Summary

The periorbital region is one of the first facial regions to show signs of aging. It is critically important to understand precisely what feature of the periocular area is of the most concern to the patient before making therapeutic recommendations. Aging skin is characterized by the appearance of fine and coarse rhytides (wrinkles), rough and uneven texture, dryness, and changes in pigmentation. Fat atrophy occurs in the upper and lower periorbital region leading to progressive skeletonization of the orbit. Fat atrophy in the lower periorbital complex leads to a more prominent infraorbital rim, increasing the height of the lower eyelid and the overall soft tissue vertical dimension of the orbit. Typically, the nasojugal crease is more evident with aging, the malar fat pad has atrophied, the temples have hollowed, and the brow and upper lid have lost volume. In general, changes in skin texture, tone, laxity, or pigmentation are treated with physician skincare cosmeceuticals, chemical peels, lasers, or energy-based solutions. I can augment volume loss with the use of fillers, Autologous fat injection, and BOTOX A. Hyaluronic acid (HA) is the workhorse for the periorbital area because of its good efficacy and predictability and an excellent choice for correcting static rhytides that cannot be treated with BoNT alone and to recontour. Millifat, microfat, and nanofat with the addition of SVF and PRP for more massive volume deficits around the eyes may also be beneficial.

Around the Eyes (periorbital) Aging Anatomy

The periorbital complex—consisting of the upper brow, upper eyelid, lateral canthus, lower eyelid, and infraorbital rim—shows signs of aging in the mid to late 30s. The composition of the youthful periorbital complex starts with an upper brow that is full, with an even fat distribution over the entire length of the brow while obscuring the supraorbital rim.  Aesthetic brow height begins medially at or below the supraorbital edge; as the brow arches laterally, the apex is superior to the supraorbital edge and lateral to the limbus. A youthful periorbital complex also has a small soft tissue vertical dimension and a short lower eyelid height. The fat distribution of the more inferior periorbital complex should be complete, obscuring the infraorbital rim and creating a convex appearance in the profile. Lastly, the skin of the periorbital complex in youth appears taut, smooth, and without redundancy.

The aging of the periorbital complex is the culmination of a multifactorial process that includes the effects of gravity, fatty change, and solar damage. The aging process is influenced by our genetic composition as well as environmental factors. Aging skin is characterized by the appearance of fine and coarse rhytides (wrinkles), rough and uneven texture, dryness, and changes in pigmentation.1 Animation lines in the glabella and lateral canthi and volume loss add to the aged appearance. Repeated facial expressions, ultraviolet radiation exposure, and cigarette smoking contribute to decreased skin elasticity and the development of aging characteristics.

Fat atrophy occurs in the upper and lower periorbital region leading to progressive skeletonization of the orbit. The upper brow loses its fullness, appearing deflated, making the supraorbital rim appear more prominent and contributing to the development of dermatochalasis. Fat atrophy in the lower periorbital complex leads to a more prominent infraorbital rim, increasing the height of the lower eyelid and the overall soft tissue vertical dimension of the orbit.

The loss of volume within the periorbital complex causes the skin to lose its fullness and become redundant. Fat atrophy or selective hypertrophy in the periorbital region can lead to a profile’s concave or wavy facial arcs. Sun exposure results in the formation of rhytids in direct correlation to the extent of sun damage. A combination of these effects leads to an aged appearance of the periorbital region.

Treatment of the periorbital complex should be designed to restore the patient to their own youthful appearance. To restore this youthful, rejuvenated appearance, treatment must address the fatty changes. Lifting procedures or the removal of excess skin alone fail to restore a youthful, rejuvenated appearance. Instead, these procedures may artificially elevate the brows or eyelid creases to higher heights than their positions were during the patient’s youth. The goal of any esthetic surgery is to “restore” the patient’s youthful attributes rather than making the patient look “lifted” or “pulled.” Advances in harvesting and placement techniques have established autologous fat transfer as a stable adjunct in facial rejuvenating procedures.

