Introduction

Thinning, deflation, and loss of subcutaneous volume are characteristic of periorbital aging. Though by no means universal, and seen largely in people who have not gained facial weight, this pattern of aging has been known through the ages and is frequently used as a caricature of the aging process. The term ‘nursing home eyes’ provides an instant visual image of the problem.

Traditional treatments around the upper lid have been largely surgical, mainly because until recently the only tools available were excisional. ‘Extra’ skin and fat around the upper lid was removed; for many eyes this proved to be an entirely satisfactory remedy. For some patients, however, the apparent extra skin was secondary to a volume loss in the upper lid and brow, and removing further tissue had the dual effect of making the orbit look more defined, but rounder and more hollow. Both of these have traditionally been considered beneficial. The perceived advantage of this look is that the orbit looks larger and dramatic in the vertical dimension, and leaves more room for makeup. It is also the traditional look of upper lid ‘rejuvenation’ and familiar. However, these are also characteristics of the nursing home eye and in some people the overall appearance of the eye is clearly older, smaller, and more tired. With the advent of tools to re-establish volume in the face, alternatives have become available, which the patient (and clinician) should be aware of before making treatment decisions in the periorbital area.

There is nothing new in these observations. Volume fillers were used exactly as they are now in the 1890s, well before facelift surgery was developed. Unfortunately all that was available at the time was paraffin and petroleum jelly (Vaseline^®); the complication rate was high and these treatments fell into disfavor, as described by Kolle and by Goldwyn.

The ‘local preview’

Patients usually have their own predetermined ideas about what looks good. If one has a choice of filling an area or defining it by removing tissue, the different potential effects must somehow be communicated to the patient. In other words, an adequate consultation should be able to explain the aesthetic alternatives to the patient. We have found no way in words to describe how the effects of filling the brow will improve the patient’s overall look; this is entirely a visual concept. It is like trying to describe a dress and assuming that the customer will like it without trying it on.

What has proved extremely useful is the ‘local preview’, as I have previously described (2009); a milliliter or two of % epinephrine is injected into the brow with the intention of visualizing the effect of filling the area and also to make it numb and vasoconstricted (Fig. 15.1). With the use of an ice cube for the initial injections, this is almost painless.

Figure 15.1 The ‘local preview’. It is difficult to communicate the visual effects of volume around the orbit without actually seeing it. An invaluable way of doing this is to inject the area with local anesthetic, which demonstrates the effect of fill and also numbs and vasoconstricts the area at the same time. Patients approve or disapprove of the visual effect before any product is injected. It usually takes more fill – about –1 mL per side – than the actual product injection. The long-term result looks like the result at the end of the procedure and typically lasts 2–3 years. (A) Before and (B) after injection.

Filling the brow with local anesthetic in a realistic way is not easy, but good practice for the final injection. The tendency for inexperienced injectors is to place the needle superficially and make individual lumps of fluid. This is convincing of nothing. The correct plane is around the orbicularis muscle or deeper and the needle must be withdrawn on injection leaving a horizontal and even flow of local anesthetic. This is done across the brow, trying to anticipate the final intended result. The area is massaged a little. After a few minutes the product has diffused enough to demonstrate the intended look.

We tell patients that what they see is about 80% accurate as to the final result. Most people, if correctly selected, like the look and say that it ‘opens their eyes’. This is perceptually interesting because in reality the orbit is being narrowed. In addition to the demonstrative ability of the preview, the area is now vasoconstricted, making the possibility of an intravascular injection smaller. Strictly speaking, brow filling could be done with topical anesthetic or none at all, but the communicative power of the preview is invaluable – patients determine whether they like the look before the clinician does anything definitive. As well, the latter can see whether he or she likes the effect. Because patients have seen the results of the injection and approved it before the product injection, no one in my experience has asked to have product removed. If they don’t like the look of the preview, then nothing further is done, no product has been injected, and other alternatives can be explored. Patients love the idea that they can see the results before a procedure is done and embrace the concept enthusiastically.

The injection

At the time of writing, hyaluronic acid (HA) products, calcium-based products, and poly-l-lactic acid are available. I myself only use HA fillers outside of the operating room, where I may use autologous fat. They are easy to use and can be removed with hyaluronidase if necessary. The duration of HA products in the brow and tear trough is 2–3 years, equal to or greater than other available products. To my mind there is no advantage to using products other than HAs in the periorbital region.

This is not an area for novice injectors. If the clinician has done only lips and nasolabial folds and injects them with bolus injections and massage, the upper lid will be a source of disappointment and complications, some of them potentially catastrophic. Though not difficult for experienced injectors, technique in the upper lid is important. The goal is to create a pleasing shape across the brow, not just to fill a hollow. The depth of this injection should be around the level of the orbicularis muscle. There are very large immobile arteries at the periosteal level that one should avoid. Injection into the sulcus of the upper lid may result in ptosis, as described by Coleman. Keeping the plane of injection superficial to the bone also keeps the needle farther away from the globe as mentioned below.

