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The Three Periorbital Hollows: A Paradigm for Periorbital Rejuvenation

2005; Lippincott Williams & Wilkins; Volume: 116; Issue: 6 Linguagem: Inglês

10.1097/01.prs.0000185623.36795.38

1529-4242

Robert A. Goldberg,

Dermatologic Treatments and Research

Traditional Concept of Facial Aging: Descent Traditionally, thinking on facial aging has focused on gravitational descent. Textbooks describe the effect of gravity on the soft tissues of the face: the presumption is that laxity of the supporting ligaments allows the cutaneous and subcutaneous soft tissues to shift inferiorly. In the periorbital area, the upper orbital region is thought to change by descent of the eyebrow. In the lower orbital area, descent of the midface tissues has been invoked to account for the hollow appearance of the orbital rim, and, to a certain extent, the orbital fat is thought to descend inferiorly and forward. The resulting prolapse of the orbital fat, limited by the septal attachment, is thought to form the lower eyelid fatty bags. Alternative Concept of Aging: Deflation Val Lambros1,2 has articulated beautifully the concept that focal loss of volume, often in areas of cutaneous attachment of the skin to deep structures, can mimic descent of the soft tissue. In the periorbital area, focal loss of volume along the orbital rim can unveil the contours of the orbital fat bound by the arcus marginalis, and of the sub–orbicularis oculi fat limited by the orbitomalar ligament. If we look at old photographs of patients, this unveiling phenomenon can be appreciated (Fig. 1). It is possible that the most important change is not "prolapse" of the orbital fat or "weakening" of the orbital septum. Rather, a significant and, perhaps, the most important aspect of aging may be the unveiling of deeper contours caused by focal loss of volume. Removing fat can cause more hollowness, including hollowness of the superior sulcus, without really rejuvenating the periorbital area (Fig. 2). The facial bones in the lower periorbital region also lose volume, contributing to the focal deflation and loss of eyelid support in the inferior orbital rim area.3–7Fig. 1: A 35-year-old man (above) and 70-year-old man (below). The lower eyelid bags are formed in part by true prolapse of orbital fat, and in part by loss of volume causing unveiling of the orbital rim.Fig. 2: A 45-year-old man, before and after upper and lower blepharoplasty. The concept underpinning traditional lower blepharoplasty is sculpture of prolapsed orbital fat. However, some of the appearance of orbital fat fullness relates to unveiling; removing fat can lead to deepening of the superior sulcus and hollowing of the lower periorbital area.Skin Changes with Deflation Skin changes are an important component of facial aging. With aging and sun damage, the skin loses elasticity and tone, allowing wrinkles to easily form in response to the underlying facial muscles (which do not likely "hypertrophy" but rather win the fight against the inelastic aged skin more easily). Some of the wrinkling also relates to loss of volume in the subcutaneous tissues.8 The effect of volume loss can be demonstrated by noting the "aged" appearance to the lower eyelid skin that can occur following fat removal in lower blepharoplasty (Fig. 3). Conversely, addition of volume can improve the apparent skin quality (Fig. 4). In the upper eyelid, deflation causes wrinkling of the skin and a hollow along the superior orbital rim.Fig. 3: Nine months after lower blepharoplasty with fat repositioning, we note increased skin wrinkles related to deflation of deep and subcutaneous fat.Fig. 4: The addition of volume to the lower periorbital area using hyaluronic acid gel improves skin wrinkles as a result of diffuse reinflation of the deep and subcutaneous tissues.Subcutaneous tissue volume loss occurs after any type of facial surgery, even if minimal tissue is actually removed, in response to the inevitable vascular and mechanical insult of surgery. The loss of volume often does not show up as much in the first 3 or even 6 months, but rather after complete wound maturation, at 9 to 12 months. Patients and surgeons, enthralled and pleased to photograph the early results, may fail to observe these late changes, which accumulate with multiple operations. The more that we can avoid open surgery, the better we can do in avoiding the inevitable backsliding from surgery. Recognizing that there is a role for lifting and debulking surgeries, a paradigm that creates rejuvenation by adding volume through minimally invasive procedures and decreases the need for open surgeries will best protect and serve our patients. The Periorbital Hollows Focal hollows in the face occur in areas of skin attachment to bone. In the periorbital area, I find it useful to consider three hollows: the orbital rim hollow, the zygomatic hollow, and the septal confluence hollow (Fig. 5). The prominence of each hollow varies depending on the specific developmental and aging features of the individual face.Fig. 5: The areas of deep attachment in the inferior periorbital area are the orbital rim ligament (OR, blue), the zygomaticomalar ligament (Zy, violet), and the septal confluence (SC, green). (Used by permission, Regents of the University of California, 2004.)The Orbital Rim Hollow The orbital rim hollow corresponds with the location of the orbital rim or orbitomalar ligament (Fig. 5).9,10 It follows the circular contour of the inferior orbital rim and is bound by the prominence of the orbital fat above and by the sub–orbicularis oculi fat and cheek fat pads below (Fig. 6). Centrally, overlying the bony depression of the inferior orbital nerve foramen and the cliff of the origin of the levator labii superioris, the orbital rim hollow often has a triangular pendant (Fig. 7). Sometimes the medial half of the hollow is more prominent; this segment is synonymous with the "tear trough" depression described by Flowers.11 In other patients, the lateral half can be prominent, particularly if the lateral orbital fat pad is full. The orbital rim hollow can also be noted in the superior orbit, particularly in Asian patients, as a depression in the sub-brow region (Fig. 8).Fig. 6: The three orbital hollows correspond to these sites of deep attachment: the orbital rim hollow (OR, blue), the zygomatic hollow (Zy, violet), and the septal confluence hollow (SC, green). (Used