With new advancements in cosmetic medicine, nonsurgical and minimally invasive procedures have become first-line treatment options. Treatments commonly used today include topical therapies, mechanical and chemical skin resurfacing techniques, lasers and radiofrequency devices, fillers, and neuromodulation by use of botulinum toxin (Botox). Each of these treatment options supplies specific benefits and different side effect profiles and can be combined to maximize results. To prescribe an appropriate treatment plan, it is essential to have a thorough understanding of both periorbital anatomy and perceived signs of aging or fatigue.

Treatment of the periorbital complex should be designed to restore the patient to their youthful appearance. To restore a youthful, rejuvenated appearance, treatment must address the fatty changes. Lifting procedures or the removal of excess skin alone fail to restore a youthful, rejuvenated appearance. Instead, these procedures may artificially elevate the brows or eyelid creases to higher heights than their positions were during the patient’s youth. The goal of any esthetic surgery is to “restore” the patient’s youthful attributes rather than making the patient look “lifted” or “pulled.” Advances in harvesting and placement techniques have established autologous fat transfer as a stable adjunct in facial rejuvenating procedures.

With new advancements in cosmetic medicine, nonsurgical and minimally invasive procedures have become first-line treatment options. Treatments commonly used today include topical therapies, mechanical and chemical skin resurfacing techniques, lasers and radiofrequency devices, fillers, and neuromodulation by use of botulinum toxin (Botox). Each of these treatment options supplies specific benefits and different side effect profiles and can be combined to maximize results. To prescribe an appropriate treatment plan, it is essential to have a thorough understanding of both periorbital anatomy and perceived signs of aging or fatigue.

Periocular rejuvenation is a complex topic and addressing only one of many needs may or may not provide a satisfactory result. It is critically important to understand precisely what feature of the periocular region is of the most concern to the patient before making therapeutic recommendations. Some patients complain of “looking tired” when in fact they are concerned about the loss of skin tone, excessive eyelid skin (dermatochalasis), eyebrow ptosis, dark circles under the eyes, hollowness in the tear trough area (medial lower eyelid below the orbital rim), bulging orbital fat pads, “hypertrophic” pretarsal orbicularis oculi muscle, and/or deep lateral canthal rhytides. The best candidates for periocular BTX injections are those with mild to moderately deep lateral canthal rhytides and/or those who develop a “roll” of pretarsal orbicularis muscle as they smile.

There are very few absolute contraindications to periocular BTX injection. I should use it with great caution in patients with right dry eye syndrome or systemic diseases that may produce dry eyes such as Sjogren syndrome and severe rheumatoid arthritis, and in patients with ocular myasthenia gravis or other conditions that may affect extraocular muscle function. I should use it with great caution in patients whose eyes do not close well (a condition known as lagophthalmos) due to earlier seventh nerve palsy, thyroid eye disease, or previous blepharoplasty.

The examination of the patient begins with an evaluation of the patient from across the room. The patient’s facial features are assessed for typical facial stigmata of aging, including lentigines, erythema, fine wrinkling, loss of skin laxity, eyebrow and/or eyelid ptosis (or chronic eyebrow elevation to correct latent brow or lid ptosis), midfacial ptosis, jowls, loss of facial volume, and deep dynamic rhytides in the glabellar, perioral, and periocular regions. It is essential to view the patient before concentrating on the periocular (or any other individual) region, as any treatment aims to create a harmonious facial appearance. An observer’s eye is drawn to asymmetry more so than rhytides or lines. That is, the creation of a “smooth island in a sea of rhytides” produces a less natural appearance than if the patient were not treated at all.

