Infraorbital Hollow Rejuvenation: Considerations, Complications, and the Contributions of Midface Volumization

Abstract

 

Infraorbital hollows are one of the most common target areas for facial aesthetic treatment; however, they are often perceived to be challenging to treat due to the complex anatomy of the periorbital area, concurrent deformities, and risk of complications. Treatment options include surgical (eg, lower eyelid blepharoplasty with fat transposition or injections) and nonsurgical approaches (eg, fillers). Among these approaches, filler injections have become common practice because they are minimally invasive and provide long-term patient satisfaction. In particular, hyaluronic acid (HA) fillers have been shown to be safe and effective for infraorbital hollow rejuvenation. This review provides an overview of infraorbital hollows, including periorbital anatomy, etiology, clinical assessment, and overlapping deformities, such as malar mounds, festoons, and dark circles under the eyes. Patient and HA filler product selection, injection techniques, as well as potential adverse events, such as bruising/swelling, lower eyelid and malar edema, and vascular occlusions, are discussed. This review also highlights the importance of midfacial volumization to improve outcomes in the infraorbital region and in the overall aesthetic appearance. By selecting appropriate patients and attaining proficiency in periorbital anatomy and infraorbital hollow rejuvenation techniques, clinicians can safely and successfully perform HA filler injections that result in high patient satisfaction.

Level of Evidence: 5

As the focal point of the face, the eyes are one of the first facial areas to show signs of aging.^1,2 Infraorbital hollowing, including tear troughs, can affect the overall facial appearance by conferring a sad or fatigued look, thus affecting facial recognition, self-esteem, and perceived attractiveness.^1,3 In a study examining the preferences of aesthetically oriented women, most respondents considered tear troughs as one of the facial areas that bothered them the most.⁴ Tear troughs were also rated as the second and third most likely facial area to be treated in the 30- to 34-year-old age group and all age groups, respectively.

One of the challenges when discussing the periorbital area is the wide variance in terminology and definitions.⁵ Infraorbital hollowing refers to the U-shaped or curvilinear depression under the eyes that has a dark shadow cast upon it.^2,6 The grooves in the infraorbital region consist of the tear trough, palpebromalar groove, nasojugal groove, and midcheek groove.⁷ The tear trough refers to the deep groove extending ∼2 cm downward and lateral from the inner canthus of the eye and commonly observed in the junction of the eyelid and cheek.⁸ It comprises the medial third of the nasojugal groove⁹ and continues in an inferolateral manner, which in some individuals can be visually observed as the midcheek groove (Figure 1).⁸

Figure 1.

Anatomy of the tear trough. The tear trough includes the medial third of the nasojugal groove, continues in an inferolateral manner, and may be discerned as the midcheek groove over time. The palpebromalar groove is located at the lid-cheek junction and is lateral to the tear trough region.

Although infraorbital hollows are one of the most common target areas for facial aesthetic treatment,⁴ they are often perceived to be challenging to treat due to complex periorbital anatomy, concurrent deformities, and the risk of complications.¹⁰ Treatment options include lower eyelid blepharoplasty with fat transposition or fat injections, laser and light treatments, radiofrequency treatments, topical agents and chemical peels, and fillers.¹¹ Of these treatment options, fat and filler injections are used for volumizing the periorbital areas; however, fat injections are time consuming because of the need to harvest fat, expensive because they require a sterile surgical field, and carry risks of lumpiness and uncertain volume retention over time.^11,12 Hyaluronic acid (HA) filler injections have become common practice because they are minimally invasive and provide long-term patient satisfaction.^7,11,12 HA fillers can easily be administered for immediate results, dissolved with hyaluronidase as needed, and injected repeatedly if necessary.^7,11,12 Multiple studies have reported the safety and effectiveness of HA fillers for infraorbital hollow rejuvenation.^{1–3,13–16}

Current practice in the facial aesthetics field involves global, integrated, and combination treatment approaches that consider the interrelationship between anatomic areas.^17–19 Several studies have shown that the use of filler products in one facial area may help to improve the appearance of another facial area.^17–19 Specifically, midface volume restoration using fillers has been shown to improve patient satisfaction with appearance of the infraorbital region.²⁰

The objectives of this review are to discuss the current understanding on infraorbital hollows (anatomy, etiology, patient selection, treatment, and potential complications) and to examine how treating the midface impacts the appearance of infraorbital hollows.

