Applied Anatomy of the Lower Eyelid Preseptal Space for Treating Ectropion and Retraction with Soft-Tissue Fillers.

BACKGROUND: Lower eyelid malposition can result from age-related changes, such as ectropion, or postsurgical changes, such as retraction after lower lid blepharoplasty. The current accepted treatment is surgical, but soft-tissue fillers have been used as well, with good outcome. The underlying anatomy, which is incompletely described, would be useful information for practitioners desiring to provide minimally invasive injections of the lower eyelid. The authors describe a minimally invasive injection technique adjusted to the complex anatomy of the lower eyelid for the treatment of ectropion and retraction of the lower eyelid. METHODS: A total of 39 periorbital regions of 31 study participants were retrospectively analyzed using photographs before and after reconstruction of the lower eyelid with soft-tissue fillers. Two independent raters assessed the degree of ectropion and lower eyelid retraction (0 to 4, best to worst) before and after the reconstruction and the overall aesthetic improvement using the Periorbital Aesthetic Improvement Scale. RESULTS: The median degree of ectropion and lower eyelid retraction score improved statistically significantly from 3.00 (SD, 1.5) to 1.00 (SD, 1.0) ( P < 0.001). The mean volume of soft-tissue filler material applied per eyelid was 0.73 cc (SD, 0.5). The median Periorbital Aesthetic Improvement Scale score after the treatment was rated as 4.00 (SD, 0.5), indicating improvement of the periorbital functional and appearance. CONCLUSIONS: Anatomic knowledge of the lower eyelid and of the preseptal space is of clinical relevance when reconstructing the lower eyelid with soft-tissue fillers. The targeted space provides optimal lifting capacities for improved aesthetic and functional outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Management of Severe Botulinum-Induced Eyelid Ptosis With Pretarsal Botulinum Toxin and Oxymetazoline Hydrochloride 0.1.

BACKGROUND: Eyelid ptosis following periocular onabotulinumtoxinA (BoNT-A) treatment is a known complication that can be frustrating for both patients and practitioners. Iatrogenic blepharoptosis occurs due to local spread of the BoNT-A from the periocular region into the levator palpebrae superioris muscle. Although injectors should have a thorough understanding of the relevant anatomy in order to prevent it, BoNT-A induced ptosis can occur even in the most experienced hands. OBJECTIVES: The aim of this study was to describe a case series of patients treated effectively with topical oxymetazoline HCl 0.1% and pretarsal BoNT-A injections in the setting of botox-induced ptosis. METHODS: The study group consisted of 8 patients who had undergone recent cosmetic BoNT-A treatment preceding the sudden onset of unilateral upper eyelid ptosis. RESULTS: A diagnosis of severe ptosis (>3 mm) was made in all the cases in this series. Pretarsal BoNT-A injections alone or in association with topical administration of Upneeq eyedrops (Upneeq, Osmotica Pharmaceuticals, Marietta, GA) significantly reversed the ptosis in all treated cases. CONCLUSIONS: This is the first documented case series of patients treated effectively with topical oxymetazoline HCl 0.1% and pretarsal BoNT-A injections in the setting of botox-induced ptosis. This treatment combination is a safe and effective option in these cases.

Soft tissue filler augmentation of the orbicularis retaining ligament to improve the lid-cheek junction.

BACKGROUND: The orientation of facial ligaments changes with increasing age due to the loss of bony support. Soft tissue filler injections placed in close proximity to facial ligaments can alter their orientation to help achieve an improved and younger aesthetic appearance. OBJECTIVE: To assess the anatomic and aesthetic effects of a standardized injection with soft tissue filler placed directly inferior to the orbicularis retaining ligament in the infraorbital region. METHODS: A total of 163 patients with signs of infraorbital aging were treated with a standardized soft tissue filler injection into and in close proximity to the orbicularis retaining ligament (ORL). 2D frontal images of the infraorbital region were rated by eleven blinded and independent raters with regards to the aesthetic appearance of the infraorbital region before and after the standardized injection treatment. RESULTS: The aesthetic appearance of the entire infraorbital region (lid-cheek junction) was rated before and after the treatment. The severity of the tear trough (medial aspect of the infraorbital region) as well as the hollowing of the lateral aspect of the infraorbital region also was rated before and after the treatment. Aesthetic improvement was statistically significant when evaluated by the blinded raters, the treating physician, and the patients. All the results were "very much improved" compared to baseline. CONCLUSION: The effectiveness of this injection technique is thought to be due to the strategic placement of soft tissue filler that helps to reposition facial ligaments that have changed their orientation during the aging process.

Comparing Water Absorption of Food and Drug Administration-Approved Hyaluronic Acid Fillers.

BACKGROUND: To compare the water absorption of 12 FDA-approved hyaluronic acid (HA) facial fillers in vitro in conditions relevant to in vivo injection. OBJECTIVE: The goal of this study was to provide long-term insight into an improved, tailored facial rejuvenation approach and to understand sequelae that could affect preoperative surgical planning. METHODS: In 2 experiments, 12 FDA-approved HA fillers were loaded into test tubes with nonpreserved normal saline and then placed in a 94.5°F-96°F environment for 1 month to allow water absorption by passive diffusion. The test tubes were centrifuged so that the hydrated filler could pass to the bottom of the tube. The tubes were centrifuged for 12 minutes at 1,200 revolutions per minute in the first experiment and for 7 minutes in the second experiment. A blue dye was then instilled to demarcate the filler/saline interface. RESULTS: There was variation in the water absorption of different HAs. Low absorption occurred in non-animal-stabilized hyaluronic acid. CONCLUSION: The pattern of water absorption was similar in the 2 experiments. The results inform us about in vivo conditions and provide guidance for filler selection.

Late-Onset Upper Eyelid and Brow Edema as a Long-Term Complication of Hyaluronic Acid Filler Injection.

BACKGROUND: Late-onset upper eyelid edema is an uncommonly recognized complication of hyaluronic acid (HA)-based filler injection to the supraorbital area. OBJECTIVES: The authors sought to report their experience in diagnosing and managing late-onset upper eyelid edema. METHODS: This was a noncomparative, retrospective study of a series of 17 consecutive patients who presented with upper eyelid edema 6 to 24 months after uneventful HA filler injection in the supraorbital area. RESULTS: The study group included 17 female patients. The average time of presentation was 13.9 months. Thirteen patients (76.4%) were satisfied after hyaluronidase and requested no further treatment (observation only); 4 patients (23.5%) elected to receive HA filler re-treatment, with satisfactory results. All patients were followed-up for at least 6 months after the re-treatment. CONCLUSIONS: The incidence of late-onset upper eyelid edema is likely to increase as the number of patients undergoing HA filler injection to the supraorbital area increases. Our study emphasizes the importance of recognizing this condition and suggests a suitable noninvasive treatment with satisfying results for both the patient and the physician.