- Injections must be at a supraperiosteal level of the orbital rim below the nasojugal defect. Caution however, to not harshly bounce the needle or cannula tip against the zygomatic periosteum as that can be traumatic to the bone, a superficial injection above the trough defect may result in a tyndall effect that makes the skin appear blue or blue-grey.
- Identify the infraorbital foramen before you inject and while injecting use one hand to identify and protect the orbital rim.
- If a patient expresses pain while injecting stop the injection immediately and observe for bleeding and blanching as you may be in proximity of the neurovascular bundle.
- To decrease irregularities the HA should be gently massaged with hand or cotton tipped applicator for even distribution. Strong massage should be avoided.
- Overcorrection should be avoided. HA is hydrophilic and may cause a swelling or beading this is temporary and will subside. 49 In addition HA may produce neocollagenesis so the area may continue to correct after initial treatment. A Staged treatment to avoid overcorrection is always advisable
- If overcorrection does occur with HA then Hyaluronidase may be injected to remove excess product, 50-100 units per side depending on the amount of volume injected. You may want to lesionally inject hyaluronidase in two separate visits as not to remove all of the product. Contraindicated in patients who are allergic to bees.50
Autologous Fat Transfer
While there is much literature written on facial fat transfer there is
little discussing autologous fat transfer and POH. Roh et al, reported
on the results of a pilot study in 2009.51 Ten patients diagnosed with
infraorbital eye circles underwent successful autologous fat transplantation.
The patients reported 78% improvement.
Blepharoplasty
Classical blepharoplasty or resection blepharoplasty is a surgical
procedure, which requires skill and training to be successfully done
to restore a natural appearance to the eye anatomy. Studies have
shown that blepharoplasty by restoring normal anatomy and removing
excess skin and fat may also affect eyelid pigmentation by
decreasing a shadow effect. In addition to classical blepharoplasty,
augmentative blepharoplasty has been described where autologous
fat transplantation occurs at the same time as blepharoplasty.
The authors report success in optimizing the periorbital complex.52
Topical Skin Bleaching Agents and Cosmeceuticals
A review of bleaching agents used for hyperpigmentation is beyond
the scope of this chapter but there are overriding clinical practices used in rejuvenation of POH. The goal of using a skinlightening
agent is to reduce the amount of melanin in the skin
as well as decrease the appearance of the darkness, shadow or
pigmentation. Bleaching agents may be used as a monotherapy
or combined with procedures to treat POH. A bleaching agent
may be composed of one compound for example ascorbic acid
or most popular now is the combination of many cosmeceutical
agents into one formulation. These “cocktail bleaching agentsâ€
have increased in popularity and each one has unique proprietary
ingredients. These ingredients target different portions of
the melanin cascade.53,54 While hydroquinone remains the gold
standard for a bleaching agent in the US, the HQ free market is
growing. With so many products to choose from it is often difficult
for the patient to navigate their way for an optimal product.
The melanin pathway is complex however the author recommends
that with knowledge of the pathway each portion of the
pathway be targeted for increasing successful outcomes, Table 4
reviews how this may be done with the gold standard bleaching
agent in each category. The table is not meant to be a comprehensive
listing of available agents but an example of an approach
toward treatment. Skin bleaching agents and cosmeceuticals are
discontinued one week prior to a procedural treatment and may
be brought back one week after a successful outcome
Cosmetic Camouflage
Cosmetic camouflage may be very useful while the patient is
undergoing treatment of POH. As treatment may be prolonged
the results seen after makeup application may give the patient
an optimistic window to a future free of dyspigmentation and
increase quality of life. Cosmetic camouflage comes in a variety
of preparations it may include liquid, cream, stick or mineral
based powders that are applied to cover the hyperpigmentation
and blend the skin tone. Because most of these products
contain zinc oxide and or titanium dioxide they also bring UV
protection to the patient. For severe cases thick cream concealers
that match the skin color or are lighter may be applied for
camouflage (Dermablend-Quik Fix Concealer®, Cover/ Fx Concealer
®). In cases with a highly vascularized component a green
concealer may neutralize the red or violaceous discoloration
(Physicians Formula Gentle Cover Concealer Stick®). A makeup
expert can counsel your patient as to the optimal product and
application techniques.
CASE 1
A 67-year-old African American female, Fitzpatrick skin type 5
(Roberts Skin Type F5/H2/G2/S0), reported progressive darkening
of the skin around her eyes and had no significant past
medical history other than a family history of eye darkening
with aging. She reports having used a prescription 4% HQ
product of and on for one year with no undereye improvement.
On presentation, she had significant bilateral confluent
brown patches periorbital patches that were bilateral and symmetrical.
She had mild skin laxity and lateral eye rhytids. Tear
