbit and is interrupted in some area at the level of the midpupillary line. This difference in the thickness of the soft tissues contributes to the formation of the clinical picture of depression in the infraorbital region (tear trough area) (Fig. 1). The orbicularis oculi muscle visible through the skin gives the area under the lower eyelid a bluish tint (so-called dark circles).

The orbicularis oculi muscle ( m. orbicularis oculi ) is a thin concentric sphincter muscle that partially overlaps the area of the cheek and zygomatic bone. The points of its attachment to fixed structures are located in the medial part of the orbit (maxillary process of the frontal bone and frontal process of the maxilla), in addition, the muscle is attached to the ligament of the inner corner of the eye [6].

The orbicularis oculi muscle has two parts: the eyelid region (including the pretarsal and preseptal portions) and the orbital (orbital). The part of the orbicularis muscle related to the eyelid covers the tarsal (cartilaginous) plates. In the area of the corners of the eye, the plates are attached to the medial and lateral canthus. The levator palpebrae superioris muscle is attached to the upper edge of the tarsal plate of the upper eyelid. In the area of attachment of the skin of the upper eyelid to the tarsal plate, when the eye is open, a groove is formed, and with age, a supraorbital fold is formed [7]. The inferior tarsal plate is located on the upper edge of the lower eyelid and is attached to the orbicularis oculi muscle and capsulopalpebral fascia. The tarsal plates, together with the fascia, form the orbital septum (septa), delimiting the contents of the orbit in front, including the intraorbital fatty tissue.

The fibers of the orbicularis oculi muscle intertwine with the fibers of the frontalis muscle and the corrugator muscle, intertwined with the overlying skin. At the border of the preseptal and orbital parts, a system of supporting ligaments is woven into the orbicularis oculi muscle, known under the collective term “orbital ligament” ( orbicularis retaining ligament ), which is attached to the bone 4–6 mm below the lower edge of the orbit and is responsible for the formation of the lacrimal and palpebromalar grooves [7].

The palpebromalar groove and its medial part (tear groove) are located at the junction of the orbital part of the orbicularis oculi muscle and its part related to the eyelid region, and lie above the upper edge of the buccal (malar) fat pad. During dissections, it was established that the lacrimal and palpebromalar grooves are located below the bony edge of the orbit, which confirms the observations of Lambros and Wong that due to the fixation of the ligamentous apparatus with bone structures, the likelihood of downward displacement of the soft tissues of the lower eyelid region is small [2, 8]. The formation and enlargement of these furrows is caused by atrophy of the orbital adipose tissue and atrophic changes in the skin.

Under the orbital portion of the orbicularis oculi muscle there is infraorbital fatty tissue ( suborbicularis oculi fat - SOOF ), which covers the anterior surface of the bones of the lower edge of the orbit - the zygomatic process of the maxillary bone and the lower orbital edge of the zygomatic bone. Due to the protrusion of axillary adipose tissue in the form of sacs, the clinical manifestations of depression in the infraorbital region are aggravated.

The SOOF region (located above the bone and below the muscle) represents the only safe level of filler injection when replenishing depression in the palpebromalar groove area. With intradermal and subcutaneous administration of drugs, it is possible to contour them and form a bumpy skin texture [1, 9]. When using fillers based on stabilized hyaluronic acid, there is a high probability of the appearance of a bluish tint of the skin due to the Tyndall effect, as well as quite persistent swelling associated with the high hydrophilicity of hyaluronic acid and a possible violation of lymphatic drainage.

The dense vascular network surrounding the orbit is represented by the branches of the angular, supra- and infraorbital, supratrochlea, transverse facial arteries and the superficial temporal artery ( aa . angularis , supraorbitalis , supraorbitalis , infraorbitalis , supratrochlearis , transversae faciei , temporalis superficialis ). Venous outflow occurs into the facial vein ( v. facialis ) through the angular vein (v. angularis ), as well as deep into the cerebral part of the skull through the ophthalmic vein system ( v. ophtalmica ). Due to the presence of a developed network of blood vessels that also supply blood to the eyeball and brain, the tear trough area - approximately 1 cm at the medial corner of the eye - is a risky area for any injection intervention (Fig. 2) [7, 10].

