Dr Tom van Eijk provides his protocol for the treatment of infraorbital hollowness by injecting hyaluronic acid.
Looking tired is one of the complaints that I find drives patients towards clinics in search of aesthetic correction.1 In the last decade, non-surgical solutions to reduce the ‘tired look’ have increased in popularity due to the limited intensity2 and cost of the treatment in comparison to surgical interventions.
Since the skin in the infraorbital area is very thin, anything that distorts this structure is visible. One night of not sleeping or even five minutes of crying can have a striking effect under the eyes. Some people show their age and tiredness more than others, leading to concerned remarks by peers regarding their wellbeing, thus influencing them to seek aesthetic treatment.
One of the most popular non-surgical treatments is the injection of hyaluronic acid (HA) in the lower eyelid region to reduce the depth of the tear trough, in order to freshen up the patient’s appearance. Unfortunately, I have found that most of the less than optimal results are seen in this particular area. This has been noted through observing the vast number of unhappy patients seeking advice on websites1 or requiring a second opinion consultation.
Treating this delicate area can be very tricky as the thin skin can be unforgiving and incapable of hiding overcorrection or misplacement of HA filler. As such, I have developed a protocol named the Palma Technique for treating infraorbital hollowness using HA filler, which aims to address both the skin and the tissue underneath.
The lower eyelid area, known as the infraorbital region, is one of the more complex areas of the face as far as anatomy goes. Delicate structures that are highly susceptible to visible signs of ageing, due to their mechanical vulnerability, are layered here; fat pads, septa, muscles, vessels and various other skin qualities all contribute towards looking healthy and well rested. When we are younger and these factors are all in good condition, the infraorbital region looks like one continuous plane. However, as we age this is no longer the case and the area can begin to look uneven in volume and skin tone. Surplus skin, intraorbital fat and changes in the quality of tissue can all reveal an individual's age and the condition of their physical and emotional wellbeing.
This area should only be treated by advanced practitioners with thorough knowledge of the infraorbital anatomy and several years of practice in injectables, as arteries run here that are connected with those responsible for blood flow to the optic nerve.
Cases of blindness after injecting hyaluronic acid causing occlusion of the ophthalmic artery have been reported, although the incidence of these complications is higher when the injections are placed in the nasal bridge or glabella region.2,3
Due to the loose connective tissue of the lower eyelid, bruising can be a real problem for the patient, as makeup can sometimes not fully conceal these haematomas. It is therefore important to explain and prepare patients for this during the consultation.
The risks of bruising and intravascular injection associated with using needles explain the popularity of the use of cannulas for this particular injection. The blunt tip of a cannula means that you are less susceptible to piercing a vessel and provides a safer way to inject the filler substance subdermally.
Although the initial opening in the skin needs to be created with a sharp tool, and in most cases a slightly bigger needle, the cannula can travel underneath the skin without causing as much damage as a needle would.
One of the main features of HA is the fact that it can fill and provide volume. Another aspect of the same material is that, when placed superficially in the dermis, it will strengthen the skin and will stimulate the fibroblasts to produce more collagen.4 Due to the bluntness of the cannula, injecting into the dermis, and therefore strengthening or thickening this layer, is impossible. In my opinion, strengthening of the infraorbital dermis is essential when injecting volume into this area and can at least compensate for the changes that come with ageing. For example, the thinning skin of the lower eyelid that reveals the underlying anatomical structures.
Using a needle enables the injector to separately correct the missing volume and the lack of dermal strength,5 which in most patients are combined in an infraorbital filler indication.
This becomes particularly apparent when the majority of suboptimal results are being observed, a suborbital hollowness is overcorrected and replaced by a protuberance. When a protuberance is placed superficially it can appear to be blue, which is known as the Tyndall effect.1 In some cases, the subdermal placement of filler interferes with the natural flow of lymph fluid, leading to an excess of swelling of the lower eyelid.2
When assessing the patient, the strength and thickness of the skin reveals itself when the skin is squeezed between the index finger and thumb. The lack of volume cannot be accurately assessed by observation alone. Palpating the region will assess the hollowness and yield a more precise indication of where and how much volume correction will be needed. Figure 1 is an example of a formal assessment that I have made on a patient. I have indicated that there is lack of skin strength, shown in purple, both the plane (secondary dermal weakness, due to ageing) and the superimposed linear (tertiary dermal weakness, due to wear and tear), combined with a lack of volume in the green sections. The level of the dermal attachment of the zygomatic cutaneous ligament is indicated in yellow.