The patient is then evaluated from a frontal perspective. Particular attention is paid to the presence of rhytides at rest, eyebrow contour and position, horizontal forehead rhytides that may be indicative of chronic brow elevation, the extent of photoaging, presence of dermatochalasis in the upper eyelid, location of the upper eyelid margin relative to the pupil, and lower eyelid position. Add ophthalmic evaluation is warranted if white sclera is visible above the superior limbus or below the inferior corneoscleral limbus. The presence of horizontal forehead rhytides may either show overactive use of the muscles, facial expression, or a compensatory response to eyebrow ptosis. One must distinguish this, as weakening the frontalis muscle in the following setting will uncover previously latent eyebrow ptosis. That is, patients who have been elevating their eyebrows continuously to prevent impairment of their superior visual field will no longer be able to do so if their frontalis muscle is weakened.

The examiner can find the patient with latent brow ptosis by studying when the frontalis muscle is completely relaxed (instruct the patient to relax their forehead). If the eyebrows assume a lower position when the frontalis muscle relaxes, BTX should not be injected into the forehead.  These patients need eyebrow and/or eyelid surgery to correct their underlying problems.

Next, the patient is asked to gently (not forcibly) close the eyes to ensure complete apposition of the upper and lower lids. Some patients who have had prior surgery, trauma, or thyroid disease may be able to forcibly close their eyes but have an incomplete blink that leaves them highly vulnerable to symptomatic dry eyes if the orbicularis oculi muscle is weakened. The patient is then instructed to close the eyes forcibly. This permits the evaluation of the pretarsal orbicularis oculi muscle in its active state.  The appearance of a prominent “bulge” in the pretarsal region is suggestive of “hypertrophic” orbicularis oculi muscle. Significantly, I must differentiate this condition from a “bunched” lower eyelid occurring because of cheek tissue recruitment with the zygomaticus major and minor muscles contraction. The use of too much toxin will minimize the action of the orbicularis oculi muscle to the point where the lateral canthus does not wrinkle at all with smiling and other facial expressions. This can signal the appearance of artificiality in some patients, and thus I should avoid overaggressive injection in the crow’s-feet region.

I should keep a careful injection record, and first-time patients are usually followed up two weeks after their injection. At the follow-up visit, the treatment goals should be reviewed and compared to the clinical results. If added doses are needed to achieve the desired goals, these should be administered at the follow-up visit. If the patient has not reached the best possible outcome, I should make careful notes about adjustments that need to be made in dosage, placement, or both. BTX can also be used to weaken the pretarsal orbicularis oculi muscle. This can reduce the prominent “roll” that appears with smiling in patients with “hypertrophic” orbicularis muscle and can also increase the size of the palpebral fissure (the distance between the upper and lower eyelids). While these goals are separate, they are indistinct in that it is challenging to carry out one objective without the other. That is, treatment of hypertrophic orbicularis oculi muscle will reduce the muscle bulk upon smiling and make the eyes appear to be open wider.

Forehead (Frontalis Muscle)

I should carefully evaluate the benefit of the treatment of these muscles. For some patients, treating the upper part of these muscles is the best choice because the treatment of the entire frontal region causes significant loss of facial expression (masked appearance). Moreover, total paralysis of the frontalis m. can cause brow ptosis. The frontal region should always be treated in association with the glabellar area for more satisfactory results, avoiding the excessive use of the glabella’s muscles, which are depressors.

The injections are typically given 2.5–5 units per injection site, depending on the extent of the area to be treated, whether totally or partially. Patients with a narrow brow should receive fewer injections (four sites, compared to five) and lower doses than patients with broader brows. Thus, the clinician should be conservative and allow some functional areas to remain intact to enable brow elevation.

The Glabella (Frown Line)

Treatment aims to reduce the vertical as well as the horizontal lines of the glabella. Contractions of the corrugators and, to a lesser degree, the medial orbicularis oculus and the depressor supercilii produce vertical lines between the eyebrow. Contraction of the procerus produces horizontal lines over the bridge of the nose. Five injections, with two injections into each corrugator and one into the procerus, have been recommended for the cosmetic outcome. Clinical techniques should consider the variation in location, size, and use of the muscles among individuals.