by permission, Regents of the University of California, 2004.)Fig. 7: (Above) The orbital rim hollow (blue) often has a triangular pennant centrally overlying the inferior orbital nerve canal and ridge of the levator labii superioris. (Below) Improvement in the orbital rim hollow following hyaluronic acid filling. (Used by permission, Regents of the University of California, 2004.)Fig. 8: Between the zygomatic hollow (purple) and the orbital rim hollow (blue) lies the triangular malar mound (*). (Right) One week after the second injection of hyaluronic acid gel, demonstrating filling of the orbital and zygomatic hollows. The upper orbital hollow was not treated. (Copyright 2004, Regents of the University of California, used by permission.)The Zygomatic Hollow The zygomatic hollow corresponds to the location of the orbitozygomatic ligament, lined up approximately with the origin of the levator labii superioris and zygomatic muscles (Fig. 5). The zygomatic hollow is bound by the triangular malar fullness above and by the lateral cheek fat below (Fig. 6). It meets the orbital rim hollow centrally and, in the triangular zone between the orbital rim and zygomatic hollows, there is formed the triangular malar mound (Fig. 8). The Septal Confluence Hollow The septal confluence hollow is not associated with a bony skin attachment, but rather it overlies a different type of deep attachment–the confluence of the lower eyelid retractors, orbital septum, and tarsal plate (Fig. 5). It is bound by the orbital fat pad below and the orbicularis roll above (Fig. 9), which sometimes contains a prominent component of subcutaneous fat.Fig. 9: Immediate postoperative view following filling of the septal confluence hollow using hyaluronic acid gel.The hollows are defined by the surrounding full areas, and in some patients the fullness, for example prolapse of orbital fat, is relatively more important in creating objectionable contours. However, the hollows themselves can give the illusion of fullness and I often find that patients who present with concerns regarding eyelid "bags" actually have circles that are created by the hollows themselves. For these patients, removing the fullness hollows them without really rejuvenating the area. Lifting the cheek can fill the orbital rim and zygomatic hollow with the elevated cheek fat, but, particularly in the medial area, this effect is somewhat unpredictable. Rather, directly filling the hollow areas is a more predictable way to achieve rejuvenation. Options for filling include solid implants such as the Flowers tear trough implant (Fig. 10),11–14 autogenous fat as an implant15 or injection,16,17 or synthetic injectable fillers such as hyaluronic acid gels.18,19 For some patients, blepharoplasty to reduce the fat fullness (especially the lateral fat pad) is effectively combined with filling (Fig. 11). If there is adequate fat to transfer, then fat repositioning into the orbital hollow can provide a vascularized pedicle to fill this area.20–26 However, we are limited by the available fat and in most cases fat repositioning improves but does not completely fill the hollow. Even after fat repositioning, patients may be motivated to consider additional filling (Fig. 12).Fig. 10: Substantial orbital rim hollow with secondary eyelid malposition, treated with Flowers orbital rim onlay implant. (Below) Four-month postoperative view.Fig. 11: For this patient with orbital rim hollow and mild orbital fat fullness, conservative transconjunctival blepharoplasty was combined with filling the orbital rim hollow using hyaluronic acid gel. Preoperative view (above) and three-month postoperative view (below). (Used by permission, Regents of the University of California, 2004.)Fig. 12: A 65-year-old man, preoperatively (above) and 8 months postoperatively (below) after lower blepharoplasty with fat transposition. Partial filling of the orbital rim hollow is achieved, but additional filling, with hyaluronic acid gel, for example, would be beneficial.Compared with standard blepharoplasty surgery, I find that filling the periorbital hollows provides a more pleasing rejuvenation, and, particularly with the advent of better fillers including the hyaluronic acid gels that are convenient, safe, and reversible, I typically offer filling before I offer blepharoplasty. Some patients do go on to have surgery such as blepharoplasty, fat repositioning, or cheek lift. However, many patients are so pleased with the result of filling, they decide to forego surgery altogether. Conclusions Loss of volume plays a critical role in facial aging, and volume loss in the areas of bony attachments can cause three-dimensional contours that mimic gravitational descent. I find it helpful to conceptualize three periorbital hollows: the orbital rim hollow, the zygomatic hollow, and the septal confluence hollow. Each hollow corresponds to an anatomic area of attachment of the skin to the bone or deep structures. Recognizing and characterizing these hollows provides a diagnostic framework and a therapeutic paradigm for filling as a rejuvenation technique. Facial aging has a number of components and varies with bony skeletal support, skin type, fat-distribution, and race. Deflation and descent probably each play a role in facial aging and it is difficult to diagnose in any given patient which mechanism is more important. Gravitational descent does not account for all of the aging changes and, in fact, may have a less important role than it has traditionally been ascribed. There may be no practical advantage to separating deflation from descent. For example, in lower periorbital rejuvenation, lifting procedures that elevate the cheek fat into the periorbital hollows are effective, as are volume procedures, such as implants or filling with hyaluronic acid gel or fat. If lifting helps a patient whose problem is really volume, and if volume augmentation helps a patient with descent, we have been successful in both cases. The value of the paradigm of filling periorbital hollows is that it allows a minimally invasive approach that can be very effective in rejuvenating the periorbital region, whether or not it addresses the actual anatomic aging change. It does not burn bridges for open surgery, but by allowing many patients to avoid going to the operating room, it can form the backbone of a minimally invasive approach that decreases risk and downtime and is very attractive to patients today.