I advise to start treatment with the correction of dermal strength by injecting minute quantities of filler into the mid-dermis, starting lateral from the lower eyelid, with the end point being the thicker skin of the cheek, at the level of the zygomatic cutaneous ligament. On average the skin lateral to the cheek is thinner and thins even more with ageing, therefore thickening this skin first will counteract that.
Separate from the correction of dermal strength, but in the same session using the same syringe, volume correction of reduced lower eyelid fat can be achieved by filling the previously palpation-assessed hollowness. This can be done with the same needle, after aspiration and appreciation of the tissue in which the needle tip is placed, by gently moving the tip from side to side, to minimise the chance of injecting in a vessel. It only takes a minor movement to feel the consistency of the tissue. One can also use a cannula for deeper volumisation. Surplus skin is quite common in this area, as well as the bulging of the intraorbital fat pads which lie in the orbit to cushion the eye. Both of these indications cannot and should not be corrected with filler, as no filler has the capacity to reduce the surface of dermal or fat tissue. This means that we cannot treat some of the factors contributing to the ‘hollow’ or ‘tired’ look by using dermal HA fillers. We also should not try to overcompensate for these factors by adding more volume than would correct the actual volume deficit.
The effect of strengthening by intradermal injecting is limited, especially the first time, particularly in thin skin like this. If one treatment of intradermal injections does not raise the strength of the dermis enough to lead to an optimal result, waiting for collagen stimulation is advised.4 Injecting more filler the first time will not further increase the dermal strength, therefore patience is key with this procedure. Once the collagen level has increased, which will take a few months, a second dose can be administered in order to further strengthen the skin. In some cases where the lateral skin is very weak in comparison to the cheek, a third treatment is advised. I find that this is common in patients who are over 40 years old.
Once the optimal result is obtained, typically after two or three sessions, I advise my patients to have the area examined every one to two years. This is so both further ageing and the decay of the results of the treatment can be assessed and addressed in a new treatment.
As the thin dermis reveals any evidence of overcorrection, the appropriate dosage of the filler injected superficially is key during this treatment. Therefore, I believe that less is more. While injecting, I advise practitioners to monitor how the skin behaves differently, particularly concentrating on its tendency to fold, when it is being squeezed, rather than the depth of the hollowness.
I would recommend focusing on strengthening the skin by continuously monitoring and squeezing the skin after each injection. Don't be surprised that it might take only 0.1ml of product to strengthen each lower eyelid. I would recommend choosing a 1ml syringe and use 0.2ml for the dermal strengthening, leaving 0.8ml for both infraorbital areas to correct the subdermal volume.
The volumisation of the subdermal areas that require correcting will immediately be visible as the shape of the area will have a less sunken appearance. Bruising and swelling can occur as a result of the treatment so the correction of volume is best assessed after approximately two weeks. In my experience, this is also when the improved strength of the dermis will contribute toward the overall aesthetic outcome of the treatment. Upon following the Palma Technique, the added volume will be covered by thicker skin and thus the evenness of the suborbital plane will be better corrected than it would have been if treated by merely adding subdermal volume.
As the stimulation of the skin’s own collagen is a process that will take several months, patients will notice a gradual improvement in the aesthetic result over time (Figure 2). I have found that the diminishing transparency of thin suborbital skin due to new collagen also contributes to the aesthetic improvement of the infraorbital area.
Further correction of volume can be planned as soon as two weeks after the first intervention. To benefit from the collagen stimulation, a second treatment of dermal strengthening is advised for at least two months after the initial session.
Since the dense dermis does not allow the dermal filler to spread as it would in subdermal loose connective tissue,8 a high number of superficial injections are needed to manually distribute the material in the skin. This will heighten the chances of bruising, especially during the first session, when the skin is at its weakest. Hitting anything vital such as an artery is unlikely with injections as shallow as these. However, it is essential that practitioners performing this treatment have a thorough understanding of depths of injection and anatomy in order to differentiate between adding volume and adding strength.
In my opinion lower eyelid hollowness, which results in a ‘tired look’ is, in most cases, defined by the lack of volume and a lack of dermal strength. It is also defined by a surplus of dermal tissue and sometimes the bulging of intraorbital fat pads. It is important to note that a surplus of skin and bulging fat pads cannot be corrected with HA. Volume compensation with subdermal filler can only partly correct this hollow look. Dermal strengthening is essential in further correcting the anatomical changes that come with ageing and I believe that using a needle is the only way to place HA into the dermis to provide dermal strength.
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