Periocular Fillers and Related Anatomy

Adding volume to the midface is important because it is the continuum of the lower eyelid. Fillers can be injected into multiple levels in this area: deep (to act as pillars to lift the malar eminence and replace bone that has rotated and soft tissue that has become atrophic or descended) and subcutaneous (to efface soft tissue along the zygomatic cutaneous ligament). Higher G' HA fillers and CaHA often are used in the midface along with PLLA. Facial framing of the temples, lateral cheeks, and preauricular area is often accomplished with PLLA but also can be done with mid to high G' HA fillers or CaHA. A cannula may be used to undermine and break apart the zygomatic cutaneous ligament’s cutaneous attachments prior to delivery of the filler in the subcutaneous plane.²⁶ If not done, filler may track away from the hollow area where the ligament is attached and instead move to adjacent areas that will accentuate the hollow and make it look worse.

The temples and lateral face often are filled with PLLA for framing. Mid or high G' HA fillers and CaHA also are used in the temples both beneath the temporalis muscle and also above the deep temporalis fascia or sometimes in the subcutaneous plane.²⁷

Prevention and Management of Periocular Complications

Blindness is the most devastating periocular complication of facial fillers, which is caused by retrograde arterial embolization followed by anterograde flow into the ophthalmic then central retinal arteries. Injectables that have caused blindness include (in descending order of frequency) fat, HA, collagen, paraffin, polymethyl methacrylate, silicone, PLLA, CaHA, polyacrylamide hydrogel, and micronized acellular dermal matrix. Of the 98 cases of blindness from periocular complications from dermal fillers reported in the world literature, the order of affected sites include the glabella (38 cases), nose (25), nasolabial folds (13), superior forehead (12), infraorbital rim (6), temples (1), malar area (1), lip (1), and chin (1). Prevention includes avoidance of danger zone arteries including the supratrochlear, supraorbital, dorsal nasal, angular, infraorbital, zygomaticofacial and zygomaticotemporal arteries.²⁸

Avoiding the average critical volume of 0.84 in any single aliquot dispensed is key to avoid filling of these periocular arteries to the critical bifurcation point that can result in anterograde flow into the eye (Freudenthal Nicolau syndrome). The smallest supratrochlear artery’s volume in this study was 0.04 cc, so aliquots that do not exceed 0.03 cc are ideal.^29,30

The injector should always be thinking about the anatomy of the danger zones (eg, infratrochlear and supratrochlear arteries, supraorbital artery, frontal branch of the superficial temporal artery, lacrimal artery, dorsal nasal artery, infraorbital artery, angular artery, zygomaticofacial artery, zygomaticotemporal artery)(Figure 3).

^{Image courtesy of Julie A. Woodward, MD.}

Figure 3. Drawing of periocular arterial anatomy.

Conclusion

In summary, periocular injections of facial fillers are useful tools for rejuvenation of the upper face when used with great caution and respect for anatomy.