lipoatrophy [11, 41, 57], and calcium hydroxylapatite (Radiesse®, BioForm Medical, San Mateo, California), which has been approved for the treatment of moderate to severe facial wrinkles [33]. Both have been reported to last years and it is suggested that this is partly due to the stimulation of collagen production [41, 57, 62]. A wider range of locally approved permanent fillers are available outside of the US, including polyacrylamide gel (Aquamid®, Ferrosan A/S, Copenhagen, Denmark) [18].A summary of the most common brands of soft-tissue fillers is given in Table 15.1.

15.5 Treatment Areas

Soft-tissue fillers have been successfully used for volume enhancement throughout the entire facial region by a range of practitioners. However, their use in the orbit and periorbital area remains fairly limited. This is due to the concerns about visual loss and hemorrhage discussed previously, as well as concerns that the thin eyelid skin will readily reveal any underlying lumps, bruising, or discoloration, resulting in a poor cosmetic outcome. However, the oculoplastic literature has seen the recent emergence of case series describing the successful use of soft-tissue fillers for treating orbital and periorbital volume loss. These novel techniques are outlined below. In all cases it is important to remember that the fillers are being used o -label and it is essential to convey this information to the patient.

15.5.1Orbit

Orbital volume augmentation has been described using permanent soft-tissue fillers, in the form of polyacrylamide gel (Aquamid®) [18]; semipermanent fillers, in the form of calcium hydroxylapatite (Radiesse®) [39, 63]; and reversible ones, in the form of both collagen (Zyplast®) [10] and hyaluronic acid gel (Restylane Sub-Q®) [44]. Calcium hydroxylapatite, polyacrylamide gel and collagen have only been used in anophthalmic patients whilst hyaluronic acid has been used in both anophthalmic and sighted orbits. Typical features of such patients have included enophthalmos, a deep superior sulcus and an increased upper eyelid pre-tarsal show. Most treated patients have already undergone conventional surgical volume replacement.

Orbital injections can generally be administered in the o ce under local anesthesia, although a few patients may desire concurrent sedation and are therefore best treated in an ambulatory surgery center [10, 63]. The patient is positioned 30° supine on a couch and the skin prepared by wiping with alcohol. A peribulbar local anesthetic injection administered approximately 10–15 min prior to injecting

the filler improves comfort and limits any potential e ects of the oculocardiac reflex, presumably caused by rectus stretch due to intraorbital and intraconal placement of the filler [44]. The injection technique is similar to that of a standard peribulbar injection, given transcutaneously through the lateral lower eyelid into the extraconal space along the orbital floor [44, 63] although transcutaneous injection has also been described [10]. It is recommended that Aquamid® be given through a 22-gauge needle [18], Radiesse® through a 27-gauge one and Restylane Sub-Q® through a 25-gauge one, all on a Luer-lock attached to the prepackaged vial of filler. Ideally, the injection is commenced after the tip of the needle is beyond the equator of the globe or implant to provide maximal correction of enophthalmos. The injection continues as the needle is advanced in a retrobulbar direction and also as the needle is redirected to distribute the filler across the orbital floor. Medial and lateral injections can also be performed, with similar pre-periosteal placement of filler within the extraconal fat [63]. Care must be taken to avoid direct intraconal or excessively posterior placement of filler due to potential visual impairment (in sighted eyes), stimulation of the oculocardiac reflex or cavernous sinus thrombosis.

One vial of filler usually su ces per treated orbit, except for polyacrylamide gel where two vials is recommended [18, 44, 63]. This equates to 1.3 ml of Radiesse and 2 ml of Restylane Sub-Q® or Aquamid®. The mean reduction in enophthalmos is 2 mm, measured using Hertel exophalmometry, for adequate placement of the filler, and is associated with a significant esthetic improvement in upper eyelid sulcus volume and skin fold. The reported duration of e ect from the treatment is over 1 year for Aquamid® and Radiesse® [18, 62] and 9 months for Restylane Sub-Q® [44].