PERIORBITAL ANATOMY

Rejuvenation of the infraorbital region can be technically challenging due to its unique anatomical features.¹² An understanding of the anatomy of the lower eyelid and midface, with special attention to the vascular and lymphatic anatomy, is imperative to ensuring optimal treatment outcomes and the avoidance of complications.²¹

Eyelid Skin and Structures

The skin of the eyelid is the thinnest in the human body (<1 mm thick).²² The eyelid margin contains the following structures: (1) the lash line, which corresponds to follicles that exit from the skin, (2) the gray line, which corresponds to the muscle of Riolan that is contiguous with the orbicularis oculi muscle, (3) the meibomian glands that are housed in the tarsal plate and contribute to the oily layer of tear film, and (4) the mucocutaneous junction where the conjunctiva lines the posterior portion of the eyelid (Figure 2A).

Figure 2.

Periorbital anatomy of the infraorbital hollow. (A) Structures of the eyelid margin. (B) Periorbital muscles. (C) Superficial (left) and deep (right) fat compartments. (D) Schematic showing relative positioning of the muscles, fat, pads, prezygomatic space, and ligaments. The superficial (eg, infraorbital fat) and deep (eg, deep medial cheek fat) fat pads are separated by the orbicularis oculi muscle. The orbitomalar ligament or orbicularis-retaining ligament and the zygomaticocutaneous ligaments represent the superior and inferior borders of the prezygomatic space. (E) Periorbital ligaments.

Muscle

Lying deep in the dermis, the orbicularis oculi muscle begins at the medial canthus and orbit and attaches to the lateral canthus and orbit.²³ The muscle is divided into the orbital and palpebral orbicularis (Figure 2B).^21,23 The orbital orbicularis controls voluntary eyelid closure and medial brow depression in order to protect the globe.^22,23 The palpebral orbicularis is further subdivided into the pretarsal orbicularis, which is responsible for eyelid closure during involuntary blinking, and the preseptal orbicularis, which is responsible for eyelid closure during voluntary blinking and tear drainage as part of the lacrimal pump.^21,23,24 The tear trough is located between the orbital and palpebral orbicularis, and the nasojugal groove corresponds to the inferior border of the orbicularis oculi muscle.⁷

Other periorbital muscles include the inferior oblique extraocular muscle, which extorts (rotates out) and elevates the eye, and eyelid retractors.²⁵ Lower eyelid retractors include the capsulopalpebral fascia, which creates the lower eyelid crease, and the inferior tarsal muscle, which depresses the lower eyelid during downgaze.²³ Beneath the tarsal plate, the orbital septum, which attaches to the arcus marginalis at the orbital rim and converges with the periorbita and periosteum, separates the eyelid from the orbital fat pads and deep orbital structures.^22,23 The orbital septum maintains the position of the orbital fat pads.

Fat Pads

Posterior to the orbital septum, the lower eyelid is composed of 3 fat compartments: the nasal, central, and lateral fat pads.^22,23 The inferior oblique extraocular muscle lies between the nasal and central fat pads.²⁵ The infraorbital region and midface are also composed of superficial (eg, nasolabial, medial, middle, and orbital) and deep fat compartments (eg, medial suborbicularis oculi fat [SOOF], lateral SOOF, and deep medial cheek) that are separated by the orbicularis oculi muscle (Figure 2C, D).^9,11,26–28 Between the superficial and deep layers of facial fat in the upper malar region is the prezygomatic space (Figure 2D).^28,29 The malar septum, a fascial structure with a relatively impermeable barrier, divides the SOOF into superior and inferior compartments.³⁰ The malar septum defines the boundary where malar edema and other deformities can occur, such as malar mounds (an elevation/bulge composed of fat within the orbicularis oculi muscle and located between the infraorbital rim and midcheek) and festoons (hanging skin or muscle tissue between the medial and lateral canthi).^30,31

Descent and deflation of fat compartments, along with ligamentous laxity, occur with aging.^27,29 Superficial fat pads are often considered “mobile”; therefore, injections that target these fat pads can be problematic and produce an abnormal appearance when the patient smiles.^28,32 Rejuvenation approaches to attain anterior projection of the cheek often target the deep medial cheek fat (which is considered “nonmobile”) and the prezygomatic space.^28,32

