Off-Label Fillers Help Reposition Aging Eyes

LAS VEGAS – Off-label use of hyaluronic acid fillers can help reposition aging eyes for a younger look.

As bones of the orbital socket dissolve with age, the globe of the eyeball descends and shifts laterally, shifting the balance of the gaze. Permanent fillers such as silicone have been used in the retro-orbital space to lift up the globe, but that doesn’t help move the globe from a lateral to a more medial position, Dr. Ellen S. Marmur said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

For a typical patient who has malar flattening and complains of looking tired all the time, Dr. Marmur uses a "two-point technique." She injects two perpendicular boluses of hyaluronic acid filler under the muscles below each eye and molds the filler upward.

She starts medially to the infraorbital foramen and stays deep, using the fewest injections to cause the fewest bruises and to give a smooth finish.

For patients who are older, she may extend the two-point technique into a five-point technique or even a circumferential technique.

"I start medially and then continue on laterally throughout the upper cheek, all the way up to near the medial canthus," said Dr. Marmur of Mount Sinai School of Medicine, New York. It’s hard to stay under the muscle all the way, so she injects using a threading technique with the bevel down so the filler is being pushed down.

Even dermatologists who are experienced in these techniques will cause bruising in approximately half of patients, she said. The worst bruising and swelling happens in the lateral aspect of the orbit because of the vessels and the histamine released there.

"You should be worried about occlusion, so try to avoid the vasculature," Dr. Marmur said.

If there is lidocaine in the injections, it will numb some of the muscle and the area might get "a little bit twitchy" during the injection.

"Once you fill these areas, you realize it’s a continuum and you want to go around" the lateral orbit itself, she said. "Some people get almost a little ‘V’ of the lateral canthus. Just filling that in also helps reassert the nice dimension and the width of the gaze and makes people look a little less serious. We start looking really serious when we’re getting older."

The eyes are considered a "danger zone" of the face because injections can tract bacteria into the cavernous sinus, she cautioned. "I’ve never seen it happen, and it hasn’t been reported, but be very clean in the area."

Filler injections also can produce a Tyndall effect, a discoloration that can get worse as the filler degrades. "I’m not exactly sure why that is," said Dr. Marmur, adding that she looks forward to newer hyaluronic acid fillers that won’t show the blue hue.

Injections also can take on a "festoonlike appearance," caused either by the filler itself or when the filler grabs water that needs to be massaged away, she said.

Dr. Marmur always talks to patients about the option of using hyaluronidase to reverse the hyaluronic acid filler. "There’s no shame in having it in your office and using it whenever you want," she said. "It’s a nice, comfortable option for people, especially if they’re doing their eyes for the first time.

Dermatologists will be learning from each other about which of the many approved hyaluronic acid fillers are good to use in different areas of the face, but the specialty really needs some well-designed, head-to-head, randomized trials comparing the strengths and weaknesses of these fillers, she said. The studies should compare the fillers for use in patients of different facial types and ages.

Planning cosmetic facial injections for aged patients involves thinking about how they may have looked when they were younger, and understanding the effects of aging, such as bone degradation, muscle thinning, skin laxity, and drooping fat. It also involves understanding the ideals of beauty that might be achieved without changing how the patient looks. Dermatologists also must commit themselves "to not overdoing it and not letting our patients push us into overdoing it," she said.

Dr. Marmur disclosed financial ties with Allergan, DUSA Pharmaceuticals, Genentech, Medicis, Merz, and Sanofi-Aventis.

LAS VEGAS – Off-label use of hyaluronic acid fillers can help reposition aging eyes for a younger look.

As bones of the orbital socket dissolve with age, the globe of the eyeball descends and shifts laterally, shifting the balance of the gaze. Permanent fillers such as silicone have been used in the retro-orbital space to lift up the globe, but that doesn’t help move the globe from a lateral to a more medial position, Dr. Ellen S. Marmur said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

For a typical patient who has malar flattening and complains of looking tired all the time, Dr. Marmur uses a "two-point technique." She injects two perpendicular boluses of hyaluronic acid filler under the muscles below each eye and molds the filler upward.

She starts medially to the infraorbital foramen and stays deep, using the fewest injections to cause the fewest bruises and to give a smooth finish.

For patients who are older, she may extend the two-point technique into a five-point technique or even a circumferential technique.

"I start medially and then continue on laterally throughout the upper cheek, all the way up to near the medial canthus," said Dr. Marmur of Mount Sinai School of Medicine, New York. It’s hard to stay under the muscle all the way, so she injects using a threading technique with the bevel down so the filler is being pushed down.

Even dermatologists who are experienced in these techniques will cause bruising in approximately half of patients, she said. The worst bruising and swelling happens in the lateral aspect of the orbit because of the vessels and the histamine released there.

"You should be worried about occlusion, so try to avoid the vasculature," Dr. Marmur said.

If there is lidocaine in the injections, it will numb some of the muscle and the area might get "a little bit twitchy" during the injection.

"Once you fill these areas, you realize it’s a continuum and you want to go around" the lateral orbit itself, she said. "Some people get almost a little ‘V’ of the lateral canthus. Just filling that in also helps reassert the nice dimension and the width of the gaze and makes people look a little less serious. We start looking really serious when we’re getting older."

