The non-surgical eye lift

Although relatively few physicians perform nonsurgical eye lifts, combining fillers and neuromodulators in this area can yield excellent results and high patient satisfaction, according to one international expert who presented at last year’s Cosmetic Bootcamp in Aspen, Colo.

Dr. LiewAge-related changes that impact the periorbital area include skin laxity, volume loss and bone resorption, all of which lead to deflation and a combination of apparent descent of the upper eyelid and brow (pseudoptosis) and in some cases true descent, says Steven Liew, FRACS. He is a Sydney, Australia-based plastic surgeon in private practice.

In This Article

The Upper Periorbit

Specific Lifting Techniques

The Upper Periorbit

The aging process of the upper periorbit is a complex and dynamic process. The signs of aging range from tissue deflation and significant volume loss that requires volume replacement, to tissue deflation and predominantly soft tissue ptosis, which requires surgical excision and lifting.

"An attractive upper periorbit includes an eyebrow of appropriate height and shape, eyebrow tissue that is firm, taught and full, a smooth upper eyelid and eyebrow-lid junction and a smooth ogee curve transitioning from the forehead down to the infra-brow region," Dr. Liew says.

Because the eyebrow can descend in many places, creating optimal results often requires filling the entire length of the eyebrow, according to Dr. Liew. Doing so improves the eyebrow's vertical position while also creating forward projection that recruits lax skin such that patients can buy a few years before they require eyelid surgery.

Instead of performing surgery on a 58-year-old Asian female patient with periorbital hollowing, Dr. Liew describes filling the patient's entire upper periorbital rim on both sides with a total of 0.4 mL Juvéderm Ultra XC (hyaluronic acid/HA, Allergan) per side, which provided volume, eyebrow contour and projection that lasted around 15 months.

"That's why I like to inject all filler products deep onto the bone here. Studies¹ have shown the potential for periosteal thickening in this area," he says, adding that the body's natural hyaluronidase is less plentiful at the bony layer.

"I typically use a 25-gauge cannula in this region, constantly feeling the bone. Once I get to the right position, I do an anterograde and a retrograde injection, putting my index finger along the supraorbital rim sulcus, feeling the cannula and moving across where the supraorbital neurovascular bundles are located."

However, there's one area Dr. Liew still prefers injecting with a needle - underneath the orbital rim. "As I approach the neurovascular bundle, I stop and placed some microbolus of products and massage antegrade towards the vascular area. I don't use a lot of product - 0.1 or 0.2 mL, a maximum of 0.3 mL. I always under-correct in this region for almost all HA (products) have some degree of water retention properties. I placed the filler right onto the bone, deep to the retro-orbicularis oculus (ROOF) fat pad. The orbital septum is a lot more posterior in this region from my experience in cadaver dissection.

Nowadays, Dr. Liew uses Volift (HA, Allergan) in the periorbital area, as it has less hydrophilic properties. "But in some patients where I want to create nice definition and projection, I still use more cohesive products like Juvéderm Ultraplus - and I use a lot less product due to the retention of fluid."

Specific Lifting Techniques

Specific Techniques

Another of Dr. Liew's cases involved a 47-year-old female patient with hollowing in the orbital and temporal regions that gave her eyebrows an unnatural appearance. For this patient, "I injected HA into the entire orbital rim and also in the A-frame (deformity), right down to the bone."

Asian patients with a short, shallow orbit can develop the appearance of "goldfish eyes," he adds. For such patients, he uses fillers to blend the eyebrow-eyelid junction. "Every part of the face - whether it's the upper eyelid, lower eyelid or jawline - should follow a lazy S curve pattern, with a smooth, gentle convexity followed by concavity without any disruption or excess shadowing. I will put the product under the muscle, and on top of the orbital septum," using a 25-gauge cannula. Dr. Liew says he injects tiny amounts (0.12 mL) of reconstituted HA because the upper eyelid is much less forgiving than the lower eyelid.

For eyebrow shaping in patients without significant aging changes, Dr. Liew may inject small amounts of neuromodulator not only in the crows' feet, but also in the glabella above the midpoint of each eyebrow to intentionally drop the medial eyebrows. "I do that by pushing the eyebrow down to see how much redundant skin I will get." In patients without redundant skin, "Compensation or recruitment of the lateral fibers of frontalis muscle, together with the  reduced downward pull of the lateral orbicularis muscle, creates a much better eyebrow lift."

In a 30-year-old patient with a sad-looking, downturned lateral brow, he injected 0.4 mL of HA right at the orbital rim to create a pendulum-like effect. "For rejuvenation or volumizing, I inject in the flat part of the (upper) orbital rim. But to elevate the lateral part of the brow, I put it right in the bony orbital margin because this was the place where this patient had a downward convexity. If I put it right at the bottom of the convexity, it would just push or rotate the eyebrow upward. That's a principle of using fat or fillers like a strut over bone. That's why I like a cohesive product in this region - so it stays until the HA integrates into the soft tissue."

Regarding the temporal fossa, Dr. Liew says that although temporal hollowing is a sign of aging, it also can happen to younger patients. Furthermore, he says that it's easy for patients to understand the need for brow lifting treatments because they tend to notice problems in the medial and inferior brow. However, "Patients often don't understand the shadows that develop in the temporal area." Concavity and shadowing affect the shape and visibility of the lateral eyebrow. Concavity can be accentuated by overvolumizing the cheek.

Most patients require deep injections in the temporal fossa unless they are young with a thick layer of soft tissue in the temporal fossa. "If I cannot see any visible veins, I will place injections in the superficial temporal fossa with a 27-gauge cannula, which saves a lot of product. I use Volift. You must pick a product that's not highly cohesive so you can spread it easily."

Disclosures

Dr. Liew is an advisory board member for Allergan (Australia, Asia and Global), and an advisory board member for Galderma (Australia). He is also a consultant for Allergan (Australia, Asia, Europe, United States), Galderma (Australia) and L'Oreal (Australia, Europe).

Reference

Mashiko T, Mori H, Kato H, et al. Semipermanent volumization by an absorbable filler: onlay injection technique to the bone. Plast Reconstr Surg Glob Open. 2013;1(1).