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Advanced techniques for using Restylane in the lower eyelids
Practice Forum
Advanced Techniques for Using Restylane in the Lower Eyelids Michael A.C. Kane, MD Dr. Kane is in private practice in New York, NY.
The author describes injecting hyaluronic acid (Restylane) in the lower eyelids. The key to the superficial injection technique he prefers, which he describes as “technically difficult,” is to minimize the volume injected per pass. Furthermore, he discourages massage, which increases eyelid swelling, unless absolutely necessary. (Aesthetic Surg J 2007;27:90–92)
T
he aging lower eyelid has many different morphologic presentations. Accordingly, there are a variety of surgical procedures to correct or minimize these signs of aging. Fat can be excised, repositioned, or added. The septum can be repaired, detached from the arcus marginalis, reset, excised, or studiously avoided. The orbicularis oculi can be ignored, excised, or redraped. There are many options, even without addressing the skin or lateral canthal structures. Since the Food and Drug Administration approved Restylane (Medicis, Scottsdale, AZ) injectable hyaluronic acid, I have added a nonsurgical approach to my lower eyelid rejuvenation procedures.
Anatomic Considerations To fully understand the injectable approach to the lower lid, it is necessary to have a complete understanding of the tear trough and aging lid. The roof of the trough is formed by the infraorbital fat, which, in the aging process, to a varying degree, begins to push the lower lid structures outward. The floor of the trough is formed by the much thicker cheek skin where it abuts the thin eyelid skin. (This thicker skin also has a layer of subcutaneous fat that the lid skin lacks, being adherent to the underlying musculature.) This floor clearly descends over time as the junction of eyelid and cheek skin descends further from the lid margin. The depth of the trough is created by the orbitomalar (also called the orbicularis) retaining ligament, which tethers the undersurface of the orbicularis oculi to the arcus.1 The apparent trough depth also becomes more pronounced over time with thinning of the overlying soft tissues, providing increased visualization of the underlying deformities.
90
AESTHETIC
SURGERY
JOURNAL
~
Restylane Injection Technique I have found that the best level in which to inject most patients is the superficial plane.2 After prepping the skin and applying a topical anesthetic, recline the patient to minimize head motion during injection. I do not use markings. Insert the needle to its hilt in a threading fashion, injecting the product as the needle is withdrawn. During this step it is critical to control the volume of product injected. During injection, despite the superficial location of the needle in the deep dermis (or dermal/orbicularis interface), no visible augmentation should be seen. If a thread of product in the skin is visible, too much product has been injected. Begin in the deepest part of the trough (usually at the 6- to 8-o’clock position in the left eye area), and proceed with multiple slightly overlapping threads, at slightly varying angles, through the deepest parts of the trough. Continue the augmentation of the skin inferiorly until the cheek skin is entered. If you limit the area of injection to the eyelid skin, an unnatural appearance can result when the patient smiles since the thickened plate of eyelid skin pushes against the cheek skin. Inject the flat sheet of Restylane superiorly until you reach (at least) the most inferior eyelid rhytid, or even higher. Carrying the sheet of Restylane up until the eyelid margin can have an effect on the lower lid, not unlike a canthopexy, by adding support to the thinning anterior lamella (Figure 1). During these injections the key is to minimize the volume injected per pass. This was made much easier for me a few years ago when, at the advice of Dr. Arnold Klein, I began to inject the product using a 32-gauge needle. This minimizes trauma to the skin, shears down the particle size and, most important to me, acts as a choke on the volume injected per pass. Not infrequently, I will inject only 0.2 to 0.25 mL of product (my median volume per lid for correction) using 50 to 60 passes of the needle. While injecting there should be no obvious movement of the plunger of the syringe. It is my goal to never massage my patients after injection. If the threads are well placed, adding some volume to the trough and thickening the anterior lamella throughout
JANUARY/FEBRUARY
2007
Practice Forum
A
B
C
D
Figure 1. This 40-year-old woman presented with asymmetric tear trough deformity and lower lid laxity. She had no prior history of surgery but said that the appearance of her eyes had changed from a pleasant almond shape to “tired”. A, Preinjection photo taken when the patient had a slight smile, minimizing her lid malposition and tear trough deformity. B, Immediate postinjection view. She received 0.31 mL of Restylane into her right lower lid and 0.34 mL into her left, injected completely in the superficial plane and carried cephalad to the tarsus, just short of the lid margin. She was also injected with 2.5 units Botox (Allergan, Irvine, CA) into each lateral lower lid/lateral canthal area. Note that the lower lids are erythematous and swollen. The boundaries of injection are evident inferiorly into the cheek skin and superiorly to the lid margin. The sheet of product has pushed the margin cephalad in a similar manner as superficial injections in the labiomental area displace the oral commissure cephalad. C, Preinjection photo with the patient in true repose (lids are lower and troughs are deeper). D, Three months postinjection with the patient in true repose. Despite the Botox, which generally makes the troughs deeper still and the lower lid more lax, the troughs are markedly improved and the lid margin clearly higher. Nevertheless, she was dissatisfied with her lower lid Botox injections because she felt the downward drift of her lower lids had become worse. Her left trough was slightly undercorrected, and an additional 0.05 mL of Restylane was injected. She returned at 13 months for repeat injection and claimed persistent correction for 11 months.