Also dangerous zones of the infraorbital region include the exit site of the infraorbital neurovascular bundle ( a., v., n. infraorbitalis ). This point is located on the midpupillary line, 7–10 mm below the edge of the orbit (the point of articulation of the zygomatic process of the maxillary bone and the orbital edge of the zygomatic bone is easily palpated) [7, 10]. The neurovascular bundle is located in a deep cellular space, which makes it possible to avoid its trauma if the puncture point is chosen correctly.

The third dangerous zone is the area of projection of the exit of the zygomaticofacial nerve ( n. zygomaticofacialis ), which is determined 5–7 mm lateral to the lower outer edge of the orbit [7, 10]. This area is also represented by a bony hole, so palpation and a feeling of pain when pressed make it possible to clarify its location.

The fairly dense location of dangerous zones in the infraorbital region is the rationale for the predominant use of a cannula when performing injection plastic surgery. A blunt cannula moves tissue apart and rarely injures blood vessels or nerves - in any case, the risk of such damage is much lower than when using a needle. The location of the dangerous zones must be taken into account when choosing the point of insertion of the cannula, since it is when forming the entrance hole with a needle that there is a risk of damage to blood vessels or nerves.

Age-related involution of various areas of the face at the morphological level is associated with atrophy processes and affects all levels - from the skin to bone tissue. Previously, there was an opinion that it was the hypotrophy of soft tissues that caused the formation of a characteristic clinical picture, including wrinkling of the skin, the appearance and deepening of furrows in the area under the eyes. However, studies in recent years have revealed significant age-related atrophy of the bone structures of the skull in the orbital area, which inevitably entails changes in the underlying soft tissues, including due to displacement of their fixation points [11, 12]. Due to the redistribution of fatty tissue (protrusion of SOOF from the axillary layer to the supramuscular layer [13]), the location of the orbital ligament changes from horizontal to vertical, which is clinically manifested by worsening of the palpebromalar groove.

The anatomical aspects of aging of the infraorbital region that we have considered serve as a rationale for the use of injection plastic surgery as the leading method for correcting developing grooves and provide guidelines for an effective and safe procedure.

SELECTION OF THE “IDEAL” PATIENT

Strict selection of patients based on the presence of not only indications, but also contraindications, as well as possible “aesthetic risks” allows us to predict the success of the procedure for correcting the grooves in the infraorbital region.

The periorbital zone of the face is one of the most dynamic, since it is actively involved in facial expression, in addition, movements of the eyeball are constantly and unconsciously carried out. Under the lower portions of the orbicularis oculi muscle, the muscle that lifts the upper lip ( m . levator labii superioris ) and the muscle that lifts the upper lip and ala nasi ( m. levator labii superioris alaequae nasi ) begin. The muscle symplast in a state of hyperactivity can cause the displacement of the filler and its subsequent visualization with an initially absolutely correct picture. Carrying out a motor test allows you to identify patients at high risk of developing such an adverse event [14]. The test is carried out as follows: the patient is in a sitting position, the head is level, and the gaze is directed straight; Without changing the position of the head, the patient directs his gaze upward, then slowly moves it downward. The movement of the eyeball is accompanied by varying degrees of protrusion of intraorbital fatty tissue, which indicates the condition of the orbital septum. If the clinical picture changes significantly when the eyeball moves up and down, we classify the patient as a risk group, since dynamic displacement of adipose tissue can affect the nearby filler.

Also at risk are patients with significant differences in the condition of the skin of the lower eyelid and cheek area. In such a situation, the first choice procedure is mesotherapy using preparations based on unstabilized hyaluronic acid or a complex composition, as well as injections of preparations based on stabilized hyaluronic acid (for example, Restylane® Vital Light), aimed at strengthening the skin of the lower eyelid. And only at the next stage is groove plastic surgery performed.

Carrying out the procedure for patients with structural features of bone structures in the form of a protruding lower edge of the orbit is a certain difficulty, and the result of correction of the palpebromalar groove often does not bring harmony to the aesthetics of the infraorbital zone.

The risk group includes patients with lower eyelid hernias and a tendency to develop swelling in the eye area. Although I would like to note that with a technically correct procedure and injection of a small volume of filler, post-procedure swelling is minimal.

Before the procedure, full-face and profile photography is required, including when conducting a dynamic test.

