Chapter 15

Core Messages

■Orbital or periorbital volume loss may be due to factors other than aging. Any sinister, progressive, or reversible etiology should be identified and addressed prior to embarking upon volume replacement.

■Injectable soft-tissue fillers o er titratable volume augmentation, precise soft-tissue placement, the ability to be performed in the o ce, biocompatibility, low down-time, minimal morbidity, high safety and, in most cases, potential reversibility.

■The two main types of injectable soft-tissue fillers are collagen and stabilized hyaluronic acid. The latter can be instantly dissolved using hyaluronidase. Nonanimal stabilized hyaluronic acid fillers are the most commonly used in orbital and periorbital volume augmentation.

■Fillers with larger particle size have increased viscosity,reduced ease of injection and increased duration. On average, a medium viscosity hyaluronic acid gel will last a year when injected in a pre-periosteal plane in the periorbital region or in the orbit.

■Soft-tissue fillers have been successfully used for volume augmentation in the orbit (both sighted and anophthalmic), the tear trough, the upper eyelid/sub-brow region and in the brow and temple region.

■2 ml of hyaluronic acid filler, administered to the orbit via an inferotemporal peribulbar injection and placed posterior to the equator of the globe or implant, usually reduces enophthalmos by up to 2 mm and restores the signs of periorbital volume deficiency.

■A serial-puncture technique, with deep preperiosteal placement of small aliquots of filler, followed by molding and massage of the gel, is recommended for filling in periorbital region.

■Typical side e ects of periorbital filler injection include bruising and mild swelling, although these usually resolve within a few days and can be concealed with make-up or glasses.

■Lumpiness can be a problem in a minority of patients but usually settles. Persistent lumpiness can be corrected with further molding, additional filler or, in the case of hyaluronic acid fillers, dissolution with hyaluronidase.

■Patient satisfaction following periorbital soft-tissue filler for rejuvenation is between 80–95%.

■The role of injectable soft-tissue fillers in treating periorbital pathology is continuing to expand, with reports of their successful use in treating paralytic lagophthalmos, lower eyelid retraction and cicatricial ectropion.

Summary for the Clinician

■Orbital volume loss typically presents with enophthalmos, a deep superior sulcus, increased

■Anophthalmic patients may also have prosthesis instability and lower eyelid laxity caused by stretching of the lower eyelid from wearing a bulky prosthesis.

■Periorbital volume loss can give rise to a negative facial vector, lagophthalmos, localized soft-tissue defects, or a generalized unmasking of the underlying bony and ligamentous anatomy.

■Bony displacement must be considered in cases of orbital and periorbital volume loss and where possible, corrected prior to soft-tissue volume augmentation.

■Occult, sinister, progressive causes of orbital and periorbital volume loss include sclerosing inflammatory disease (e.g., Wegeners granulomatosis), scirrhous carcinoma, silent –sinus syndrome and idiopathic hemifacial atrophy.

■More obvious causes include phthisis, facial trauma, surgery, radiotherapy, neurofibromatosis, and HIV-treatment-induced facial lipoatrophy.

■Soft-tissue atrophy due to aging is the most common cause of periorbital volume loss presenting to oculoplastic surgeons.

■Typical features include:

■Unmasking of the lower eyelid fat-pads and infra-orbital rim both medially (tear trough) and laterally

■Superior sulcus hollowing and increased upper eyelid pre-tarsal show

■Sub-brow deflation, brow descent and lateral hooding

■Temple hollowing, revealing the lateral orbital rim outline and clipping the tail of the brow in the frontal view

■Rare but serious complications of orbital and periorbital soft-tissue filler injections include visual loss and skin necrosis. All patients should be consented for this and sighted patients should have their visual acuity documented.

■Patients should be informed of the current o - label status of fillers when applied to the orbit and periorbital region.

■Orbital soft-tissue fillers are administered via a peribulbar injection.

■In general, 2 ml of hyaluronic acid gel will reduce enophthalmos by up to 2 mm.

■Filler should be placed just posterior to the equator of the globe or implant.

■Deliberate intraconal placement should be avoided.

■Prior peribulbar injection with local anesthetic helps to improve comfort and reduce the oculocardiac reflex.

■Periorbital fillers are best placed pre-periosteally for the upper eyelid, lower eyelid and brow, and in the superficial temporalis fascia for the temple region.

■Vigorous molding against the underlying bony orbital rim is usually necessary to achieve a smooth contour.

■Application is using a serial puncture technique with 3–5 injection sites.

■Upper eyelid and sub-brow fillers should be administered from lateral to medial, avoiding the supraorbital notch, whilst tear trough fillers are best applied from medial to lateral.

■Ice is a suitable anesthetic for periorbital filler injections.

■Bruising is minimized by reducing the number of superficial passes of the needle and by deep preperiosteal placement of the filler. Ice also aids in producing vasoconstriction.

■Following periorbital soft-tissue filler injections, patients are advised to avoid alcohol, vigorous exercise and direct pressure to the treated area for 24 hours.

■Most patients experience mild bruising and swelling following periorbital soft-tissue filler injections. This usually settles within 1 week.

■One third of patients may experience mild initial lumpiness which also settles.

■Persistent lumps or blue discoloration can be treated by further molding, injection of additional filler or, in the case of hyaluronic acid based fillers, dissolution with hyaluronidase.

■Additional periorbital applications of soft-tissue fillers include upper eyelid loading, lower eyelid elevation and correction of cicatricial ectropion.