Bernardini, Francesco P.

Background: Lower eyelid malposition can result from age-related changes, such as ectropion, or postsurgical changes, such as retraction after lower lid blepharoplasty. The current accepted treatment is surgical, but soft-tissue fillers have been used as well, with good outcome. The underlying anatomy, which is incompletely described, would be useful information for practitioners desiring to provide minimally invasive injections of the lower eyelid. The authors describe a minimally invasive injection technique adjusted to the complex anatomy of the lower eyelid for the treatment of ectropion and retraction of the lower eyelid. Methods: A total of 39 periorbital regions of 31 study participants were retrospectively analyzed using photographs before and after reconstruction of the lower eyelid with soft-tissue fillers. Two independent raters assessed the degree of ectropion and lower eyelid retraction (0 to 4, best to worst) before and after the reconstruction and the overall aesthetic improvement using the Periorbital Aesthetic Improvement Scale. Results: The median degree of ectropion and lower eyelid retraction score improved statistically significantly from 3.00 (SD, 1.5) to 1.00 (SD, 1.0) (P < 0.001). The mean volume of soft-tissue filler material applied per eyelid was 0.73 cc (SD, 0.5). The median Periorbital Aesthetic Improvement Scale score after the treatment was rated as 4.00 (SD, 0.5), indicating improvement of the periorbital functional and appearance. Conclusions: Anatomic knowledge of the lower eyelid and of the preseptal space is of clinical relevance when reconstructing the lower eyelid with soft-tissue fillers. The targeted space provides optimal lifting capacities for improved aesthetic and functional outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Abstract Background It is still unclear which facial region contributes most to the perception of an aged face when evaluated by eye-tracking analyses. Objectives The authors sought to apply eye-tracking technology to identify whether mature faces require longer fixation durations than young faces and which facial region contributes most to the perception of a mature face. Methods Eye-tracking analyses were conducted in 74 volunteers (37 males, 37 females; 43 ≤ 40 years, 31 &gt; 40 years) evaluating their gaze pattern and the fixation durations for the entire face and 9 facial subregions. Frontal facial images of 16 younger (&lt;40 years) and older (&gt;40 years) gender-matched individuals were presented in a standardized setting. Results Independent of age or gender of the observer, a younger stimulus image was viewed shorter than an older stimulus image with 0.82 (0.63) seconds vs 1.06 (0.73) seconds with P &lt; 0.001. There was no statistically significant difference in their duration of a stable eye fixation when observers inspected a male vs a female stimulus image [0.94 (0.70) seconds vs 0.94 (0.68) seconds; P = 0.657] independent of the observer’s age or gender. The facial image that captured the most attention of the observer (rank 9) was the perioral region with 1.61 (0.73) seconds for younger observers and 1.57 (0.73) seconds for older observers. Conclusions It was revealed that the perioral region attracts the most attention of observers and contributes most to an aged facial appearance. Practitioners should be mindful of the importance of the perioral region when designing an aesthetic treatment plan.

AbstractBackgroundThe orientation of facial ligaments changes with increasing age due to the loss of bony support. Soft tissue filler injections placed in close proximity to facial ligaments can alter their orientation to help achieve an improved and younger aesthetic appearance.ObjectiveTo assess the anatomic and aesthetic effects of a standardized injection with soft tissue filler placed directly inferior to the orbicularis retaining ligament in the infraorbital region.MethodsA total of 163 patients with signs of infraorbital aging were treated with a standardized soft tissue filler injection into and in close proximity to the orbicularis retaining ligament (ORL). 2D frontal images of the infraorbital region were rated by eleven blinded and independent raters with regards to the aesthetic appearance of the infraorbital region before and after the standardized injection treatment.ResultsThe aesthetic appearance of the entire infraorbital region (lid‐cheek junction) was rated before and after the treatment. The severity of the tear trough (medial aspect of the infraorbital region) as well as the hollowing of the lateral aspect of the infraorbital region also was rated before and after the treatment. Aesthetic improvement was statistically significant when evaluated by the blinded raters, the treating physician, and the patients. All the results were “very much improved” compared to baseline.ConclusionThe effectiveness of this injection technique is thought to be due to the strategic placement of soft tissue filler that helps to reposition facial ligaments that have changed their orientation during the aging process.