CHOICE OF CORRECTION TACTICS

Injection plastic surgery of the infraorbital region is carried out using various drugs: collagen, polylactic acid, calcium hydroxyapatite, autologous fat [15, 16]. However, most experts are inclined to use drugs based on stabilized hyaluronic acid [1, 2, 4, 9]. The undeniable advantages of such fillers include the ability to select a product with the required plasticity and elasticity, as well as its accelerated biodegradation through the introduction of hyaluronidase preparations.

Since 2005, reports on large-scale clinical studies of the use of drugs of the Restylane® family in the periorbital zone began to be published in the literature [1, 16–19]. Goldberg and Faschetti analyzed the experience of 244 injections using Restylane in the area of the palpebromalar sulcus [20]. Almost 90% of patients were satisfied with the result of the correction with a duration of effect of 6–12 months. The drug was administered using a needle, and the study authors noted adverse events in the form of hemorrhage (10%), edema (15%), changes in skin color due to hemosiderin deposition as a result of hemorrhage or the Tyndall effect (7%), and uneven contour skin (11%). Let us clarify that in most cases, adverse events were associated with the needle injections themselves, and not with the drug. Analysis of the study results became the impetus for the development of a safer method for correcting the grooves of the infraorbital region.

Correction of the palpebromalar groove using the Hyalurostructure method

Over the past five years, the technique of correcting the periorbital area with drugs based on stabilized hyaluronic acid has undergone significant changes. The use of a cannula for the injection of fillers in the periorbital zone allowed the procedure to be carried out in a much safer manner, while the number of adverse events was significantly reduced.

In 2010, Philippe Berros (Ph. Berros) published the results of a clinical study of the correction of infraorbital grooves using dense but flexible fillers based on stabilized hyaluronic acid of the NASHA™ family, which were administered using 25 and 28 G cannulas of 4 cm in length [9]. Flexible cannulas with a reinforced base allow you to follow the required trajectory of filler injection as accurately as possible; moreover, the extrusion of a fairly viscous drug from the cannula occurs evenly, which allows you to avoid undesirable consequences in the form of tubercles on the skin. When using a cannula, the risk of introducing the drug into the lumen of the angular artery or vein is significantly reduced.

The study involved 26 patients (21 women and 5 men, aged 36–53 years). Control examinations were scheduled 15 days, 3 and 6 months after the procedure.

Criteria for inclusion in the study: a characteristic clinical picture of depression in the form of a palpebromalar groove in the infraorbital region.

Exclusion criteria, in addition to those generally accepted for injection plastic surgery using preparations based on stabilized hyaluronic acid, included:

• positive result of the dynamic test (see above);
• the presence of pronounced sagging skin of the lower eyelids, dermatochalasis, fatty hernias in the lower eyelid area.

It was mandatory to check the allergy history of the patients (including with regard to anesthetic drugs), as well as the pharmacological one (taking drugs that affect blood clotting sharply increases the likelihood of developing hemorrhages and their consequences in the form of hemosiderin deposition).

During the procedure, patients were in a semi-sitting position. Marking was carried out to indicate both dangerous zones and places of cannula insertion. The cannula insertion point was located 1.5 cm below the temporal edge of the orbit (or 2–2.5 cm below the lateral canthus of the eye) (Fig. 3). Advancement of the cannula over the periosteum, under the orbicularis oculi muscle, in the projection of the palpebromalar groove occurs quite easily, as was shown during dissection.

To increase the comfort of the procedure, topical anesthesia using EMLA cream is recommended. Intradermal infiltration anesthesia is performed at the cannula entry site by administering 0.05 ml of the drugs septanest, ultracaine or ubistezin. When using filler with lidocaine, there is no need for cutaneous anesthesia, but the entry point of the cannula is anesthetized.

According to the proposed method, the skin is punctured using a 25 G gauge needle or slightly larger. A cannula is inserted through the formed hole, and with the help of back-and-forth movements it slowly moves, spreading the muscle, to the level of the periosteum. Thus, the tip of the cannula reaches the medial edge of the palpebromalar beard without affecting the area of the tear trough (risk zone). The filler is injected slowly and evenly in the projection of the line of the palpebromalar groove (Fig. 4). The safe injection level of the drug can be controlled by placing the finger of your free hand in the projection of the lower edge of the orbit.