the lid, but not creating surface irregularities, no massage is necessary. Massage, if used, will increase eyelid swelling. If an obvious lump or worm is visible from too much volume in one pass, you must make a choice. If the irregularity is small (by experience), I would leave it as is and, typically, it will disappear within a week. I massage larger lumps, which is the lesser of 2 evils when compared with a visible lump that the patient may see for months. I send the patient home with instructions to use ice compresses to the eyelids that day and to sleep with the head elevated. I advise patients not to schedule an impor-
tant social or work engagement for 3 days after injection, although most patients look presentable before that time. If the patient sees a bump or ridge, he or she is instructed not to manipulate it in any way. If it is still visible after 10 days, patients are instructed to return to the office where I then massage it out. About 5% of patients need this late massage. I tell patients that most results will persist for 9 to 10 months, but most patients sustain improvement for at least a year. For older patients with extremely thin skin and patients of any age with a severe deformity, I inject the
Advanced Techniques for Using Restylane in the Lower Eyelids
SURGERY
AESTHETIC
JOURNAL
~
January/February
2007
91
Practice Forum
Restylane in two layers.3 To avoid a Tyndall effect, which is a bluish-gray discoloration secondary to light refraction, and to ensure an even surface topography, I limit the amount of superficial augmentation to 0.25 to 0.35 mL (depending on skin thickness). It is extremely difficult to place a large amount of material in this plane without creating visible surface irregularities.
Discussion Initially, I placed my deep layer onto the infraorbital rim. While it added volume and did not contribute to surface irregularities, it was deficient in that it did not thicken the overlying soft tissues, and relatively large volumes were needed for correction. I then began to sandwich the orbicularis between flat sheets of Restylane. This technique greatly thickens and stiffens the anterior soft tissues of the eyelid, which conceal signs of aging below. It also breaks up the sheets of hyaluronic acid with muscle to minimize potential pigmentary changes. The lower sheet is placed in a similar fashion to the upper sheet. Currently, I rarely use deep orbital rim injections. Obviously, the superficial plane is not the only plane amenable to augmentation. Shortly after the publication of my paper,2 another study detailing deeper injections along the orbital rim was published.4 This is a layer that I have also occasionally injected with Restylane. While it certainly adds volume to the trough, it does not address other stigma of aging of the lower eyelid and is thus somewhat limited in my hands. I think it is best suited for the young patient (20s, early 30s) and especially the young Asian patient with tear trough deformity. These patients have this deformity due to structure of the inferior orbital rim rather than laxity, thin tissues, and gravity. Simple volume addition in the deep plane works very well for them. Complications vary between techniques in terms of incidence and severity. All techniques can produce surface irregularities, swelling, ecchymosis, and discoloration. Blindness is a remote possibility5 that is discussed before injection. I believe that superficial injection carries a theoretical benefit in this area because of the smaller vessels affected in this plane and its distance from the orbital septum. Another article on deep plane injection,6 which I urge you to read, was published this year, describing use of the product in a fanning fashion just below the orbicularis oculi, but above the orbital rim. Results were similarly excellent, and the problem of surface irregularities was largely avoided. In considering which technique to use, I don’t believe there are absolute right or wrong choices; each technique has inherent strengths and weaknesses. In my hands the superficial technique yields the best long-term results by
92
Aesthetic
Surgery
Journal
~