Bones and Ligaments

The orbit contains 7 bones, and the infraorbital rim is composed of the maxilla medially and the zygoma laterally.^24,33 Periorbital ligaments include the orbitomalar ligament (orbicularis-retaining ligament [ORL]), the lateral orbital thickening (LOT), and the zygomaticocutaneous ligament (ZCL; Figure 2D, E).^23,25,28,34 The ORL is a series of attachments with varying length that extends from the inferior orbital rim to the skin; it defines the superior edge of the SOOF. The medial part of the ORL is the tear trough ligament.³⁵ Tissue atrophy in the ORL contributes to infraorbital hollows and can thus benefit from filler correction.²⁵ The LOT adheres the eyelids to the lateral orbital rim.²⁵ The ZCL suspends the zygomaticus major and minor muscles, as well as sends attachments to the skin over the malar eminence of the zygoma; it defines the inferior edge of the SOOF (Figure 2D).^25,28

Blood and Lymphatic Vessels

Blood Vessels

Infraorbital hollows are supplied by numerous arterial branches, including the angular artery, zygomaticofacial artery, and infraorbital artery (Figure 3A).^7,36,37 Far medial, the angular artery anastomoses with the dorsal nasal artery, which exits the orbit via the supratrochlear artery.²³ Approximately 6 mm beneath the inferior orbital rim at the inferior lateral orbital notch, the zygomaticofacial artery exits through a small foramen in the zygoma.³⁸ The infraorbital artery typically branches out from the internal maxillary artery, but in some cases, it anastomoses with the angular artery, which connects with the posterior orbit.³⁹ In the majority of cases, there are no major arteries directly on the infraorbital rim, so this area may be considered relatively safe for injection.^7,24 However, some anomalies have been described wherein the position of the angular artery is shifted laterally, very close to the infraorbital rim.³⁸ This detouring pattern has been observed in about 30% of Asians and should be considered when performing injections in this area to avoid potential hemorrhage or embolisms.³⁸

Figure 3.

Blood and lymphatic vessels in the periorbital area. (A) Periorbital blood vessels. Needle illustrates approximate injection location to minimize vascular complications: a, artery; v, vein. (B) Periorbital lymphatic vessels. Light green lines (middle and right) represent the superficial lymphatic system, which drains to the preauricular (laterally) and mandibular/submandibular lymph nodes (medially). The dark green line (left) represents the deep lymphatic system, which drains to preauricular lymph nodes within the parotid gland. Adapted with permission from Shoukath et al.⁴¹ The Creative Commons license does not apply to this content. Use of the material in any format is prohibited without written permission from the publisher, Wolters Kluwer Health, Inc. Please contact permissions@lww.com for further information.

Over the orbital rim, and superficial to the orbicularis oculi muscle, there are several small vertical veins that may contribute to bruising if damaged during filler injections.²² The inferior palpebral vein generally runs from the lateral canthal area in an inferomedial direction to anastomose with the angular vein⁴⁰; this vein can be visualized beneath the skin in most patients.²² Four patterns of the inferior palpebral vein distribution have been identified, which has implications for safe filler injections.⁴⁰

Lymphatic Vessels

Lymphatic vessels in the periorbital area and midface can be divided into superficial and deep lymphatic systems with dual drainage to the preauricular and mandibular/submandibular lymph nodes (Figure 3B).^23,41 The superficial lymphatic system drains the conjunctiva and skin of the eyelid from vessels in the dermis near the medial and lateral canthi. Lymphatic vessels of the superficial system travel above the preseptal orbicularis oculi muscle. Lateral and medial vessels drain toward the preauricular and mandibular/submandibular nodes, respectively. The superficial lymphatic system connects with the deep lymphatic system in the preseptal orbicularis oculi muscle. The deep lymphatic system drains the conjunctiva directly from vessels in the tarsal plate and meibomian glands. Lymphatic vessels of the deep system travel beneath the surface of the preseptal orbicularis oculi muscle, which drain to the preauricular lymph nodes within the parotid gland. Unlike lymphatic vessels in the limbs, lymphatic vessels in the periorbital area and midface have fewer valves, thus predisposing these vessels to obstruction.⁴¹ Compromised lymphatic outflow of the lower eyelid can lead to prolonged lower eyelid edema.

