Possibilities of injection methods in rejuvenation of the periorbital zone

Sofia Gritsak, dermatologist, cosmetologist, founder of the International School of Medical Cosmetology, member of the Association of Preventive and Anti-age Medicine, certified national trainer of the Academy of Scientific Beauty in contour correction and mesotherapy (Lvov)

The majority of patients who underwent injection correction of the periorbital zone reported positive results from the procedure. There is only one thing: the high risk of complications (hematomas, hypercorrection, secondary hyperpigmentation as a result of hemosiderin deposition) forces many doctors to refuse procedures for introducing hyaluronic acid preparations into this area or to minimize such interventions. But in vain. Carrying out the procedure for injection correction of the periorbital zone using an atraumatic blunt-ended cannula significantly reduces the risk of adverse events, and the use of drugs specially synthesized for injection into the periorbital zone gives a very natural and long-lasting effect, does not cause swelling and does not put pressure on the surrounding tissues.

Features of topographic anatomy of the periorbital zone

The skin of the periorbital zone is very thin and practically devoid of subcutaneous fat. The fat pad of the cheek with its upper edge is somewhat distant from the lower edge of the orbit and at the level of the midpupillary line is interrupted in a certain area, which forms a depression of the soft tissues in the infraorbital region. Transmission through the thin skin of the underlying orbicularis oculi muscle gives this area a bluish tint.

The orbicularis oculi muscle in the form of a thin plate partially covers the area of the cheek and zygomatic bone, is fixed in the medial part of the orbit to the maxillary process of the frontal bone and the frontal process of the upper jaw, as well as to the ligament of the inner corner of the eye. The structure of this muscle is divided into two parts - palpebral and orbital. The palpebral part covers cartilaginous (tarsal) plates, which are attached to the medial and lateral canthus. The upper tarsal plate, together with the skin of the upper eyelid, which is fixed to it, forms the supraorbital fold with age, and the orbicularis oculi muscle and capsulopalpebral fascia are attached to the lower one. Thus, with the help of the tarsal plates, an orbital septa is formed, which delimits the contents of the orbit.

At the border of the preseptal and orbital parts, the orbital ligament (orbicularis retaining lig.) is woven into the orbicularis oculi muscle, which is fixed to the bone 4–6 mm distal to the lower edge of the orbit and is responsible for the formation of the palpebromalar (PMB) and lacrimal (LA) grooves. These grooves are located above the upper edge of the malar fat compartment.

Between the orbital portion of the orbicularis oculi muscle and the anterior surface of the lower edge of the orbit there is suborbicular fatty tissue (SOOF) - the only safe level of filler injection when correcting PMB.

Prolapse of axillary adipose tissue aggravates the manifestations of depression in the infraorbital region.

Rice. 1. Features of the topographic anatomy of the periorbital zone

The blood supply to the periorbital zone and orbit is carried out by the branches of the angular, supra- and infraorbital, supratrochlear arteries, the transverse facial artery and the superficial temporal artery. Venous outflow occurs through the angular vein into the facial vein, as well as through the ophthalmic vein system.

Age-related changes in the periorbital zone

Age-related changes in the periorbital zone include:

• atrophy of the bone structures of the orbit;
• redistribution of fatty tissue (displacement of SOOF into the supramuscular layer and its prolapse);
• transposition of the orbital ligament from a horizontal to a vertical position, which is clinically manifested in a change in the size of the orbit and its skeletonization, a decrease in the eyelid-cheek separation, and the acquisition of a descending direction by the palpebral fissure axis;
• formation of the PMB, SB and nasolabial fold.

Rice. 2. Age-related changes in the periorbital zone

Danger zones when performing injection correction of the periorbital zone

Based on the above-mentioned features of the anatomical structure of the periorbital region, the following dangerous zones can be distinguished:

• the area of the medial corner of the eye is the place of passage of a. et v. angularis;
• the medial segment of the lacrimal trough – for 1 cm from the internal canthus;
• the exit point of the supraorbital neurovascular bundle is along the midpupillary line at the level of the eyebrow;
• the exit point of the infraorbital neurovascular bundle is 0.8–1 cm below the bony edge of the orbit, at the level of the medial edge of the iris;
• the projection area of the exit of the zygomaticofacial nerve is 5–7 mm lateral to the inferolateral edge of the orbit.

Rice. 3. Danger zones when performing injection correction of the periorbital zone

Patient selection

The degree of satisfaction with the correction effect depends not only on the correct execution technique and choice of drug, but also on a thorough analysis of aesthetic indications and contraindications in patients.

Aesthetic contraindications for the correction of PMB, SB and dark circles under the eyes include:

• presence of skin dyspigmentation under the eyes;
• large malar hernias of the eyelids;
• pronounced lower dermochalasis;
• lymphostasis;
• failure of the ligamentous apparatus of the lower eyelid;
• overstretch of the orbicularis oculi muscle.