far. When I compare results in these patients with my patients who have undergone orbital rim treatment only, there is no comparison with the exception of the young patient with tear trough deformity. However, while yielding the best results, the superficial technique is also technically much more difficult. The thin dermis of the lower lid is extremely unforgiving and exacting control of volume is necessary to avoid irregularities. The suborbicularis approach alleviates some of the surface concerns but in my hands does not correct the skin rhytids of the lower lid as well or allow for raising the lid margin. Of course, no technique needs to be exclusive, and I frequently combine superficial and suborbicularis techniques in patients requiring a high volume of material. Currently, I believe that the deep rim technique is the one most widely used precisely because of its ease of use (certainly not a criticism) and reproducibility. While the superficial technique may sometimes yield spectacular results, it usually produces more swelling than do deep injections immediately after injection. However, in my hands, it has a much lower rate of ecchymosis than suborbicularis injections. The key is to match the technique to the patient’s structure, the skill of the injector, and the patient’s desires in terms of willingness to accept small irregularities for a few days. ■ The author is a Medical Advisory Board member for Medicis, Allergan, and Sanofi-Aventis. He is a stockholder in Allergan, Medicis, and Mentor. References 1. Sullivan PK. The anatomic basis for the tear trough and crescent deformity at the lower eyelid-cheek junction. Plastic Surgery 2003. San Diego, CA. Oct 28, 2003. 2. Kane MA. Treatment of tear trough deformity and lower lid bowing with injectable hyaluronic acid. Aesthetic Plast Surg 2005;29:363367. 3. Kane MA. Discussion: filling the periorbital hollows with hyaluronic acid gel: initial experience with 244 injections. Ophthal Plast Reconstr Surg 200;22:341-343. 4. Airan LE, Born TM, Nonsurgical lower eyelid lift. Plast Reconstr Surg 2005;116:1785-1792. 5. Coleman S. Avoidance of arterial occlusion from injection of soft tissue fillers. Aesthetic Surg J 2005;22:555-557. 6. Goldberg RA, Fiaschetti D. Filling the periorbital hollows with hyaluronic acid gel: initial experience with 244 injections. Ophthal Plast Reconstr Surg 2006;22:335-341. Reprint requests: Michael A. C. Kane, 630 Park Avenue, New York, NY 10021. Copyright © 2007 by The American Society for Aesthetic Plastic Surgery, Inc. 1090-820X/$32.00 doi:10.1016.j.asj.2006.12.004
January/February
2007
Volume 27, Number 1
Advanced Techniques for Using Restylane in the Lower Eyelids Michael A.C. Kane, MD Dr. Kane is in private practice in New York, NY.
The author describes injecting hyaluronic acid (Restylane) in the lower eyelids. The key to the superficial injection technique he prefers, which he describes as “technically difficult,” is to minimize the volume injected per pass. Furthermore, he discourages massage, which increases eyelid swelling, unless absolutely necessary. (Aesthetic Surg J 2007;27:90–92)
T
he aging lower eyelid has many different morphologic presentations. Accordingly, there are a variety of surgical procedures to correct or minimize these signs of aging. Fat can be excised, repositioned, or added. The septum can be repaired, detached from the arcus marginalis, reset, excised, or studiously avoided. The orbicularis oculi can be ignored, excised, or redraped. There are many options, even without addressing the skin or lateral canthal structures. Since the Food and Drug Administration approved Restylane (Medicis, Scottsdale, AZ) injectable hyaluronic acid, I have added a nonsurgical approach to my lower eyelid rejuvenation procedures.
Anatomic Considerations To fully understand the injectable approach to the lower lid, it is necessary to have a complete understanding of the tear trough and aging lid. The roof of the trough is formed by the infraorbital fat, which, in the aging process, to a varying degree, begins to push the lower lid structures outward. The floor of the trough is formed by the much thicker cheek skin where it abuts the thin eyelid skin. (This thicker skin also has a layer of subcutaneous fat that the lid skin lacks, being adherent to the underlying musculature.) This floor clearly descends over time as the junction of eyelid and cheek skin descends further from the lid margin. The depth of the trough is created by the orbitomalar (also called the orbicularis) retaining ligament, which tethers the undersurface of the orbicularis oculi to the arcus.1 The apparent trough depth also becomes more pronounced over time with thinning of the overlying soft tissues, providing increased visualization of the underlying deformities.
