Introduction

Traditionally, a major method of a rejuvenation of the periorbital area is surgical blepharoplasty. But its frequently limited efficiency in the long-term prospect, and the increasing interest in low-invasive procedures create injection blepharoplasty as an important method of correction of a palpebromalar groove and tear trough, an injection camouflage of prominent orbital fat of a lower eyelid.

The delayed adverse effects of correction of the tear trough and injection camouflage of prominent orbital fat of a lower eyelid are important. They include the accumulation of hyaluronic acid (HA)-filler out of tear trough, enlargement of hernia of a lower eyelid, puffiness of a periorbital zone, short and insufficient effect of correction [4]. All this can develop several months after the procedure.

We would like to consider options of injection correction of a lower eyelid by means of HA-filler depending on anatomic features of the patient, and specifically expression of prominent orbital fat of a lower eyelid to decrease the possibility of emergence of these adverse effects [1,5,6].

We suggest our clinical classification of aging changes in lower eyelid area for convenience correction.

We mark out 3 types of a zone of a lower eyelid (Fig.1) [5,6].

Fig. 1: Three types of aging of the lower eyelid.

The first type is characterized by loss of volume in lower eyelid. This type is most common in young patients or patients after surgical blepharoplasty [2,5].

In this case we recommend to place filler in the space limited from above (сranial) by bony orbital margin or septae, lower (caudal) – by ORL, deeply with periosteum and superficially by SMAS [1,5,6] (Fig.2).

Fig. 2: Lower lid correction in case of no prominent orbital fat. Fan-technique, microboluses, supraperiosteal injections of HA-filler by sharp needle placed between bony orbital margin and eyelid-cheek junction. Projection of angular and infraorbital vessels are marked by red.

We use microboluses fan injections by sharp needle for precise injection of filler in this space [3] (Fig.2).

Dangerous zones should be marked before an injection for the prevention of their trauma by a needle. They are: zone of angular vessels and a zone of an infraorbital neurovascular fascicle [3].

After we mark space borders where we will enter filler. It is a projection of edge of an orbit and eyelid- cheek junction (ORL projection). We do a puncture of a skin 1-2 mm higher than eyelid- cheek junction, we enter a needle perpendicular to a surface of a skin and we move a needle till periosteum. Then we turn a needle almost parallel to periosteum and we enter all length under the SMAS [2]. We inject filler into space limited by eyelid-cheek junction and projection of edge of an orbit (1 mm above these borders) with the microboluses, retrograde fan injections. Tear trough and a palpebromalar groove are corrected at the same time.

Filler accumulation lower (more caudal) than the tear trough can occur after correction of the tear trough by cannula with an entry point in a malar zone at this type of lower eyelid. It can be due excess amount of filler, injected to medial SOOF [4]. We don’t recommend to place filler caudal to ORL for prevention of accumulation it out of the tear through. It is possible to use a blunt cannula with entry point in a lateral part of an orbit (between a lateral cantus and eyelid- cheek junction) for correction of this type.

The second type of changes of a lower eyelid is prominent orbital fat of a lower eyelid in a medial part of an orbit and visualization of bony edge of an orbit in a lateral part of an orbit [1]. We also use the microboluses, retrograde fan injections by needle with preliminary marking of dangerous zones for correction of this type [3, 5] (Fig.3).

Fig. 3: Technique for lower lid correction in case of prominent orbital fat and visualisation of lateral portion of bony orbital margin. Microboluses supraperiosteal injection of HA filler by sharp needle. In lateral part: between projection of ORL and bony orbital margin. In medial part: in projection of attachment of ORL or more caudal.

Filler is injected under SMAS in lateral part of an orbit into the space limited by ORL (eyelid- cheek junction) and bony edge of orbit as well as in the first type. And in a medial part of an orbit filler is injected in a deep fatty tissue caudal to ORL and in projection of ORL fixation [1]. To avoid injection of filler in hernia we don’t inject filler cranial to ORL projections in a medial part of an orbit.

It is possible to use for correction of this type a blunt cannula with entry points: in a lateral part between a lateral cantus and eyelid- cheek junction, in a medial part in a buccal zone below eyelid- cheek junction.

The third type of changing in a zone of an upper eyelid is determined by visualization of hernias of a lower eyelid both in medial, and in a lateral part of an orbit [1]. This type is indication to surgical blepharoplasty usually. If there are contraindications to surgery, it might be corrected by HA-filler. Incomplete correction of the tear through and palpebromalar groove is preferable to the prevention of effect “pillow face” in this case.

It is possible to use both a needle, and a blunt cannula in correction of this type. Filler should be injected into deep fat compartments caudal to ORL projections (eyelid-cheek junction). We prefer the microboluses technique by needle [3,5] (Fig. 4).

Fig. 4: Technique for lower lid correction in case of prominent orbital fat, visible in lateral and medial part. Supraperiosteal microboluses injection of HA-filler by sharp needle more caudal to projection of ORL (eyelid-cheek juncton).

When correcting the lower eyelid, the right choice of filler is very important. Filler must have the necessary elasticity and plasticity to evenly fill the depression and prevent contouring. We use monophasic HA-filler of average degree of a reticulation – Filorga XHA-3 0.2 – 0.5 cc – on the side with good clinical effect from 10 to 18 months (Fig. 5).

Fig. 5a – c: Periorbital zone (types 1, 2 and 3) before correction by filler Filorga XHA-3 and 2 weeks after correction.

We recommend to correct loss of volume of a buccal and malar zone as first procedure, and then correct zone of a lower eyelid for obtaining optimum effect in all cases [6].

In conclusion, it is important to underline that correction with HA-filler of lower eyelid has to be performed with consideration of anatomic features of every patient, especially existence and expression of prominent orbital fat of a lower eyelid for optimum results and decreasing risks of adverse events. It is necessary to use a filler with specific physicochemical properties. In our hands, HA-filler Filorga XHA-3 is optimal for the correction of this area.