In this article, we will discuss lower eyelid indentation and nasojugal grooves. Along with pretarsal rolls, lower eyelid hollowing is another area that patients frequently want to correct. The lower eyelid indentation often occurs under the orbital rim and lies at the borders of the orbital and palpebral portions of the orbicularis oculi muscle. The tear trough lies medial to the orbicularis oculi muscle which attaches to the bone. The lateral palpebromalr groove attaches to the orbicularis retaining ligament. Let us start by looking at the tear trough.
If the tear trough is severely indented along the medial third of the horizontal length of the eye, it creates a rather fatigued expression of the face. This can be seen in younger and older patients alike and is caused by orbital fat bulging, sagging skin and volume loss of the eye areas.
Figure 1. Placement of mono PDO threads in under-eye fat.
Tear trough correction needs a great deal of caution as bruising can occur easily due to the inferior palpebral vein and angular vein passing this area. Dermal filler injection is the most effective modality for this procedure. If there is volume loss around the orbicularis retaining ligament, I use deep injections into the frontal cheekbone at the SOOF layer and superficial injections in the skin above the orbicularis oculi muscle, using a cannula. I use a 23G cannula for deep injections and 27-30G cannula for superficial injections. I have the patient in a sitting position during the treatment.
The injected filler may appear natural in a supine position but may protrude unnaturally in an upright position. For this reason, I also have the patient create various facial expressions to adjust the amount of filler as needed. As a rule of thumb, a slight lack is better than excess. It is always better to leave some room for retouching at follow-up. I use medium hardness filler for deep injections and soft filler for superficial injection.
Now, let us move onto the palpebromalar groove correction. Palpebromalar grooves form between the lower eyelid and cheekbone, stretching toward the lateral edges of the orbit. They may appear like the lines that form from wearing swim goggles. They are caused by protrusion of the under-eye fat or accumulation of fat on the cheekbone. This can also be corrected by dermal filler injections, with deep injections into the orbital septum and superficial injections above the orbicularis oculi muscle. I use the same hardness of fillers as in the tear trough correction.
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I often come across patients who are concerned about the dark circles around their eyes. Dark circles can be caused by various factors such as darker pigmentation, veins showing under thin, translucent skin, lower eyelid sagging, or a shadow caused by protruding lower eyelid fat, etc. Dermal fillers can be effective if the cause is thin, translucent skin of the under-eye area. Shallow, flat injection of semi-crosslinked HA filler can improve skin elasticity and brighten the tone. MTx combined with oral supplementation of antioxidants, etc. can be used to thicken the skin and brighten the tone in some cases.
-To be continued