ETIOLOGIES

The etiology of infraorbital hollows is multifactorial and may vary among individuals.^11,26 They may be present at youth and become more pronounced with aging. Infraorbital hollows may occur due to preexisting maxillary bone hypoplasia, as well as age-related loss of subcutaneous fat, descent of superficial fat pads, thinning of the skin overlying the fixed orbital rim, or orbital bone resorption.⁴² As bone resorption progresses with age, the bony floor of the orbit increases its distance from the globe.⁴³ Descent of the orbital floor elongates the lower eyelid and adds to the creation of a hollow, recessed infraorbital rim. Age-related changes in midfacial fat compartments can also contribute to infraorbital hollowing.²⁷

Infraorbital hollows may occur with concomitant and overlapping deformities, which can be classified into 3 groups: atrophic (eg, palpebromalar grooves, anteromedial cheek volume deficiency), bulging steatoblepharon due to weakening of the orbital septum (eg, palpebral bags/lower eyelid eyebags, malar mounds, and festoons), and laxity (eg, cheek and lower eyelid laxity).^10,11 Periorbital hyperpigmentation (eg, postinflammatory hyperpigmentation due to rubbing of the eyes as seen in individuals with allergies or atopic dermatitis) may accentuate infraorbital hollows, contributing to lower eyelid dark circles.^11,42 Individualized treatment plans depend on a clear understanding of the concurrent deformities.¹⁰

ASSESSMENTS

Classification Systems and Grading Scales

Different classification systems and grading scales have been proposed with the purpose of providing an objective method for assessing infraorbital hollows/tear troughs and selecting appropriate patients for filler treatment.¹² Several grading scales based on anatomic studies and clinical evaluations have been developed in the last 10 years, including Belhaouari's Classification,⁴⁴ Raspaldo's Scale,¹⁷ the Allergan Infraorbital Hollows Scale,^16,45 and the Atrophy, Bulging, Laxity Categorization with 6-step evaluation test.¹⁰

Patient Assessment

During initial consultation, standard clinical practice involves documenting any ocular issues and history of previous injections, as well as checking visual acuity. Previous transcutaneous blepharoplasty should be noted because this procedure may leave patients with subtle ectropion¹² that may improve with filler treatments.⁴⁶ Discussion about patient asymmetries is also an important part of the pre-injection consultation. The degree of infraorbital hollowing can be graded using classifications as mentioned above. Photography in primary gaze with and without a flash is recommended for documentation and patient counseling.

Patient Selection

The criteria for patient selection differ for individuals who may benefit from infraorbital hollowing correction using fillers and for those who may benefit from other approaches, such as lower eyelid blepharoplasty.^47,48 A proper diagnosis of the underlying etiology(ies) of the infraorbital hollow is essential for selecting the most optimal treatment strategy.⁴⁷ Underlying etiologies of infraorbital hollows that are amenable to improvement by fillers include atrophy of soft tissue of skin and muscle along the infraorbital rim and inferior and posterior rotation of the bony rim with aging.^7,21,25 Less severe cases of steatoblepharon (orbital fat pad prolapse) may be amenable to camouflage by filler injections.²¹ The ideal patient for treating infraorbital hollows using fillers is one with a minimal amount of steatoblepharon and dermatochalasis (skin laxity), as well as mild to moderately deep tear toughs with well-defined infraorbital hollowing due to loss of soft tissue and bony volume.^{21,42,43,47,48} Similar to other facial areas, patients of all Fitzpatrick skin types can be candidates for infraorbital rejuvenation.^2,3 Characteristics of ideal and nonideal candidates for infraorbital rejuvenation using filler injections are summarized in Table 1.^21,42,47,48 For repeat treatment, a history of filler-related issues (eg, eyelid and malar edema) or the presence of fillers in the area may affect the decision to undergo subsequent procedures. The presence of retained fillers may result in the formation of lumps and irregularities and Tyndall effect in the periocular region.^21,42,47 Hyaluronidase treatment may be considered to dissolve and remove retained fillers.⁴⁷

Table 1.

Ideal and Nonideal Candidates for Infraorbital Hollow Rejuvenation Using Hyaluronic Acid (HA) Fillers

