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Special Communication |

Nonsurgical Considerations for Addressing Periocular Aesthetics A Conceptual Dimensional Approach

Ronald Mancini, MD1
[+] Author Affiliations
1Section of Oculoplastic and Orbit Surgery, Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas
JAMA Facial Plast Surg. 2014;16(6):451-456. doi:10.1001/jamafacial.2014.498.
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Article Information

Accepted for Publication: May 20, 2014.

Corresponding Author: Ronald Mancini, MD, Section of Oculoplastic and Orbit Surgery, Department of Ophthalmology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390 (Ronald.Mancini@utsouthwesten.edu).

Published Online: August 21, 2014. doi:10.1001/jamafacial.2014.498.

Conflict of Interest Disclosures: None reported.

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Figure 1.
Aesthetic Parameters Viewed in the 2-Dimensional Frontal Plane

A, Margin reflex distance 1 (MRD1): the distance from the central corneal light reflex to the central upper eyelid margin; B, tarsal platform show: the distance from the eyelid margin to the eyelid fold; C, brow fat span: the distance from the eyelid fold to the eyebrow; D, eyebrow position; E, lower eyelid margin position quantitated as scleral show when eyelid retraction is present; and F, orbital rim hollow.

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Figure 2.
Nonsurgical Management of the Eyebrow Region

A, Botulinum toxin A injection pattern for a “chemical brow lift.” Chemodenervation of the corrugator-procerus muscle complex can be achieved with on average 5 injections of 5 units per injection of botulinum toxin A and chemodenervation of the lateral orbital orbicularis muscle with on average 2 injections of 2.5 units of botulinum toxin A per injection site. B, An average of 5 injections of 2.5 units per injection of botulinum toxin A can readily allow for brow lowering by weakening the frontalis muscle. C, A 59-year-old woman with eyebrow asymmetry, relative ptosis on the left, and relative retraction on the right before and after botulinum toxin A injection to relatively lower the right brow and relatively raise the left brow. D, Titrated injection of hyaluronic acid gel filler along the inferior border of the eyebrow fat pad in the suborbicularis oculi plane can volumize the skin envelope and elevate the brow soft tissues. E, A 58-year-old woman before and after injection of 0.5-mL hyaluronic acid gel to the eyebrow fat pad.

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Figure 3.
Nonsurgical Management of the Upper Eyelid Region

A, Botulinum toxin A at low doses (an average of 2 injection sites with 2 units per site) injected into the pretarsal orbicularis muscle can subtly raise a relatively ptotic eyelid. B, A 24-year-old woman with left residual upper eyelid ptosis despite 2 prior surgical procedures with improved left upper eyelid ptosis after injection of botulinum toxin A. C, Conversely, a relatively retracted upper eyelid can be lowered with the use of titrated hyaluronic acid gel (HAG) filler. D, A 48-year-old woman with relative left upper eyelid retraction secondary to thyroid eye disease with improved left upper eyelid position after HAG injection. E, Titrated injection of HAG in the lateral and central subbrow region to improve supratarsal volume loss. F, A 67-year-old Asian patient with superior sulcus volume loss and hollowing before and after HAG injection. G, A 38-year-old Asian patient with supratarsal volume loss and development of multiple eyelid folds before and after HAG injection.

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Figure 4.
Nonsurgical Management of the Lower Eyelid Region and Eyelid-Cheek Junction

A, Lower eyelid retraction addressed with hyaluronic acid gel (HAG) injected in small aliquots through multiple injection sites across the length of the lower eyelid. B, A 67-year-old patient with right greater than left lower eyelid retraction before and after HAG injection to improve the lower eyelid position and lessen scleral show. C and D, Orbital rim hollow in a 44-year-old woman before and after 0.5 mL per side of HAG filler. E, Titrated injection of HAG in the malar region can improve the 3-dimensional aesthetics of the entire midface and eyelid cheek junction. F, A 53-year-old woman before and after HAG injection, 1 mL, to the right malar region. Note upper cheek/malar fullness, natural softening of the nasolabial fold, and relative shortening of the lower eyelid appearance.

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