Postoperatively patients may note mild orbital discomfort, which is controllable with oral analgesia [18]. Complications of orbital soft-tissue filler treatments include vasovagal attacks, peribulbar hemorrhage and anterior migration of the filler into the lower eyelid [18, 44, 63]. The latter can be readily treated by dissolution using hyaluronidase in the case of Restylane Sub-Q®. [44] No cases of visual impairment or raised intraocular pressure have been described in the sighted eyes that have been treated [44].

Such orbital soft-tissue filler injections can be covered through insurance under Current Procedural Terminology code 67550, orbital implant (outside muscle cone) insertion. However, reimbursement for the filler itself may not be possible due to a lack of appropriate healthcare Common Procedure Coding System supply code [63]. Examples of the technique and outcome of orbital volume augmentation with injectable soft-tis- sue filler are shown in Fig. 15.2.

Company

Allergan, Irvine, CA

Inamed Division of

Allergan, Santa

Barbara, CA

AlloDerm, LifeCell

Corporation, Palo

Alto, CA

Biosystems, Beverly

Hills, CA

Q-med, Uppsala,

Sweden, and

Medicis, Scottsdale,

AZ

Allergan, Irvine, CA

Genzyme,

Framingham,

MASS; Allergan,

Irvine, CA

Allergan, Irvine, CA

Mentor, Santa Barbara,

CA

Genzyme,

Framingham, MA;

Allergan, Irvine,

CA

Dermik Labs,

Bridgewater, NJ

BioForm Medical, San

Mateo, CA

Ferrosan A/S,

Copenhagen,

Denmark

15.5.2Upper Eyelid and Brow

In some cases of orbital volume loss the deficiency is primarily anterior, and enophthalmos is not such a concern.

15 However, a hollow superior sulcus and an increased upper eyelid pre-tarsal show remain. Examples include patients with Parry-Romberg syndrome, patients who have undergone excessive fat excision during upper eyelid blephroplasty, and some patients with aging and fat atrophy without concurrent dermatochalasis. In such cases, volume replacement with soft-tissue filler applied directly to the upper eyelid sulcus can be very e ective in restoring facial symmetry and in improving the contour of the pre-septal skin fold. At present, this has only been reported using the NASHA filler Restylane® [6, 48], although a range of collagen and hyaluronic acid fillers are theoretically suitable. However, the thin upper eyelid skin does call for the use of a medium-low viscosity compound to prevent visible lumpiness and permit a smooth contor. Filler placement should also be as deep as possible within the pre-periosteal plane to minimize this problem.

Once again, the procedure can be carried out in the o ce [48]. The skin is numbed with ice 15 minutes before injecting and wiped with an alcohol swab. The former provides good analgesia and vasoconstriction without distorting the local tissue architecture. The patient is then positioned supine at 45° with the eyes in downgaze. The 30-gauge needle provided with the filler is usually adequate for injection. A needle puncture is created close to the junction of the lateral orbital wall and roof and the needle tip advanced in the sub-orbicularis plane until the inferior border of the superior orbital rim is reached (Fig. 15.3a). 0.1 ml of filler is then injected pre-periosteally and the needle is withdrawn. The raised bleb of filler is massaged and molded over the anterior aspect of the orbital rim in a medial direction to achieve a smooth contour (Fig. 15.3b). The needle is then passed further medially at the inferior border of the orbital rim and a further 0.1 ml of product is injected, followed by molding. Additional aliquots of filler can be injected as necessary using serial puncture sites, each progressively more medial. Usually three puncture sites su ce [48]. Injecting directly over the supraorbital notch should be avoided due to the risk of retrograde embolization of filler down the supraorbital vasculature. After injecting, the patient is asked to raise their eyebrows and the filler is molded onto the anterior surface of the orbital rim. With the brows relaxed, the upper eyelid contour is reassessed to evaluate any residual lumpiness or irregularities. Suitable injection end points include symmetrical fullness of the pre-septal skin fold and softening of any hollows [48].