We must also remember that a significant difference in the tone of the skin of the lower eyelid and cheek, as well as thinning of the skin under the eyes with translucency of the orbicularis oculi muscle, require previous cosmetic correction using chemical peels and revitalization. In patients with a round orbit, as well as with a protruding lower edge of the orbit, it is very difficult to achieve the desired aesthetic results when correcting PMB and SB.

Choice of drug and technique

In order to reduce the risk of swelling in the periorbital area, preference should be given to drugs with low hydrophilicity, but at the same time with appropriate viscoelasticity.

Taking into account the delicacy of the periorbital zone, as well as the high risk of trauma to anatomical structures, it is advisable to carry out injection correction using atraumatic blunt-ended microcannulas. However, when working with the category of older patients, due to the loss of elasticity and sagging of their connective tissue septa, preference should be given to injecting the drug with a needle to avoid migration of the gel.

A few words about safety

Regardless of whether you work with a needle or a cannula, the main principle of the correction should be safety. Therefore, it is important to follow several rules:

• The patient’s position during the examination is sitting;
• Before the procedure, we carry out tests with eye movements up and down and with pressure on the eyeball, we note the difference in the tone of the skin of the lower eyelid and cheek in order to determine the feasibility of correction;
• we determine the limits of the bony edge of the orbit, apply markings indicating the exit points of the neurovascular bundles;
• During the procedure, constantly control the end of the cannula or needle with the finger of your free hand;
• the dose of the injected drug should create a picture of hypocorrection; if necessary, additional correction is carried out after two weeks.

Features of cannula correction of PMB and SB

Using infiltration anesthesia, we numb the cannula insertion site. To do this, we use the drug “Ultracain DS” in a dose of 0.05 ml, injecting it antegrade.

Further puncture of the skin is carried out with a sterile needle measuring 25 or 23 G. To perform correction of the periorbital area, I use a blunt-ended cannula TM Magic Needle measuring 25 G and 40 or 50 mm long, which has a unique balance between rigidity and flexibility, which allows you to control its progress.

We first insert the cannula towards the bone, then easily slide it under the muscle and delicately move the instrument towards the intended area.
Before administering the drug, check the position of the cannula outlet (straight down), which is indicated by a special indicator on the connector. Hyaluronic acid gel is injected strictly onto the periosteum to achieve the most natural result and to avoid the Tyndall effect or uneven distribution of the filler. The dose of the drug per administration is determined by the appearance of a slight elevation of tissue and in total should not exceed 0.5 ml on one side (0.2–0.5 ml).

After the procedure is completed, a light massage is performed in order to distribute the drug evenly and to slightly advance it into the medial part of the furrow, where any interventions are strictly contraindicated. The final stage is the application of the cold pack.

Rice. 4. Cannula administration of Teosyal® PureSense Redensity II

Features of needle correction of PMB and SB

The drug is administered using a needle strictly perpendicularly supraperiostally to the edge of the orbit when correcting PMB.

Rice. 5. Technique for correcting PMB using a needle

Or the SB is “stitched” to a depth of 4 mm.

Rice. 6. Technique for “stitching” the SB using a needle

The distance between injections is 0.3–0.4 mm, the dose of the injected bolus is determined by visualization of a small tubercle and in total should not exceed 0.2–0.5 ml of the drug per zone. This technique is mainly used in the correction of PMB and SB in older patients.

Conclusion

The presence of PMB and SB, as well as dark circles under the eyes, disharmonize the face of young patients, giving a tired appearance, and aggravate the picture of involutive changes in representatives of the age category, therefore, minimally invasive methods of rejuvenating the periorbital area by introducing fillers based on hyaluronic acid are becoming increasingly in demand. And in order to minimize the number of post-procedural complications, it is necessary to carefully select patients, taking into account their aesthetic contraindications, and correctly select the tactics of injection correction. This approach will ensure the most satisfactory results.

Rice. 7. Results of correction of the periorbital zone using Teosyal® PureSense Redensity II (photo courtesy of Dr. Galatoire, Ocular Plastic Surgeon, Rotschild Foundation, Paris, France)

Literature

1. Lambros VS Hyaluronic acid injections for correction of the teartrough deformity // Plast Reconstr Surg. – 2007; 120, 6 Suppl: 74–80.
2. Hirmand H. Anatomy and nonsurgical correction of the teartrough deformity // Plast Reconstr Surg. – 2010; 125, 2 Suppl: 699–708.
3. Ingalina F. M., Trevidik P. Anatomy and injections of botulinum toxin // Medical publication of the scientific society E2E. – France, 2010.
4. Karpova E. Topographic anatomy and morphological elements of the periorbital region: applied aspects. – 2010; 3:10–14.
5. Berros Ph. Periorbital contour abnormalities: hollow eye ring management with hyaluronostructure // Orbit. – 2010; 29, 2: 119–125.

6. First published: KOSMETIK international journal, No. 4 (58) / 2014