I begin the injection at the conclusion of the local preview once the patient has approved the look. The area is now vasoconstricted and numb. The presence of the anesthetic in no way alters the ability to distribute the product evenly which is done partially visually and partially by feel. Though I cannot prove it, I believe that HAs distribute more evenly in a very wet environment.

As illustrated in Figure 15.2, my preferred technique is to begin laterally and place three fanning longitudinal fills with a 30 g -inch (6 mm) needle: high, middle, and low. The process is repeated across the brow. Tiny amounts are placed with each pass. If the thumb moves perceptibly then the volume is excessive. A small needle like the 30 g inch is protective in avoiding overfills. Palpation is an excellent way to determine the evenness of the injection. Typically the injection should not go inferior to the border of the orbital bone laterally and centrally. Unless one is confident of the intention and results it is very easy to create irregularities or worse here. The expansion of the curve of the orbital bone suffices to improve the hollow of all but the most deep-set and hollow orbits. As one proceeds medially the injection might need to drop inferior to the level of the bone somewhat. Usually mL per side is injected. For economic reasons, this seems a good place to start and in fact most brows and the expressive qualities of the face are improvable by even this small amount, even if undercorrected. I am always amazed by the ability of such a small amount of filler to create as much difference as it does. With experience, it is obvious where the product needs to be placed.

Figure 15.2 Author’s injection technique: once the area is numb and vasoconstricted I use three passes from each injection site – high, medium, and low. The injection is repeated across the brow and repeated if necessary. The presence of local anesthetic in no way alters the ability of the injector to visualize the results.

The injection should not be overdone. More is not better. The patient is given an ice pack to use later in the day. Bruising is occasional. There is not much swelling though there is some. Usual complications are minor and are usually related to irregularities that can be dissolved or added to. In general the appearance at the end of the injection is the final result.

Intra-arterial injection

Injections are by and large innocuous and low risk. However the specter of intra-arterial injection is ever present though fortunately uncommon. For this to occur, the needle tip must be in an artery and a bolus of sufficient size injected to cause upstream flow, as blindness from a periocular injection, or distal embolization as in a lip or nasal necrosis from injection into the nasolabial fold, as described by Coleman. These are excellent arguments for not doing bolus injections. We favor threading injections, always keeping the tip of the needle moving with small low-pressure flows and vasoconstriction. We believe that this complication is largely technical and avoidable.

Some orbits are flat superiorly without an upper lid sulcus. In orbits like these the globe is immediately adjacent to the orbital rim and there is a distinct possibility of a direct needle injury. We have never seen this complication, but it is easy to see how it could happen. The clinician must focus on the position of the globe and needle tip. Keeping the tip of the needle away from the orbital bone will also keep it away from the globe. We are uncertain of the use of blunt cannulas here. Though they are blunt, they are also long and whippy and could easily track subcutaneously and wind up in unexpected places.

Who is a candidate for brow volume treatments?

Unlike the lip or nasolabial fold, one cannot rely on formula or dogma to treat the brow. Though some brows may have been fuller when younger, the look of the eye might be worse on restoring or amplifying the brow volume. There are configurations that lend themselves to this treatment and configurations that are made worse by adding volume. In general except for some Asian eyelids, full upper lids are not made better by additional filling. Very hollow eyes are only made modestly better. As mentioned by Mancini et al, there is concern that injection into the actual sulcus may cause a space-occupying ptosis.

Brows that have deflated evenly (Figs 15.3–15.5) and brows where the medial supraorbital crease peaks medially are excellent candidates. This latter group is interesting in that a medial peak of the supraorbital crease gives people a look of anxiety or worry. A very small amount of filler in this location alters the emotional projection of the face (Fig. 15.6). Though actual elevation of the brows of a millimeter or two is sometimes seen with injection, we believe that the impression of elevation is largely illusory, based on greater light reflection from the now filled and rounder brow. In any event, trying to lift brows with volume may provide a slight elevation at the cost of an unnaturally overfilled eye.

Figure 15.3 A 43-year-old patient seen in 1999 (A), 2007 (B) and 2009 (C), 2 years after injection of 1/2 mL per side in her brows. Note the age-related volume change from 1999 to 2007. Most of the patients shown are slightly undercorrected, but still improved.

Figure 15.4 (A) A 58-year-old patient with hollow superior orbit; (B) seen 3 years after brow injection 1 mL/side. The temples were also filled 6 months previously.

Figure 15.5 (A) A 68-year-old patient with hollow brows, (B) 3 years after 1 mL hyaluronic acid filler was placed in each brow.

Figure 15.6 (A) A 54-year-old patient with very hollow and anxious eyes; (B) seen here 3 years after 1 mL hyaluronic acid (HA) filler per side and 10 months after a fill of her temples 2 mL per side with diluted HA fillers.

The point with these treatments is not necessarily to make the orbit fuller: rather it is to make the periorbital area look better, and if one does not have at least a rudimentary appreciation for what looks good on the face, one will have limited success in treating the area.