In general, 0.4–0.5 ml of hyaluronic acid filler is suitable for treating each upper eyelid, although the range extends from 0.1–1 ml [48]. Duration of the filler is less than for orbital injections due to the mobility of the eyelid and the need for a filler with smaller particle size and hence reduced longevity. However, despite this, e ects persist for over six months [48].

All patients receiving upper eyelid filler experience some bruising and swelling which can last for up to five days. However, this is readily managed with the use of concealer or sunglasses. In some patients the filler is also visible on marked brow elevation which can be a cosmetic concern. Additional complications of upper eyelid filler have not been reported [48]. Patients are advised to avoid alcohol and exercise for 24 hours following filler treatment as these activities may exacerbate bruising. Direct pressure over the treated site should also be avoided.

Reported patient satisfaction rates for such upper eyelid contouring are extremely high, at over 95% [48]. However, careful patient selection and assessment is essential. We have found classifying patients into the following four groups very helpful in predicting outcome and planning treatment.

(i)Medial A-shaped hollow

(ii)Generalized hollow

(iii)Post-blepharoplasty generalized volume loss with no skin excess

(iv)Upper eyelid hooding with sub-brow deflation

Overall, patients from the first three groups do very well with upper eyelid soft-tissue augmentation. Patients in group iv with very mild sub-brow deflation can also benefit from lateral sub-brow placement of filler to lift the brow slightly in this area. However, most group iv patients either require too much filler, resulting a prominent lateral brow bulge which contrasts with the adjacent temple hollowing, or else have persistent hooding or dermatochalasis. Consequently, these patients often do better with an eyelid ptosis/blepharoplasty, or brow lift procedure [48]. Comparisons should also always be made with old photographs as the degree of upper eyelid show desired by patients is very variable and often influenced by their youthful appearance. Examples of outcomes of upper eyelid contouring in patients from each of the four groups is shown in Fig. 15.4.

15.5.3 Tear Trough

Most studies describing the use of injectable soft-tissue fillers for contouring of the tear trough relate to

rejuvenation of this area through volume augmentation [1, 37, 30, 59]. This reflects our growing understanding of the contribution that bony resorption and soft-tissue atrophy play in aging, and the consequent shift towards

treatment by volume replacement or redistribution as opposed to tissue excision [27, 28, 34, 35]. Once again, most available data relates to nonanimal stabilized hyaluronic acid fillers, particularly Restylane®. However,

Restylane Perlane®, which is of slightly higher viscosity and longevity has also been used [47].

A range of injection techniques have been described in association with tear trough filling. These include the “linear threading” or “hay stack” technique, using 25–50 passes of the needle to create a haystack configuration of multiple fine threads [29, 30, 37], and serial puncture, as described previously for upper eyelid contouring. This involves the placement of small aliquots of filler in a specific location, followed by vigorous molding of the filler against the underlying tissues [1, 47, 59]. The former is preferable for superficial placement of filler [37], whilst the latter is suited to deep pre-periosteal placement with molding against the underlying bone [1, 47, 59]. We prefer deep serial puncture due to its ease of performance

and its potential for use with longer acting filler compounds. However, it does call for greater volume of filler to achieve adequate volume augmentation.

Patient consent and skin preparation are as described for upper eyelid injections, although some authors prefer to use topical anesthetic creams such as betacaine [30, 37, 59] or even small amounts of injected local anesthetic [1]. Once again, the procedure can be undertaken in the o ce with only ice to numb the skin. The patient is positioned upright with their head firmly supported and asked to look upwards to accentuate the tear trough anatomy. Injections are commenced medially, with the skin of the tear trough held taut, and the 30-gauge needle is passed into the pre-periosteal plane just anterior to the inferior orbital rim (Fig. 15.3c) [47]. A 0.1–0.2 ml aliquot of filler