London-based consultant oculoplastic surgeon Mrs Sabrina Shah-Desai discusses the importance of a thorough knowledge of the periorbital anatomy
The periorbital area (Figure 1) is the aesthetic epicentre of the face; its delicate critical structures and intricate anatomic relations pose a unique challenge for even the most experienced aesthetic practitioner. The thin fragile eyelid skin and mobile orbicularis oculi lend themselves to the possibility of overfilling and Tyndall effect,1 whilst the complex vascularity can result in visible bruising and swelling,2 having a negative impact on the patient experience. Vascular compromise and visual loss2 are devastating complications that must be avoided at all costs. Mid-facial ageing is a combination of the ‘gravitational theory’ (vertical descent of soft tissues due to ligamentous attenuation)3 and the ‘volumetric theory’ (relative volume loss and gain of neighbouring fat compartments oftheface).4 In2007,RohrichandPessa published their seminal study on the facial fat compartments.5 This not only serves
as a road map to understanding facial ageing, but has also revolutionised how we rejuvenate the ageing face. To successfully navigate the hollows and troughs of the periorbital zone, it is vital to understand how ageing in one sub-zone affects the other, rather than non-specific targeting of the tear trough or cheek.
Using an anatomical guide to the deep and superficial facial fat compartments for volume restoration, in multiple key areas, results in a naturally harmonious rejuvenation to lift and fill the central face (eyelid, eyebrow, temple, cheek and mid-face).
1. Consider restoration of volume in the temple, brow and upper lid sulcus at three to four points, with the lateral canthal area as an optional extra (Figure 4).
Volumetric deflation of the upper-lid and lid- brow junction causes a ‘flatness’ replacing the ‘convex’ fullness of this zone accompanied by an alteration in the drape of upper-lid skin. Landmarks for brow position are based upon underlying bony anatomy; the superior orbital rim is easily palpable and serves as a fixed landmark for the medial head of the brow. Deflation due to soft tissue volume loss can present as temple hollows, with skeletonisation of the lateral orbital rim and clipping of the eyebrow tail (Figures 2a pre- and 2b post-rejuvenation). Upper eyelid deflation can present as ‘medial A-shaped hollow’ or localised central and lateral hollowing of the upper lid sulcus, with the development of an extra fold of skin above the natural eyelid skin crease (Figures 3a and 3b).
Branches of the external carotid artery (ECA) provide the blood supply to the face with the exception of a mask-like area of the central forehead, upper eyelids and the upper part of nose, which are supplied though the internal carotid system (ICA) by the ophthalmic artery. Vascular anastomoses between ECA and ICA are danger zones for the aesthetic practitioner as inadvertent intravascular injection can lead to vascular compromise and permanent blindness.14
The infraorbital foramen: Infraorbital vessels arise from maxillary branch of external carotid which anastomose with branches of the ophthalmic artery. The supraorbital notch and glabella: Supraorbital and supratrochlear, infratrochlear and external nasal branches of ophthalmic artery anastomose with branches of the external carotid artery. The temple area: Superficial temporal artery crosses the zygomatic arch and 2cm above the arch divides into anterior and posterior branches. The anterior branch anastomoses with branches of the ophthalmic artery.
A sound anatomic approach to surgery with thorough pre-operative planning remains the basis for achieving successful cosmetic and reconstructive outcomes. This should be no different for non-surgical rejuvenation of the eyelids and adjacent areas, where the injector is well trained with a firm understanding of the facial vascular anatomy, safe injection planes, varied injection techniques and types of filler for achieving pleasing aesthetic results in different anatomical areas. The hyper dynamic periorbital area should ideally be treated with low molecular weight, high viscosity materials which are easier to inject and mould. This area should be assessed with non-flash photography, whilst the patient is seated, to assist with patient education by identification of areas of deflation. Treating the patient whilst seated upright, after marking areas of deflation and key anatomic landmarks, allows for injection in the correct plane, using conservative volumes and avoiding adverse events due to incorrect placement and overcorrection.
Using different injection techniques like retrograde linear threading for the cheek, lateral brow and lateral tear trough region (with a cannula or needle), serial puncture technique (with a needle) at targeted sites like the medial superior sulcus and fanning technique (with a cannula) for the lateral cheek and temple area, helps reduce adjacent tissue trauma and minimizes the risk of intravascular injection.1 The primary goal of ‘eye-zone’ rejuvenation is restoration of youthful 3-dimensional periorbital topography, so that the eyelids are not harshly demarcated from, but naturally blend into the brow and cheek.
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