A woman with her hand on her face

Looking tired is among one of the most common complaints that prompts the aesthetic correction of the infraorbital area. The skin in this area is thin, so anything that distorts its structure is visible.  Some people simply show age and fatigue more easily, which can have a negative impact on self-esteem.

A popular treatment option for the infraorbital area is injecting a hyaluronic acid (HA) dermal filler. Such a filler can be injected in the lower eyelid region to reduce the depth of the tear troughs and freshen up the face. Unfortunately, the area is difficult to treat due to the fact that the skin in this area is unforgiving, so it does not hide overcorrection or filler misplacement. As a result of this, Dr. Tom van Ejik developed the Palma Technique.

 

A complex, high-risk area

The infraorbital area is a delicate region that is layered with structures that are susceptible to aging; these include fat pads, septa, muscles, and vessels, and they all contribute to looking healthy and rested. As we age, these structures begin to deteriorate, and the area may begin to consequently look uneven in volume and tone.

The infraorbital area should only be treated by highly experienced practitioners with a deep understanding of the anatomy of the area and several years of practice with injectables. The area contains arteries that provide blood flow to the optic nerve, and cases of blindness caused by occlusion have been reported. Additionally, the loose connective tissue of the lower eyelid makes it prone to bruising; all of these risks should be explained to patients as part of the consultation process.

 

Using a cannula

Cannulas have become popular tools for treating this area due to the fact that they are less likely to cause bruising. Their blunt tip reduces the chances of piercing a vessel, and it is a safer way to inject a filler in a subdermal manner. The first opening in the skin must be created with a sharp tool, such as a bigger needle, but the cannula can move underneath the skin without causing substantial damage.

 

Using a needle

The hygroscopic qualities of HA allow it to effectively fill and add volume where it is injected. When used superficially in the dermis, it strengthens the skin and encourages fibroblasts to increase collagen production. Unfortunately, the blunt end of the cannula does not allow for injection into the dermis, so it can’t be used for strengthening this layer. Strengthening the infraorbital dermis is critical when injecting filler into the area, as it can help minimize changes that occur with aging. 

On the other hand, a needle allows the injector to correct both a lack of volume and dermal strength. Suboptimal results are characterized by hollowness that can be overcorrected and HA that protrudes from under the thin skin. The infraorbital area can even look blue with the injection of HA under the skin due to the Tyndall effect.  The placement of filler under the skin may also interfere with the flow of lymph fluid, which can cause swelling.

 

The Palma Technique

Using the Palma Technique, the strength and thickness of the skin should be assessed by a simple squeeze with the fingers prior to treatment. The practitioner can also palpate the area to determine hollowness and develop a sense of the amount of volume correction required. The first step of the treatment is to correct dermal strength, which is done by injecting tiny volumes of filler into the mid-dermis. This is done laterally from the lower eyelid towards the thick skin of the cheek at the zygomatic cutaneous ligament.

Afterwards, the volume-related correction of lower eyelid fat can be corrected by filling in the palpation-assessed hollows. This can be done with a needle post-aspiration. Use the needle to examine the tissue by moving the needle very carefully from side to side. These movements reduce the chances of piercing a blood vessel. If deeper volume correction is required, a cannula can be used.

Often, patients present excess skin and bulging infraorbital fat pads in the eye area. Neither of these should be corrected with filler, as fillers are unable to reduce their appearance. Additionally, there should not be attempts made to overcompensate for these factors by increasing volume more than necessary to correct the actual volume deficit.

Strengthening the skin via injection has a limited effect, especially in the thin skin of the infraorbital area and in the first treatment session. As such, it is advised that patients wait for collagen stimulation, as injecting more filler will not have further benefits. Collagen quantities will increase within a few months, and a second dose can be administered to further increase the skin’s strength. Once the patients display optimal results, they should get regular examinations of the infraorbital area to check on aging and the decay of the results in the area over time; these issues may be corrected in a new treatment session.

Since this area shows overcorrection so easily, the appropriate quantity of filler is important to achieve a natural-looking result. In reality, less is more with these injections. The behaviour of the skin should be monitored throughout the process, and, instead of paying attention to the depth of the hollowness, attention should be paid to how it folds when it is squeezed. Practitioners can also monitor the strengthening of the skin by squeezing it after each injection. A surprisingly small amount of product, such as 0.1ml, may be all that is required to strengthen it.

 

Results

Changes in a subdermal area that is injected with an HA filler can be visible almost immediately; the area will appear less sunken. Optimal results should be visible after approximately two weeks when bruising and swelling from the treatment session usually subside. The overall look of the area will also be improved by the strengthened dermis.  The injected filler will be under thickened skin, so the suborbital plane will be better improved than if only filler was added. Since collagen formation will continue for several more months, gradual improvements in the overall results will occur over time as well. A second treatment for dermal strengthening is recommended after two months.

Risk

Dermal fillers do not spread as easily in dense dermal tissue as they do in subdermal loose connective tissue. As such, superficial injections are required to manually distribute an HA filler in the skin. However, this increases the possibility of bruising, especially during the first treatment session when the skin is still weak at this stage.

The likelihood of piercing an artery is very low, as the injections performed are very shallow; however, it is still important that the practitioner has a thorough understanding of the depths of injections and facial anatomy.

 

Conclusion

Lower eyelid hollowness that makes people look fatigued occurs due to a lack of volume and lack of dermal strength. It can also be caused by excess dermal tissue and even bulging infraorbital fat pads, though these cannot be corrected with the use of an HA filler. Only increasing volume with a subdermally-implanted dermal filler may partly correct the hollowness. Strengthening the dermis is essential to further correcting anatomical changes that occur with aging, and this can only be done accurately with a needle in the opinion of Dr. Tom van Ejik.