Supraciliary wrinkles

Injection of botulinum toxin into certain areas of the face that carry a high risk of ptosis (danger zone) needs caution in the application. An example is a lateral forehead, particularly the lower part. Recently, however, injection of BTX-A through the temporal hairline to correct supraciliary wrinkles seems safe and effective.

Crow’s feet, Hypertrophic Lower Lid, Narrow Eye Aperture, and Eyebrow Elevation)

The main cosmetic indications in the periorbital area include crow’s feet, hypertrophic lower eyelid orbicularis, narrow eye aperture, and eyebrow elevation. Patient assessment is critical to making an individualized treatment plan. The practitioner determines the source of the wrinkles- when assessing the lines while the patient animates and at rest. Evaluation should include a “snap test” to measure skin laxity along the lower lid margin. Skin that does not snap back into place after downward tugging may not respond well to neurotoxin treatment and be at higher risk for ectropion.

Hypertrophic Orbicularis

During smiling, the size of the eye aperture tends to be diminished partly due to the contraction of the pretarsal orbicularis. Hypertrophy of the pretarsal portion of the orbicularis oculi can give a “jelly roll” appearance to the lower eyelid, enough that some individuals may complain that they look overweight. We have found that two botulinum toxins injected into the lower pretarsal orbicularis will open the palpebral aperture both at rest and when smiling. This procedure should be used only for patients who respond well to a pre-injection snap test; treatment is contraindicated for patients who have had earlier lower eyelid ablative resurfacing or infra-lash blepharoplasty without a coexisting canthopexy to support the normal position of the lower eyelid. Surprisingly, inferior eyelid injection is painless.

Eyebrow Asymmetry and Shaping

Injection of BTX-A for glabellar frown lines can cause mild medial brow ptosis, a lateral brow elevation, and a more pleasing contour to the eyebrow.

Chemical Brow Lift

Brow depressors include the glabellar complex, most notably the procerus and depressor supercilii. Clinicians can use the knowledge and understanding of how BTX-A works in the glabellar region to change the appearance of the brows in patients who desire a more aesthetically pleasing look.

Lower Eyelid Wrinkles and Eye Aperture Widening

Treatment of the eyelids has become popular, especially among two groups, those patients with fine wrinkling found on the lower eyelid and those who have a ptotic brow that is dropping down and adding weight to the upper eyelid.  Treatment can be afforded using botulinum toxin, which allows improvement of wrinkling of the lower lid and eye aperture widening. I can achieve lateral brow elevation by treating fibers of the orbicularis oculi, which slightly lifts the lateral brow off the upper eyelid.

Lower eyelid wrinkles are caused in part by contractions of the orbicularis oculi muscle. This muscle is intimately associated with the thin eyelid dermis and has multiple insertions around the peri-ocular skin.  Contraction of the inferior pretarsal orbicularis produces inferior eyelid wrinkles. This inferior part of the muscle serves to crinkle the lower lid and helps to suspend the lower eyelid. 2U of botulinum type A toxin placed in the mid-pupillary line of the lower eyelid, 3mm below the ciliary margin, was helpful to remove lower eyelid wrinkles. It was also noted to increase the palpebral aperture. A more significant effect can be seen when the inferior eyelid is treated along with the crow’s feet area. This is because a more considerable orbicularis oculi muscle is relaxed and serves to open further and widen the eye aperture. However, overtreatment can produce complications, including excessive drooping of the lower eyelid skin, photophobia, and the inability to close the eye entirely.

Although effective in diminishing the hyperkinetic lines, it is not recommended to treat the static wrinkles caused by photodamage or other causes, such as skin laxity. In these cases, I would recommend combination therapy. For this sign, lower doses and superficial injections should be used. I should avoid the treatment of the lower eyelid with BoNTA in individuals with lower eyelid laxity or recent lower blepharoplasty.