Target area	Ideal candidate	Nonideal candidate
Skin21,42,48	Smooth, thick skin; minimal or no skin laxity (dermatochalasis)	Transparent skin; prominent skin laxity (dermatochalasis)
Fat pad21,42,47,48	Mild-to-no fat pad prolapse (steatoblepharon)	Prominent or herniated fat pad prolapse (steatoblepharon)
Orbicularis oculi muscle21	No orbicularis oculi muscle hypertrophy	Hypertrophied orbicularis muscle. In this situation, the hollow area is preseptal rather than along the infraorbital rim. The preseptal area is a difficult area to inject and treatment tends to be unsuccessful.
Eyelid/malar edema21,42	No history of fluid retention; no eyelid or malar edema	History of fluid retention; eyelid or malar edema
Concurrent deformities21,42	Mild-to-no hyperpigmentation (darkening or coloration that does not contribute to the depth or extension of the infraorbital hollow) and rhytids Mild-to-no palpebral bags, malar mounds, and festoons	Patients with volume loss and concurrent hyperpigmentation can still benefit from fillers; however, filler treatment will not address hyperpigmentation, although it may reduce the shadowing effect. Festoons are often congenital and may require multimodal treatments with surgery and lasers, but may be improved with concurrent midface fillers.

Patients with concomitant hyperpigmentation (ie, darkening or coloration that does not contribute to the depth or extension of the infraorbital hollow) should be informed that filler treatment may reduce the shadowing effect, but hyperpigmentation may still persist.^21,42 Patients with the following characteristics that can result in dark undereye circles may be less amenable to improvement by fillers^5,21,42,48: (1) hypertrophied pretarsal orbicularis muscle (ie, the “jelly-roll”), (2) superficial dermal pigment or lentigos, which may be more amenable to laser treatments, (3) deep dermal pigment, which may be associated with venous stasis, (4) multiple small rhytids that cast collections of shadows, (5) translucent skin (ie, loss of dermal collagen, fat, and elastin allowing visualization of the orbicularis oculi muscle, which appears dark), and (6) malar mounds and festoons. Moreover, patients with severe steatoblepharon and dermatochalasis are not good candidates because even large amounts of filler would not be able to camouflage the contour irregularity.⁴⁷ These patients may benefit from blepharoplasty to remove or reposition the orbital fat⁴⁷ and may benefit from fillers after their surgery has healed. After the etiology of a patient's infraorbital hollow and the patient's clinical history and motivations have been considered, an appropriate treatment plan should be discussed.²¹

TREATMENTS

Treatment options to rejuvenate infraorbital hollows include surgical and nonsurgical approaches, although recent trends favor the use of minimally invasive approaches, such as HA filler injections.¹¹

HA Filler Selection

Knowledge of filler rheology and physicochemical properties is important for achieving optimal results and reducing adverse events (AEs).^21,25 In general, an HA filler with lower elasticity and firmness is recommended for treating infraorbital hollows.^2,24,49 Fillers that can pass through a 30G or 32G needle are preferable to those requiring larger bore needles.

Although several studies have reported the safety and effectiveness of HA fillers for treating infraorbital hollows,^{1–3,13–16} only Juvéderm Volbella XC (VYC-15L, 15 mg/mL HA; Allergan Aesthetics, an AbbVie Company, Irvine, CA) has been approved by the United States Food and Drug Administration for this indication. Previous studies have reported correction of infraorbital hollows (>95% of subjects at month 1) and increased patient satisfaction (>75% of subjects at month 1) after treatment with VYC-15L, with results lasting up to 1 year.^3,16 The safety profiles were comparable for injections with cannula and with needle.¹⁶ The duration of treatment effectiveness in the infraorbital region is longer compared with that reported in more dynamic areas, such as the lips.⁵⁰ This observation may be related to the lower degree of muscle activity in the infraorbital area compared with other facial areas.⁴⁸

Filler Injection Techniques

Positioning the patient in an upright sitting position with eyes open and fixed on a designated target provides the best assessment of the relevant area without distorting the anatomy.²⁴ If the eyelids are closed, the eyes may rotate upward due to the Bell's phenomenon, which can prolapse the inferior fat pads and distort the area for injection.²⁵ Laying the patient in a supine position may also disorient the injector from recognizing major vascular zones.

Prior to filler injections, the face is cleaned, and an appropriate aseptic preparation that is safe in the periocular area is applied.^6,15 Topical anesthetics may not be necessary because the infraorbital rim is not as sensitive as other facial regions (eg, the perioral area). Furthermore, topical anesthetics may cause skin edema that can distort the anatomy.

