Periorbital fillers are an attractive option to the myriad of surgical face-lift procedures available to patients seeking skin rejuvenation, according to Dr. Janet M. Neigel. "The advantages to using fillers for periorbital rejuvenation are that they are a lunchtime treatment, there’s minimal risk, it results in a natural appearance, it’s minimally invasive, and it’s a good nonsurgical alternative, especially if a patient is not ready for surgery," Dr. Neigel said at the annual meeting of the American Academy of Cosmetic Surgery. "It’s also a great way to get to know your patients before they undergo a bigger procedure."
Dr. Janet Neigel
According to statistics from the American Society of Plastic Surgeons, clinicians performed 12.2 million nonsurgical cosmetic surgical procedures in the United States in 2011. Of these, 1.9 million were fillers.
"With aging there are certain structural changes to the face, including dermal thinning, fat loss, prolapse, redistribution, and skeletal bone remodeling," said Dr. Neigel, a West Orange, N.J.–based cosmetic surgeon who specializes in plastic and reconstructive surgery of the eyes and face. "The natural oval, upside down egg shape of the face changes more to a peanut-shaped face."
Prior to using any fillers, Dr. Neigel said she examines the intended treatment area of skin for hyperpigmentation and points out the relevant spots to patients. "Sometimes patients think that the use of fillers is going to make them have normal skin," she said. "With fillers you’ll improve the shadows, but you’re not going to be able to improve the hyperpigmentation."
Her go-to products for periorbital rejuvenation include the hyaluronic acids Juvederm, Restylane, and Belotero as well as the stimulatory fillers Sculptra (poly-l-lactic acid) and Radiesse (calcium hydroxylapatite). "Crow’s feet are difficult to deal with if they don’t respond completely to your neuromodulator of choice," Dr. Neigel noted. "Botox, Dysport, or Xeomin are the first injections of choice, but I have recently been using Belotero and have been very impressed with how it can improve the eyelid area. It’s used superficially in a layered manner."
When treating the lower-lid tear trough Dr. Neigel said she makes it a point to inject deep just over the periosteum and more inferiorly on the cheek. "Many times if you just inject above the orbital rim, you’re not going to address the full defect," she said. "Oftentimes you need to inject in multiple tissue planes. I use Restylane and Belotero around the eyes, and I inject in a retrograde fashion. I’m always nervous that Juvederm is going to cause too much water to be brought in and too much swelling. I reserve Juvederm for the lower face."
When treating the midface region, Dr. Neigel said that she most often uses Sculptra. "The goal in this area is to volumize the deep medial cheek fat, try to get anterior projection of the cheek and effacement of the lower-lid bags," she said. "We’re reflating the tissue, fighting some gravity, and filling Ristow’s space."
In her clinical experience, the most common complications from using stimulator fillers are ecchymosis and edema. "I have not seen any infections," she said. "I have seen several granulomas, papules, and nodules. If you get lumpiness, you can massage and most of the time it goes away, or you can use hyaluronidase. You can get a Tyndall effect, but I have not seen it in this area. You can also get overcorrection or undercorrection."