90
AESTHETIC
SURGERY
JOURNAL
~
Restylane Injection Technique I have found that the best level in which to inject most patients is the superficial plane.2 After prepping the skin and applying a topical anesthetic, recline the patient to minimize head motion during injection. I do not use markings. Insert the needle to its hilt in a threading fashion, injecting the product as the needle is withdrawn. During this step it is critical to control the volume of product injected. During injection, despite the superficial location of the needle in the deep dermis (or dermal/orbicularis interface), no visible augmentation should be seen. If a thread of product in the skin is visible, too much product has been injected. Begin in the deepest part of the trough (usually at the 6- to 8-o’clock position in the left eye area), and proceed with multiple slightly overlapping threads, at slightly varying angles, through the deepest parts of the trough. Continue the augmentation of the skin inferiorly until the cheek skin is entered. If you limit the area of injection to the eyelid skin, an unnatural appearance can result when the patient smiles since the thickened plate of eyelid skin pushes against the cheek skin. Inject the flat sheet of Restylane superiorly until you reach (at least) the most inferior eyelid rhytid, or even higher. Carrying the sheet of Restylane up until the eyelid margin can have an effect on the lower lid, not unlike a canthopexy, by adding support to the thinning anterior lamella (Figure 1). During these injections the key is to minimize the volume injected per pass. This was made much easier for me a few years ago when, at the advice of Dr. Arnold Klein, I began to inject the product using a 32-gauge needle. This minimizes trauma to the skin, shears down the particle size and, most important to me, acts as a choke on the volume injected per pass. Not infrequently, I will inject only 0.2 to 0.25 mL of product (my median volume per lid for correction) using 50 to 60 passes of the needle. While injecting there should be no obvious movement of the plunger of the syringe. It is my goal to never massage my patients after injection. If the threads are well placed, adding some volume to the trough and thickening the anterior lamella throughout
JANUARY/FEBRUARY
2007
Practice Forum
A
B
C
D
Figure 1. This 40-year-old woman presented with asymmetric tear trough deformity and lower lid laxity. She had no prior history of surgery but said that the appearance of her eyes had changed from a pleasant almond shape to “tired”. A, Preinjection photo taken when the patient had a slight smile, minimizing her lid malposition and tear trough deformity. B, Immediate postinjection view. She received 0.31 mL of Restylane into her right lower lid and 0.34 mL into her left, injected completely in the superficial plane and carried cephalad to the tarsus, just short of the lid margin. She was also injected with 2.5 units Botox (Allergan, Irvine, CA) into each lateral lower lid/lateral canthal area. Note that the lower lids are erythematous and swollen. The boundaries of injection are evident inferiorly into the cheek skin and superiorly to the lid margin. The sheet of product has pushed the margin cephalad in a similar manner as superficial injections in the labiomental area displace the oral commissure cephalad. C, Preinjection photo with the patient in true repose (lids are lower and troughs are deeper). D, Three months postinjection with the patient in true repose. Despite the Botox, which generally makes the troughs deeper still and the lower lid more lax, the troughs are markedly improved and the lid margin clearly higher. Nevertheless, she was dissatisfied with her lower lid Botox injections because she felt the downward drift of her lower lids had become worse. Her left trough was slightly undercorrected, and an additional 0.05 mL of Restylane was injected. She returned at 13 months for repeat injection and claimed persistent correction for 11 months.
the lid, but not creating surface irregularities, no massage is necessary. Massage, if used, will increase eyelid swelling. If an obvious lump or worm is visible from too much volume in one pass, you must make a choice. If the irregularity is small (by experience), I would leave it as is and, typically, it will disappear within a week. I massage larger lumps, which is the lesser of 2 evils when compared with a visible lump that the patient may see for months. I send the patient home with instructions to use ice compresses to the eyelids that day and to sleep with the head elevated. I advise patients not to schedule an impor-
tant social or work engagement for 3 days after injection, although most patients look presentable before that time. If the patient sees a bump or ridge, he or she is instructed not to manipulate it in any way. If it is still visible after 10 days, patients are instructed to return to the office where I then massage it out. About 5% of patients need this late massage. I tell patients that most results will persist for 9 to 10 months, but most patients sustain improvement for at least a year. For older patients with extremely thin skin and patients of any age with a severe deformity, I inject the
Advanced Techniques for Using Restylane in the Lower Eyelids
SURGERY
AESTHETIC
JOURNAL
~
January/February
2007
91
Practice Forum
Restylane in two layers.3 To avoid a Tyndall effect, which is a bluish-gray discoloration secondary to light refraction, and to ensure an even surface topography, I limit the amount of superficial augmentation to 0.25 to 0.35 mL (depending on skin thickness). It is extremely difficult to place a large amount of material in this plane without creating visible surface irregularities.