The eyes are considered a "danger zone" of the face because injections can tract bacteria into the cavernous sinus, she cautioned. "I’ve never seen it happen, and it hasn’t been reported, but be very clean in the area."

Filler injections also can produce a Tyndall effect, a discoloration that can get worse as the filler degrades. "I’m not exactly sure why that is," said Dr. Marmur, adding that she looks forward to newer hyaluronic acid fillers that won’t show the blue hue.

Injections also can take on a "festoonlike appearance," caused either by the filler itself or when the filler grabs water that needs to be massaged away, she said.

Dr. Marmur always talks to patients about the option of using hyaluronidase to reverse the hyaluronic acid filler. "There’s no shame in having it in your office and using it whenever you want," she said. "It’s a nice, comfortable option for people, especially if they’re doing their eyes for the first time.

Dermatologists will be learning from each other about which of the many approved hyaluronic acid fillers are good to use in different areas of the face, but the specialty really needs some well-designed, head-to-head, randomized trials comparing the strengths and weaknesses of these fillers, she said. The studies should compare the fillers for use in patients of different facial types and ages.

Planning cosmetic facial injections for aged patients involves thinking about how they may have looked when they were younger, and understanding the effects of aging, such as bone degradation, muscle thinning, skin laxity, and drooping fat. It also involves understanding the ideals of beauty that might be achieved without changing how the patient looks. Dermatologists also must commit themselves "to not overdoing it and not letting our patients push us into overdoing it," she said.

Dr. Marmur disclosed financial ties with Allergan, DUSA Pharmaceuticals, Genentech, Medicis, Merz, and Sanofi-Aventis.

LAS VEGAS – Off-label use of hyaluronic acid fillers can help reposition aging eyes for a younger look.

As bones of the orbital socket dissolve with age, the globe of the eyeball descends and shifts laterally, shifting the balance of the gaze. Permanent fillers such as silicone have been used in the retro-orbital space to lift up the globe, but that doesn’t help move the globe from a lateral to a more medial position, Dr. Ellen S. Marmur said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

For a typical patient who has malar flattening and complains of looking tired all the time, Dr. Marmur uses a "two-point technique." She injects two perpendicular boluses of hyaluronic acid filler under the muscles below each eye and molds the filler upward.

She starts medially to the infraorbital foramen and stays deep, using the fewest injections to cause the fewest bruises and to give a smooth finish.

For patients who are older, she may extend the two-point technique into a five-point technique or even a circumferential technique.

"I start medially and then continue on laterally throughout the upper cheek, all the way up to near the medial canthus," said Dr. Marmur of Mount Sinai School of Medicine, New York. It’s hard to stay under the muscle all the way, so she injects using a threading technique with the bevel down so the filler is being pushed down.

Even dermatologists who are experienced in these techniques will cause bruising in approximately half of patients, she said. The worst bruising and swelling happens in the lateral aspect of the orbit because of the vessels and the histamine released there.

"You should be worried about occlusion, so try to avoid the vasculature," Dr. Marmur said.

If there is lidocaine in the injections, it will numb some of the muscle and the area might get "a little bit twitchy" during the injection.

"Once you fill these areas, you realize it’s a continuum and you want to go around" the lateral orbit itself, she said. "Some people get almost a little ‘V’ of the lateral canthus. Just filling that in also helps reassert the nice dimension and the width of the gaze and makes people look a little less serious. We start looking really serious when we’re getting older."

The eyes are considered a "danger zone" of the face because injections can tract bacteria into the cavernous sinus, she cautioned. "I’ve never seen it happen, and it hasn’t been reported, but be very clean in the area."

Filler injections also can produce a Tyndall effect, a discoloration that can get worse as the filler degrades. "I’m not exactly sure why that is," said Dr. Marmur, adding that she looks forward to newer hyaluronic acid fillers that won’t show the blue hue.

Injections also can take on a "festoonlike appearance," caused either by the filler itself or when the filler grabs water that needs to be massaged away, she said.

Dr. Marmur always talks to patients about the option of using hyaluronidase to reverse the hyaluronic acid filler. "There’s no shame in having it in your office and using it whenever you want," she said. "It’s a nice, comfortable option for people, especially if they’re doing their eyes for the first time.

Dermatologists will be learning from each other about which of the many approved hyaluronic acid fillers are good to use in different areas of the face, but the specialty really needs some well-designed, head-to-head, randomized trials comparing the strengths and weaknesses of these fillers, she said. The studies should compare the fillers for use in patients of different facial types and ages.

Planning cosmetic facial injections for aged patients involves thinking about how they may have looked when they were younger, and understanding the effects of aging, such as bone degradation, muscle thinning, skin laxity, and drooping fat. It also involves understanding the ideals of beauty that might be achieved without changing how the patient looks. Dermatologists also must commit themselves "to not overdoing it and not letting our patients push us into overdoing it," she said.

Dr. Marmur disclosed financial ties with Allergan, DUSA Pharmaceuticals, Genentech, Medicis, Merz, and Sanofi-Aventis.