Review of Periorbital and Upper Face: Pertinent Anatomy, Aging, Injection Techniques, Prevention, and Management of Complications of Facial Fillers

December 2016 | Volume 15 | Issue 12 | Original Article | 1524 | Copyright © December 2016

Julie Woodward MD

Department of Ophthalmology and Dermatology and Oculofacial Surgery, Duke University Medical Center, Durham, NC

This paper aims to review articles related to facial fillers in the periorbital area, forehead, and temple. Anatomy, anatomical changes with aging, techniques of rejuvenation and facial harmonization with fillers are reviewed. Topics for complication prevention and management including knowledge of danger zones, timing of hyaluronidase injections, aspiration, definition a small aliquot, and thoughts about particle size are discussed. J Drugs Dermatol. 2016;15(12):1524-1531.
Pertinent Periorbital Anatomy A basic understanding of anatomy and effects of aging should be appreciated. Eye This precious little organ refracts light through the cornea and lens to the retina so that 1.2 million nerve bers can carry vi sion signals to the brain. The retina’s blood supply is from the central retinal artery that branches into 4 arcades once it enters the eye. The superotemporal and inferotemporal arcades supply the central vision area termed the fovea. The choroid and optic nerve supplied by 15-20 short posterior ciliary arteries that pierce the sclera in a circle surrounding the optic nerve.1,2 Secretory System This consists of 9 different types of glands that produce tears to lubricate the surface of the eye. There are 3 of each type of gland: oil, aqueous, and mucin.The tear lm has its’ own anat- omy that layers in this order (hydrophobic/mucin, hydrophilic/ aqueous, hydrophobic/oil) on the cornea for lubrication. With aging, glands can become atrophic resulting in dry eye. Lacrimal System This system continually drains the basal tear secretion through the punctum, the ampulla, canaliculi, lacrimal sac, and nasolacrimal duct into the inferior meatus. Periocular Muscles There are 6 extraocular muscles that control the movements of the eyes in yoked positions to allow binocular vision. The corrugators, depressor supercilli, procerus, and orbicularis are protractors that depress the brow and close the eyelids via the 7th cranial nerve.The frontalis, levator palpebrae superioris, and Mu?ller’s muscle are retractors that serve to open the eye. The levator is innervated by the 3rd cranial nerve. The corruga- tors and procerus tend to hypertrophy with age.This increased muscle mass with strength results in brow depression and their repeated action contributes to vertical rhytids in the glabella. Repeated action of the orbicularis results in “crows feet” and if the temporalis muscle becomes atrophic, there can be a step-off between a contracted orbicularis and the hollow temple.3 Orbital Osteology Seven bones create the cone shaped orbit. The superior equator of the globe remains a constant distance from the orbital roof throughout life. The orbital aperture widens with age mostly superomedially and inferolaterally.4,5 The oor of the orbit moves inferiorly by about 2mm with advanced age.[Richard] The inferior maxilla rotates inward according to Lambroth’s algorithm. [Richard, Pessa, Pessa, Goldberg]Facial llers can help restore contours that help to counteract the inevitable changes of the facial bones.6,7,8,9 Fat Facial fat provides necessary glide planes for facial animation. There are deep and super cial fat compartments. These were originally defined by injecting methylene blue dye into cadavers in 2007.10 Loss of facial fat begins in the mid 20’s and eventually takes its’ toll as signs of facial aging. Newer theories speculate that deep fat compartments atrophy more because they are inactive and adjacent to bone and that superficial fat compartments maintain or hypertrophy in size.11 Replacing this lost volume is a key role of facial llers. Orbital fat suspends the eye in the orbit and allows the extraocular muscles to move rapidly for eye movements known as saccades