Filler injections using a needle, cannula, or a combination thereof have been used for infraorbital hollow rejuvenation.^{2,3,13–15,42} Needles may be preferred for rapid injections or making fine contours when injecting into a subdermal area above the orbicularis oculi muscle.⁷ Cannulas may be preferred for injections in the medial to the midpupillary line to minimize bruising, bleeding, and other vascular complications.^7,51

Anatomic landmarks for needle injection points may include the inferior margin of the infraorbital hollow (located between the lateral limbus and lateral canthus), the midpupil level of the infraorbital hollow, and the location 0.5 cm from the medial canthus along the infraorbital hollow.³⁶ Some entry points for canula injections may include the following: (1) an entry point 1.5–2 cm from the orbital rim on the vertical midline of lateral limbus, (2) the point at which the nasojugal fold projection converges with a virtual line perpendicular to the outer canthus of the eye, or (3) the midpoint of the perpendicular projection from the outer canthus of the eye between 2 virtual lines that mark the upper and lower rim of the zygomatic bone.^7,21 Injections are generally made in the supraperiosteal or submuscular plane.^10,16,36 Technical recommendations and best practices for injecting HA fillers are summarized in Table 2.^{6,17,24,25,49,52}Figure 4 shows representative patients treated with HA fillers to correct infraorbital hollows.

Table 2.

Author Recommendations for Injecting Hyaluronic Acid (HA) Fillers to Rejuvenate Infraorbital Hollows

Recommendations

Avoid procedures (eg, laser resurfacing) that could produce considerable swelling on the same day as filler injections. Practice aseptic technique, such as cleansing the face prior to injection and not touching the needle/cannula.52 When marking the infraorbital rim, request the patient to lower their chin with eyes looking up (Figure 1). The infraorbital rim becomes visible in this position. Perform injections with the patient seated in a neutral gaze25,49; infraorbital hollows are better visualized in this position than when the patient is lying down.24 Inject slowly and directly on the periosteum along the infraorbital rim.6,17 Inject small quantities of filler using a staged approach.17 For example, patients with more severe infraorbital hollows may be treated in multiple sessions using small quantities of filler. Avoid superficial injections to prevent the Tyndall effect (bluish discoloration under the skin).6,49 Be cautious while injecting around the infraorbital foramen to avoid injury to the neurovascular bundle.6 Gently massage the HA filler for even distribution; avoid massaging too strongly.6 Follow the key principle “less is more” in order to prevent bulges under the eye; it is much better to undercorrect than to overcorrect infraorbital hollows.6 Inform patients to avoid any strong or extended pressure to the treated area.6

Figure 4.

Representative photographs of patients before and after filler treatment. (A) A 48-year-old female received 1.0 mL of VYC-15L in the tear troughs (0.5 mL on each side) and 1 mL of VYC-20L in the cheek (0.5 mL on each side). (B) The patient is shown at 1-month posttreatment. (C) A 41-year-old female received 1.0 mL of VYC-15L on each side to correct infraorbital hollowing. A needle was used in the middle and lateral region and a cannula was used in the medial region. The patient's photograph was taken (D) 1 month and (E) 18 months posttreatment. (F) A 47-year-old female received 0.6 mL of VYC-15L on each side to correct infraorbital hollowing in the first treatment session. Injections were performed in the submuscular plane with a cannula using a fanning technique. Using the same technique in the second treatment session, the patient received 0.75 mL VYC-15L in the left infraorbital hollow and 0.55 mL VYC-15L in the right infraorbital hollow. (G) The patient's photograph was taken 13 months after the second treatment session.

Complications With HA Filler Injections

Commonly reported AEs associated with HA filler treatment in the periorbital region include bruising, swelling, contour irregularities, and discoloration due to the Tyndall effect.^6,53 Adverse events with corresponding recommendations for prevention/treatment are listed in Table 3.^{6,36,37,53–58}

Table 3.

Adverse Events (AEs) With Corresponding Prevention/Treatment Measures in Patients Undergoing Infraorbital Hollow Rejuvenation With Hyaluronic Acid (HA) Fillers

