Aspects of art and beauty

A comprehensive knowledge of facial proportion, divine proportion and artistic dimension must be incorporated into all aesthetic medical procedures. At the periorbital level, it remains important and the doctor should always maintain symmetry with procedures and steer away from treating to an unnatural proportion. Another important point is to maintain results that are not just natural, but also age-appropriate. With facial volumisation, one can usually achieve very natural looking results in the mature woman, but removing every single wrinkle might not be suitable for the age of the patient. It is also important to understand the patient’s lifestyle and career, for example, to ensure that the results are a complement to these.

Treatment plan for the periorbital area

The aforementioned aspects should be taken into consideration when evaluating the patient for treatment. The treatment options can be divided according to the depth of the pathology. However, the majority of patients will have a combination of factors relating to the aged appearance of the periorbital area, and as a result, combination therapies will always be more successful than single treatments alone.

The delicate skin around the eye should be treated with the utmost respect, especially when performing ablative or resurfacing procedures: one should keep in mind that the epidermis and dermis is much thinner here compared with the rest of the face. In patients with loose skin around the eye, skin tightening procedures such as radiofrequency, fractional laser, chemical peels, mesotherapy or skin needling can be performed. However, it is essential to treat patients with a Fitzpatrick skin type IV–VI with caution when undertaking resurfacing procedures. Rather, it is recommended to opt for non-ablative fractional lasers than ablative; and more superficial peels rather than deep, to reduce the risk of possible postinflammatory hyperpigmentation.

Periorbital hyperpigmentation is very common in patients with a Fitzpatrick skin type IV–VI, and especially in patients of South Asian origin. Treatment options may include multiple superficial peelings, pigmentation focused laser treatment options, such as non-ablative fractional laser, IPL and/ or depigmenting creams applied daily.

The use of superficially placed fillers may be useful in thin or wrinkled periorbital skin periorbital, but the product may be visible for a few days to a few weeks owing to the very thin epidermal, dermal and subcutaneous fat aspects.

Therefore, the amount of product placed per injection point should be the absolute minimal to ensure that the nodules are not visible. Low viscosity, low cross-linked hyaluronic acid fillers are recommended and the technique used is mostly multi-puncture with micro-droplets of the product. The patient can massage the area regularly after the procedure with a post-injection cream to help diffuse the droplets for an even result. This technique can be very useful in most lateral eye wrinkles, which form over the zygomatic arch and run down towards the cheek.

Figure 2 Botulinum toxin injection points for orbicularis oculi muscle

Figure 2 Botulinum toxin injection points for orbicularis oculi muscle

Muscular periorbital treatment is usually carried out for the overactive contraction of the orbicularis oculi muscle. The use of botulinum toxin in this muscle is off-label. The most lateral aspect of the orbital part of the orbicularis oculi is treated to reduce so-called ‘crow’s feet’, or smile wrinkles (Figure 2).

Figure 2 shows the injection points and amount of units of onabotulinum toxin A recommended for the patient shown, with a typically hyperactive orbicularis oculi muscle contraction. Between 6 and 10 units of onabotulinum toxin A distributed over 3–5 points per side of the orbicularis oculi muscle is sufficient to achieve successful results. The treatment will improve lateral eye wrinkles and further enhance an opening of the eye area, as the orbicularis oculi muscle closes the eye area in a sphincteric action. In some patients the palpebral part of orbicularis oculi muscle may also be hyperactive, as seen in the patient in Figure 2. This results in the eye closing almost completely when smiling. Injection of 0.5–1 units of onabotulinum toxin A will reduce the closing of the eye during the mimical action of smiling. The injection point is placed centrally in the palpebral part.

Figure 3 Supraorbital dermal filler injection with a cannula, to enhance hollowness and the brow

Figure 3 Supraorbital dermal filler injection with a cannula, to enhance hollowness and the brow

The treatment of the fat pads and subcutaneous tissue around the eye region requires excellent analysis, an artistic eye, and an expert anatomical knowledge of both the fat pads and vascular structures. Injection of dermal fillers into vascular vessels can result in disastrous complications that may include skin necrosis, hyperpigmentation and even reports of blindness1, 2.

The use of cannulae for the injection of dermal fillers reduces the risk of intravascular placement significantly. In the opinion of the author, the use of hyaluronic acid fillers remains the safest and most reliable treatment option for the periorbital region. A variety of hyaluronic acid fillers with different viscosity and concentration can be used according to the area injected and the depth of injection.

Figure 4 Lateral cheek enhancement of wrinkles

Figure 4 Lateral cheek enhancement of wrinkles

Low viscosity hyaluronic acid fillers are ideally used for skin restructuring in this area, as well as for the treatment of fine lines. It can also be used as a safer and softer option for tear trough filling, though more treatment sessions may be required. Medium viscosity hyaluronic acid fillers in the periorbital area are used for medium folds such as tear trough filling and supraorbital volume replacement, while high viscosity hyaluronic acid fillers are typically used for large volume replacement such as cheek augmentation and malar enhancement. The type of filler and its indication should be respected and chosen correctly at all times.