Injectables to Shape the Periocular Region

Introduction
As expert of the eye and the periocular region ophthalmologists are theoretically the specialists better prepared and formed to use fillers to aesthetically treat this region safely and more effectively. The objective of the presentation, implemented by the corresponding outline is to help all the potential injectors in their progression towards a delivery of safe and pleasing aesthetic results to all of your patients.

Anatomy
The anatomy of the eyelids and neighbouring regions is probably the most complex of the entire face and it reflects the complicate functions and the primary role of the eye.

However, most of us as a category are surgeons and as such we are used to address conditions to which we provide direct surgical access and we therefore see the anatomy and the changes that our manipulation produces as we make them.

Whether you are considering to start injecting fillers around the eye or you are already an injector, but willing to evolve and treat the periocular region, there are some important considerations that should taken in account and include regional anatomy, aesthetic assessment of the region and technical skill formation.

It has been demonstrated that volume loss in the face plays a dominant role in determining facial ageing and this also applies to the periocular area. The individual fat compartments that seem to be confluent in the youthful face, when they show demarcations between them, represented by the retaining ligaments, cause the most common periocular aesthetic concerns. Recognising the anatomical structures functionally involved is of crucial importance, and the knowledge of the position of the individual fat compartments and retaining ligaments involved is the base of the injector, which should be able to mentally visualise the relevant anatomy as if he possessed an ultrasound probe in his hands along with the filler syringe.

Aesthetic Considerations
The role of volume restoration in the periocular area is of maximal relevance as the eyes are the first to show signs of ageing. Specific volume related conditions that affect the aesthetic appearance of the periocular region include tear trough deformity, orbito-malar sulcus, eyelid bags. The wise injector should not behave as a ‘dumper’ trying to fill a hole, but should take advantage of the filler properties to stretch and reposition the retaining ligaments and concomitantly offer support to the depleted fat compartments.

This paradigm shift from overfill the center of the face to targeting the periphery to ‘lift’ first can be applied to all the different anatomical units of the face and helps to achieve natural results and reduce complications, so difficult to manage in the periocular region especially.

I found there appears to exist various analogies between periocular filler injection and surgery, such as aesthetic and anatomical considerations and aesthetic goals, represented by correcting hollows, eliminating bags, tightening of the lid and improving the skin quality.

As injectors we want to achieve surgical results with a non invasive office treatment. Combining the knowledge of the surgical and filler anatomy I have come to recognise the existence of a common aesthetic “G-Point”, which once properly addressed help the surgeon and the injector to achieve the aesthetic goals of rejuvenating the periocular aesthetic unit.

Figure 1: impact of the aesthetic G-point in addressing all of the aesthetic concerns occurring in the periocular unit.

Figure 2: The G-point can be found at the joining of the bisettrix among the Hinderer’s lines and line drawn from the lateral canthus, forming with it a 90 degrees angle.

Injections Skills
Instead of trying to fill the emptiness represented by the insertion of the orbito-malar ligament, which is very tight and difficult to elevate without releasing it, in my injection technique I target the G-point first with a deep bolus (defined as at least a .1cc) of a high G-prime filler (Figure 3: lateral grey dot) in order to provide lift and stretch of the tissues superficial to the ORL.

Subsequently I provide central support at the apex of the V of the orbito-malar groove (Figure 3: central grey dot). In the end I finalise the treatment using a low-G-prime filler injected with a min-bolus technique (defined as .02-.03 boluses) to smooth the transitions (Figure 3: pink dots).

Figure 3: demonstration of the treatment planning (left) and the result right after injection of the right side (right); the aesthetic goals of the treatment, including hollows correction, bags elimination, tightening of the lid and improving the skin, quality appears to have been met.

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