AE	Prevention/treatment
Pain	Use fillers with lidocaine.6,54
Erythema	Persistent erythema may be addressed with rosacea treatments (eg, oral tetracycline or isotretinoin), low-potency topical steroids, laser treatment, or vitamin K cream.54
Swelling/bruising	If possible, avoid blood-thinning medications/anticoagulants.54,55 Apply ice to minimize swelling/bruising.6,55 If bruising occurs, pulse dye laser treatment may be used 24 h afterward.56
Orange-brown staininga	Apply ice prior to injections.6 Perform injections at an appropriate depth.6 If possible, avoid blood-thinning medications/anticoagulants at least 7 days before injections.6 Q-switched alexandrite laser treatment may also be used.57
Postinflammatory hyperpigmentationb	Limit the number of skin punctures (eg, using the linear threading or fanning technique).54 Persistent hyperpigmentation may be initially treated with a bleaching agent (eg, 2%-8% topical hydroquinone) and tretinoin combined with sunscreen application.54,55 Further therapeutic strategies may include laser treatments and chemical peels.
Tyndall effectc	Treat with hyaluronidase.55
Infections	Avoid performing filler injections if there is an infection in the adjacent site.6 Practice sterile aseptic techniques (eg, disinfect the injection site using a topical disinfectant).54 Infections may be treated with antibiotics active against frequent skin bacteria including Staphylococcus epidermidis or Propionibacterium acnes.6,55
Nodules	For lumps/bumps that occur early after the procedure, massage the area; incise and drain the product if infectious and fluctuant.6,54,55 Dissolve noninflammatory nodules using hyaluronidase.6,54,55 Inflammatory nodules and granulomas may require treatment with steroids and antibiotics.54 Surgical removal may be necessary in rare cases.55 Ultrasound imaging may be used to locate and monitor nodules resulting from fillers.58
Lower eyelid/malar edema	Select appropriate patients (eg, no history of fluid retention) and product (eg, avoid HA fillers with a greater swelling potential).53,55 Limit filler volume, and place filler deep into the malar septum at the immediate preperiosteal level.53,55 Perform a staged treatment approach (eg, small quantities of filler across multiple sessions) and undercorrect.53 Edema may be addressed with head elevation, cold compress, methylprednisolone, and hyaluronidase.55
Vascular occlusionsd	Possess a clear mastery of periorbital anatomy. Inject slowly and apply minimal pressure on the syringe; this technique may decrease the risk of retrograde flow into the retinal arteries.6,37 Limit the amount of filler bolus injected in one site.6,37 Because treatments for vision loss are usually unsuccessful, prevention is key.37 Contacting an ophthalmologist or oculoplastic specialist directly instead of a generalized emergency department is recommended.

^aOrange-brown staining may be associated with bruising and subsequent deposition of hemosiderin.⁶

^bHyperpigmentation, which usually results from bruising and hematomas, is associated with dark skin types (Fitzpatrick skin types IV-VI), although it has been observed in all skin types.^54,55

^cTyndall effect occurs when HA fillers are inappropriately injected in the superficial dermis or epidermis.⁵⁵

^dVascular occlusions are rare events that may result in vision loss/blindness.⁵⁴

In general, although most AEs resulting from HA fillers are mild and transient regardless of the area treated, serious AEs may occur.⁵⁴ Because the periorbital area is supplied by numerous arterial branches, vascular complications, such as the occlusion of the retinal arteries, may result from migration of a filler embolus.³⁶ Vision loss or stroke resulting from an emboli can be one of the most devastating complications. A clear mastery of periorbital anatomy and injecting small aliquots are key to avoiding such tragedies.^6,36,59

Incidences of chronic lower eyelid edema have been reported.^6,30 Acute, mild edema, occurring within 30 days of injection and usually requiring no intervention, may be related to improper injection technique or inappropriate selection of filler.⁶⁰ More rarely, late-onset or chronic lower eyelid edema develops within weeks, months, or years of injection. The cause is usually unclear but may include the injection approach or unique patient anatomic, metabolic, and immunologic factors.^60–62 Injecting filler superficial to the malar septum may augment its impermeable barrier, thereby impeding lymphatic drainage and resulting in fluid accumulation.^30,41 Appropriate filler selection, good injection techniques (eg, staged approach and undercorrection), and thorough knowledge of periorbital anatomy and understanding of patient characteristics may help reduce the incidence of malar edema.^6,53,55,63 Cases of chronic edema may be addressed by injecting hyaluronidase to dissolve existing HA, which may be followed by repeat treatment with the appropriate filler to correct the tear troughs.^60,64

As with lower eyelid edema, the development of nodules after HA filler injection may be acute or delayed, with early onset nodules being more likely related to injection approaches and late-onset nodules with a less clear etiology (eg, variable immunologic triggers).^52,65,66 There are several approaches to the treatment of late-onset nodules, such as antibiotics, steroids, and anti-inflammatory medication that may be considered if medical intervention is required.⁵²