Deep periosteal injection of filler guarantees a natural result, the absence of the Tyndall effect, and minimizes the likelihood of uneven location of the drug, visualized in the form of tubercles (Fig. 5). To clarify the level of cannula location, an elevation test is useful - when trying to slightly raise the cannula located under the muscle, its range of movement is extremely limited.

The total volume of Restylane required for correction on both sides is 0.8–1.0 ml. In the study, the drug was injected in a retrograde manner, but it is possible to use an anterograde or combined technique, especially when working with a drug containing lidocaine.

Light massage movements help to distribute the drug evenly. The application of a cold pack prevents the development of swelling and minimizes the appearance of hemorrhages.

The method for correcting the palpebromalar groove described above was named by its author Hyalurostructure by analogy with the lipostructure developed by Colleman.

Table 1 summarizes the results of F. Berroz's study. 23 out of 26 patients (88%) were absolutely satisfied with the result, despite the appearance of hemorrhages in 7 of them (13%) at the point of puncture of the skin with a needle. 2 patients (8%) did not note any positive changes in the treatment area, and 1 patient (3%) reported the appearance of pigmentation due to hemosiderin deposition in the correction area. Twelve patients (21%) experienced minor swelling on one or both sides, which resolved spontaneously after three days. In 2 patients (8%) there was a tendency to uneven skin relief over the injection site, however, upon repeated examinations after 15 days and 3 months, the result of correction by the patient and the specialist was considered satisfactory. One patient (3%) underwent a repeat procedure after 2 months due to lack of effect.

Table 1. Design and results of the study of the effectiveness and safety of the Hyalurostructure method

POSSIBILITIES OF COMBINATION THERAPY

The Hyalurostructure technique can be used not only to correct areas of depression in the infraorbital zone. In the same way, injection plastic surgery of the nasozygomatic groove, temples, eyebrows, and crow's feet area is performed.

A retrospective study of the effectiveness of correction of various types of asymmetries in the periorbital region was conducted at the Alcazar Ophthalmology Clinic and the Department of Ophthalmic Surgery at the Princess Grace Clinic [21]. The study involved 9 patients with asymmetry in the location of the eyebrows (2 participants), the upper eyelid sulcus (2 participants), the palpebromalar sulcus (2 participants) and the volume of the orbit (3 participants with eyeball prostheses). To correct asymmetry, all participants underwent injection plastic surgery using the Hyalurostructure method and injections of botulinum toxin (Azzalure, Dysport). Patients were monitored for a year.

The combination of two procedures - injection plastic surgery and botulinum therapy - allows for effective correction of asymmetry in the periorbital area. A year later, 88% of patients noted high satisfaction with the result of complex therapy.

CONCLUSION

The grooves in the infraorbital region contribute to the formation of the clinical picture of a “tired face” even in young patients and aggravate the overall picture of involutional changes in the face in older patients.

The Hyalurostructure technique for correcting the palpebromalar groove using stabilized hyaluronic acid preparations, developed by F. Berroz, represents a worthy alternative to lipofilling. Research by Goldberg and Faschetti proved the absence of a negative reaction to the injected drug based on stabilized hyaluronic acid, and it was the technical nuances of injection that came to the fore when analyzing adverse events.

The “ideal” patient for the Hyalurostructure procedure is a young to middle-aged person with preserved muscle tone and good elasticity of the skin of the lower eyelid. Flabbiness and excess skin of the lower eyelid, fatty hernias and a tendency to transient swelling in this area are aesthetic contraindications for the procedure.

Injection plastic surgery using the Hyalurostructure method is carried out on an outpatient basis, strictly in a treatment room, in compliance with all standards of asepsis and antiseptics. The introduction of drugs into the deep layers (under the orbicularis oculi muscle) using a 25 or 28 G cannula ensures the prevention of damage to important anatomical structures. Correction of the entire area is carried out from one point, so the risk of hemorrhage is significantly reduced.

The result of the correction is quite long-lasting; the procedure is repeated after 6–18 months. After gaining experience in carrying out similar procedures, we have achieved patient satisfaction with the result at a level of almost 100%.

The combination of injection plastic surgery and botulinum therapy makes it possible to safely and effectively solve quite complex aesthetic problems - for example, correcting asymmetry.

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First published: Les Nouvelles Esthetiques Ukraine, No. 5(81)/2013