Volume loss is a natural phenomenon of the aging process and can be augmented with fillers. Hyaluronic acid (HA) is the workhorse for the periorbital area because of its good efficacy and predictability, but autologous fat is also beneficial for more massive volume deficits. HA creates effective cosmetic results, good duration, and minimal complications. Volume augmentation in the periorbital region can be beneficial for treating deep nasojugal lines (often referred to as “tear trough” defects), the elevation of the temporal brow, and even smoothing of fine eyelid wrinkling. It is also an excellent choice for correcting static wrinkles that it cannot treat with BoNT alone and re-contour. The choice of product for each application varies according to personal preference.

Patient Selection and Pretreatment Evaluation

Patients with deep tear trough defects, ptosis of the midface, and descent of the brow’s tail may all be excellent candidates for periorbital soft tissue volume augmentation. Beware of patients who do not have a profound tear trough defect but complain of “dark circles” under the eyes. These patients have dyspigmentation of the skin and thus will not benefit from volume augmentation.

I must counsel patients that bruising and swelling may be more common after periorbital soft tissue volume injection than after injections elsewhere. Bruising is quite common and can, occasionally, be severe. When medically acceptable, patients are often recommended to avoid anticoagulants for 10 to 14 days before the injection.

Glabella and Central Brow

The glabella and central brow are anatomically unforgiving areas about both safety and aesthetic considerations. For security, it is necessary to visualize vital structures such as nerves and vessels and take measures to avoid them when injecting fillers or botox (neuromodulators). Regarding aesthetics, the slightest overfilling or misplacement of a fraction of a milliliter of filler within the glabella and central brow can cause suboptimal results. Therefore, it is recommended that HA fillers be used, as contour correction can be performed if needed by removing them in part or entirely by the injection of hyaluronidase. Dilution of fillers with saline and/or lidocaine suspension makes them easier to spread with post-injection tissue molding to achieve smooth contours. This is because dilution reduces filler viscosity. Dilution is best performed with the aid of a sterile two-way female-to-female adaptor to which the syringe of filler and another syringe holding the diluent can be attached.

An understanding of structural and functional anatomy and the physicochemical characteristics of fillers –including the flow-related (rheologic) properties of elasticity (G prime) and viscosity that predict their behavior – informs the choice of appropriate filler products and injection techniques to achieve optimal results Fillers may be injected into the glabella and the central brow via two approaches: deep and superficial. These approaches may be used alone or in combination with a multi-plane or ‘sandwich technique.

The path of least resistance, or glide plane, in the forehead, including the central brow, is the subgaleal (pre-periosteal) plane, which stands for the plane between the superficial and deep fascia of this facial zone. This glide plane can be bluntly dissected with ease using the filler product with the anterograde flow. The in-depth approach is well suited to corrective contouring for restoring volume to the glabella and central brow and augmentation of the forehead, including the central brow.

Implantation of fillers into superficial tissue planes to the frontalis (high subcutaneous or intradermal) carries no risk of nerve damage at the brow level since the supraorbital, supratrochlear nerves run and ramify within the frontalis. There is also no risk of meeting the vessels associated with these nerves since they follow the same course. I may use the simple approach for contouring to restore or augment volume and for filling rhytides.

Lateral Eyebrow

I may administer injections into the underlying retro-orbicularis oculi fat (ROOF) pad, which lies above the orbital rim posterior to the brow cilia. For patients with skeletonization of the lateral bony orbital rim, dermal filler is introduced along the lateral orbital edge and lateral sub-brow to restore soft tissue loss and supply a youthful and pleasing cushioning effect to camouflage the visible bony prominence. This approach also supports the lateral brow, which reverses the illusion of brow descent from the shadow it casts due to the lack of sub-brow fullness.