Overcorrection with fillers and/or depositing large volumes in 1 location over a single session may result in an unnatural bulge.^17,48 The periorbital anatomy may help explain why overcorrection of infraorbital hollows leads to this complication, as well as the Tyndall effect and malar edema. Haddock et al⁶⁷ observed that there is no dissectible anatomic plane deep to the orbicularis oculi muscle in the infraorbital hollow; therefore, injections in this region may be considered “intraorbicularis.” This observation has been confirmed by imaging and anatomic studies, which show that preperiosteal injections of HA to the infraorbital hollows did not show a high degree of precision and injected material can lie within the muscle fibers.^26,68 These results suggest that the HA filler may be displaced from deeper to more superficial fat compartments or through gaps in the orbicularis oculi muscle, resulting in periorbital edema.²⁶ Overcorrection of the infraorbital hollows may be managed by hyaluronidase treatment to dissolve the remaining filler.⁴⁷ It is also important to avoid injecting HA filler into the fat pad that lies between the bilaminar subfascial membranes of the ORL, as this may result in an oblong mass under the eye that is difficult to correct.⁶⁹

CONTRIBUTIONS OF MIDFACE VOLUMIZATION TO INFRAORBITAL HOLLOW REJUVENATION

Previous studies have reported the contributions of age-dependent changes in the midface to deficits in other facial areas, such as infraorbital hollows/tear troughs.^18,27,30 A cross-sectional survey consisting of >3,500 participants (age range, 18–75 years) found an association between midfacial volume loss and tear trough and nasolabial fold severity.¹⁸ This positive association was observed in both men and women after adjusting for age, race/ethnicity, and other demographic characteristics.¹⁸ Computed tomographic imaging of the midface demonstrated inferior migration and volume shift of fat compartments during aging, which may worsen the appearance of the infraorbital hollow.²⁷ Treating the midface may therefore help to improve the aesthetic appearance of the infraorbital area.^17,42 In the pivotal clinical study demonstrating the safety and effectiveness of Juvéderm Voluma (VYC-20L, 20 mg/mL HA, Allergan Aesthetics) for midfacial volume deficit, patients reported satisfaction with overall facial appearance and adjacent midfacial areas, such as the tear troughs, for up to 2 years.²⁰ Compared with baseline, there was a 37.5% increase in the proportion of subjects who reported feeling satisfied with their tear troughs at 6 months after treatment.

In addition to treating individual facial deficiencies, such as infraorbital hollows, patients may seek global facial aesthetic improvement.¹⁹ Treating multiple facial areas has been shown to be safe and effective, as well as to considerably improve patient satisfaction.^19,70 This approach can potentially lead to more efficient product use (ie, lower injection volumes of product used during combination treatment vs treatment of an individual facial area).¹⁹ Comprehensive protocols and algorithms, which take into consideration infraorbital hollow/tear trough classification, concurrent deformities, and treatment of other facial areas (eg, zygomatic arch, anteromedial cheek, lateral lower cheek, and submalar area) have been published.^10,71

CONCLUSIONS

The periorbital region is one of the most important regions in facial aesthetics. Hollowing and contour irregularities at the eyelid-cheek junction are a common sign of aging that patients present with for rejuvenation¹; however, infraorbital hollows are often considered challenging to treat.¹⁰ HA fillers can be used to safely and effectively treat infraorbital hollows across the different etiologies.^{1–3,13–15} A thorough understanding of the periorbital anatomy, appropriate patient and product selection, proper injection technique and potential complications, as well as the contributions of midface rejuvenation would allow for successful treatment outcomes and patient satisfaction with treatment.

Disclosures

Dr Woodward is a speaker and consultant for Allergan (Irvine, CA), Galderma (Lausanne, Switzerland), and SkinCeuticals (New York, NY); a speaker for Prollenium (Ontario, Canada) and Lutronic (Billerica, MA); a consultant for Merz (Frankfurt, Germany) and Tarsus (Irvine, CA); and an investor for Stroma Medical (Irvine, CA). Dr Cox is an investigator for Allergan Aesthetics, an AbbVie Company; Galderma, Teoxane (Geneva, Switzerland); and Croma. Dr Boyd is an investigator for Allergan Aesthetics, an AbbVie Company. Dr Ashourian was an employee of AbbVie (North Chicago, IL) at the time the study was conducted. The remaining authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

This research was supported by Allergan Aesthetics, an AbbVie Company. Employees of Allergan Aesthetics participated in the research, the interpretation of data, the review of the manuscript, and the decision to submit for publication.