Discussion Initially, I placed my deep layer onto the infraorbital rim. While it added volume and did not contribute to surface irregularities, it was deficient in that it did not thicken the overlying soft tissues, and relatively large volumes were needed for correction. I then began to sandwich the orbicularis between flat sheets of Restylane. This technique greatly thickens and stiffens the anterior soft tissues of the eyelid, which conceal signs of aging below. It also breaks up the sheets of hyaluronic acid with muscle to minimize potential pigmentary changes. The lower sheet is placed in a similar fashion to the upper sheet. Currently, I rarely use deep orbital rim injections. Obviously, the superficial plane is not the only plane amenable to augmentation. Shortly after the publication of my paper,2 another study detailing deeper injections along the orbital rim was published.4 This is a layer that I have also occasionally injected with Restylane. While it certainly adds volume to the trough, it does not address other stigma of aging of the lower eyelid and is thus somewhat limited in my hands. I think it is best suited for the young patient (20s, early 30s) and especially the young Asian patient with tear trough deformity. These patients have this deformity due to structure of the inferior orbital rim rather than laxity, thin tissues, and gravity. Simple volume addition in the deep plane works very well for them. Complications vary between techniques in terms of incidence and severity. All techniques can produce surface irregularities, swelling, ecchymosis, and discoloration. Blindness is a remote possibility5 that is discussed before injection. I believe that superficial injection carries a theoretical benefit in this area because of the smaller vessels affected in this plane and its distance from the orbital septum. Another article on deep plane injection,6 which I urge you to read, was published this year, describing use of the product in a fanning fashion just below the orbicularis oculi, but above the orbital rim. Results were similarly excellent, and the problem of surface irregularities was largely avoided. In considering which technique to use, I don’t believe there are absolute right or wrong choices; each technique has inherent strengths and weaknesses. In my hands the superficial technique yields the best long-term results by
92
Aesthetic
Surgery
Journal
~
far. When I compare results in these patients with my patients who have undergone orbital rim treatment only, there is no comparison with the exception of the young patient with tear trough deformity. However, while yielding the best results, the superficial technique is also technically much more difficult. The thin dermis of the lower lid is extremely unforgiving and exacting control of volume is necessary to avoid irregularities. The suborbicularis approach alleviates some of the surface concerns but in my hands does not correct the skin rhytids of the lower lid as well or allow for raising the lid margin. Of course, no technique needs to be exclusive, and I frequently combine superficial and suborbicularis techniques in patients requiring a high volume of material. Currently, I believe that the deep rim technique is the one most widely used precisely because of its ease of use (certainly not a criticism) and reproducibility. While the superficial technique may sometimes yield spectacular results, it usually produces more swelling than do deep injections immediately after injection. However, in my hands, it has a much lower rate of ecchymosis than suborbicularis injections. The key is to match the technique to the patient’s structure, the skill of the injector, and the patient’s desires in terms of willingness to accept small irregularities for a few days. ■ The author is a Medical Advisory Board member for Medicis, Allergan, and Sanofi-Aventis. He is a stockholder in Allergan, Medicis, and Mentor. References 1. Sullivan PK. The anatomic basis for the tear trough and crescent deformity at the lower eyelid-cheek junction. Plastic Surgery 2003. San Diego, CA. Oct 28, 2003. 2. Kane MA. Treatment of tear trough deformity and lower lid bowing with injectable hyaluronic acid. Aesthetic Plast Surg 2005;29:363367. 3. Kane MA. Discussion: filling the periorbital hollows with hyaluronic acid gel: initial experience with 244 injections. Ophthal Plast Reconstr Surg 200;22:341-343. 4. Airan LE, Born TM, Nonsurgical lower eyelid lift. Plast Reconstr Surg 2005;116:1785-1792. 5. Coleman S. Avoidance of arterial occlusion from injection of soft tissue fillers. Aesthetic Surg J 2005;22:555-557. 6. Goldberg RA, Fiaschetti D. Filling the periorbital hollows with hyaluronic acid gel: initial experience with 244 injections. Ophthal Plast Reconstr Surg 2006;22:335-341. Reprint requests: Michael A. C. Kane, 630 Park Avenue, New York, NY 10021. Copyright © 2007 by The American Society for Aesthetic Plastic Surgery, Inc. 1090-820X/$32.00 doi:10.1016.j.asj.2006.12.004
January/February
2007
Volume 27, Number 1