Infra-orbital Hollow / Tear Trough/Lid Cheek Junction

The hyaluronic acid fillers are an excellent alternative to fat in the cheek–lid junction because of their ease of use, unique safety profile, and limited nodularity.  Restylane is most safely injected deep into the orbicularis muscle. Frequently, mild irregularities can be massaged to diminish nodularity.

Linear threading (the fanning technique) and serial puncture are the most commonly used techniques in the IOH. Small aliquots of 0.1–0.2 mL are deposited along the length of the groove, using digital manipulation instead of direct injection in the medial portion to avoid inadvertent injection of the infratrochlear vessels and infraorbital nerve. A filling agent can also be ‘pushed’ into the desired location manually.

The periorbital region is one of the first facial regions to show signs of aging. Typically, the nasojugal crease is more evident with aging, the malar fat pad has atrophied, the temples have hollowed, and the brow and upper lid have lost volume. This volume loss is accentuated by brow lifts and blepharoplasty procedures that alter brow position and remove fat, further skeletonizing the patient. Suboptimal results, however, have led surgeons to reassess their approach to the periorbital area. Prof Moawad is a pioneer in rejuvenating the periorbital region through volume restoration using autologous fat transplantation. A conservative trans-conjunctival blepharoplasty or skin-only upper blepharoplasty combined with fat grafting can provide reliable rejuvenation and limit morbidity associated with higher volumes of fat grafting that would otherwise be necessary without concomitant excisional-based surgery.

Fat transfer to the forehead is an excellent method to lift the eyebrows.  The brow is directed outward through fat augmentation and can support the overlying skin without raising the brow to an unnaturally high position. Furthermore, by placing the fat into the lower eyelid region, the transition from the eyelid to the cheek is shifted up, and the convexity of the youthful eye is restored. Lower-lid volume replacement is also helpful in treating dark circles under the eyes by reducing shadows and the appearance of blood vessels under the skin. Prof Moawad uses the “Pearl” technique with small quantities of fat tissue injected through a 1-mL Luer-lock syringe and a 20-gauge microcannula with one hole for better control. In a novel approach, platelet-rich plasma is added to micro fat were injected, giving a promising natural result.

Superior Orbital Rim

The superior orbital rim is approached through a lateral forehead entry site. A 1.2 mm cannula is used for all upper face injections barring the upper eyelid sulcus, where 0.9 is utilized. The fat is placed over the rim in much the same way as the lower orbital rim, using non-dominant tactile feedback. Overall, 1 to 2mL is placed over the lateral edge. A midline entry site is then utilized to blend the fat into the medial rim and glabellar region, totaling 1 to 2 mL per side. When the orbital rim is grafted adequately, the brow will have a Cro-magnon–like appearance that can be pretty disturbing. However, by adding fat to the forehead in a subcutaneous plane, this appearance will quickly disappear as the forehead deficiency is filled and the entire upper face blended into the volume restored orbital rim.

Eyebrow

When fat is grafted to the brow, millifat is used to provide a structural change in brow projection and is grafted retrograde in tiny threads or pulses, depositing the fat in the shape of a multidimensional wedge. Hence, it blends into both the medial and superior brow. The fat graft is injected under the eyebrow and slightly biased inferiorly. If mild brow ptosis is associated with excessive upper eyelid skin lateral to the lateral canthus, fat grafting is performed to lift the lateral brow. If moderate to severe brow ptosis is present fat grafting is carried out first, followed by endoscopic or minimally invasive temporal browlift.

Upper Eyelid Sulcus

Upper eyelid sulcus grafting may take place utilizing an entry site in the brow. During the consultation, a specific conversation about this area is advised to the patient. Many will not understand the concept of a volume-restored upper eyelid, and some may be displeased with the outcome. Comparing youthful photos of the patient is helpful to explain to them how their upper eyelid had more volume in youth, assuming they have not had a deep sulcus naturally. In our experience, however, even with an explanation, many women prefer more tarsal show than an entire lid and opt for an upper eyelid skin removal rather than volume restoration. If volume replacement is chosen, approximately 0.5 to 1.0 mL of fat is placed into the upper sulcus, starting in the infra brow and working inferiorly. Additional micro-fat or nano fat grafting can be performed for refinement of the subcutaneous tissue of the upper eyelid. Nano fat can also be delivered by micro-needling

Orbital Rim and Infraorbital Area

Highly desirable smooth transition from the lower eyelid to the cheek that is generally unobtainable by traditional lower eyelid surgery, fat transpositions, septal resets, midface lifts, free fat grafts, and other like means. Fat grafting the infraorbital area allows comprehensive correction of age-associated hollowness that lends the face an ill or tired appearance that shortens the lower eyelid’s apparent length and produces a youthful, attractive. The inferior orbital rim is considered the most technically tricky area to achieve a consistently excellent result. I must take care not to place the fat with too large a bolus per cannula pass into the wrong plane or with too large a total volume, all of which can lead to a complication that may cause difficulties to rectify.

In treating the upper orbit, fat need not and should not be grafted in the pretarsal lower eyelid. Fat should be injected deep in a sub-muscular/pre-periosteal plane. I should think of the technical goal of the procedure as raising up and anteriorly projecting the infraorbital rim rather than filling the lid itself. Like the upper orbit, volumes required to obtain corrections in the lower orbit are typically more than might initially be expected, and 2 to 3 mL per side are necessary to produce the desired effect in most cases, and occasionally more. However, unlike the upper orbit, experience has shown that fat is best and most easily injected perpendicular to the infraorbital rim. When this is done, lumps and irregularities are far less common. Fat should not be injected parallel to the lid-cheek junction in the infraorbital area. It is wise to avoid any subcutaneous injection in the infraorbital area because of the fragile skin present and the likelihood of creating visible lumps and irregularities and to limit grafting to a preperiosteal/sub–orbicularis oculi plane.

Although microinjection at the preperiosteal level has reduced the incidence of nodules caused by misplaced fat, there remains an incidence of persistent irregularities. These irregularities are typically caused by accidental fat placement superficially within the orbicularis muscle. The best treatment for visible fat bumps includes direct excision through small incisions. I should avoid steroid injection because of the absence of efficacy and potential further soft-tissue atrophy. The supposed benefits of superficial grafting (improving skin texture and color) are too small an improvement in most cases for all but expert injectors to offset the likely occurrence of visible and difficult-to-correct irregularities.

Tear Trough

Where the infraorbital area ends, and the tear trough and cheek areas begin hard to define precisely; the treatment of the infraorbital, cheek and tear trough areas must be undertaken concurrently in most patients, and the treated areas overlap each other to a certain extent, as they do on different areas of the face. In addition, I must never forget that the goal of the procedure is creating youthful and attractive contours, not merely filling a specific area. Treatment of the severe tear is most easily and best performed using incisions situated inferior to the medial orbit and placing fat predominantly perpendicularly, as in the cheek. A 4 cm long, 0.7-mm (22-gauge) cannula is typically used, and fat is situated deep in a preperiosteal/ sub–orbicularis oculi plane, especially superiorly and medially, where the skin is the thinnest.

Fat can safely be placed more superficially, especially in the lower, more lateral part of the tear trough that is frequently seen to run down into and onto the cheek, and when this is done, improved outcomes are obtained. From 0.5 to 1.5 mL of fat are typically placed on each side in the tear trough area, depending on how far inferiorly and laterally it extends onto the cheek. Because of the sensitive nature of the lower lid region, fat grafting should be reserved for when one has achieved significant experience with fat grafts to the other areas of the face. Combining micro-fat and nano fat with a 1927-nm fractional laser may be used synergistically to treat photodamage and superficial fat loss. The laser targets the epithelium and superficial dermal layers, while the nano fat addresses the deep dermis and epithelium, and the micro fat addresses the subcutaneous, superficial fat loss.