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Surgical Pearls |

Filler Enhancement of the Superior Periocular Area ONLINE FIRST

Julie A. Woodward, MD1; Nicole Langelier, MD2
[+] Author Affiliations
1Departments of Ophthalmology and Dermatology, Duke University Medical Center, Durham, North Carolina
2Duke University Department of Ophthalmology, Durham, North Carolina
JAMA Facial Plast Surg. Published online June 23, 2016. doi:10.1001/jamafacial.2016.0636
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This Surgery Pearl reports that detailed knowledge of anatomy and careful placement of hyaluronic acid filler can be used to restore volume to the eyebrow, forehead, and superior sulcus to improve appearance and patient satisfaction.

Human appearance and nonverbal communication are largely influenced by the superior periocular area. Therefore, patients desire this area to appear as vital as possible. Appropriate volume of the fat compartments of the eyebrow and eyelid, including the frontalis fat, retro-orbicularis oculi fat (ROOF), and preaponeurotic fat are essential for a youthful appearance (Figure 1A, Figure 2). These fat compartments also allow for smooth movement of surrounding tissues to facilitate eyelid function and facial expression.

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Figure 1.
Upper Periocular Anatomy

A, Fat compartments. Tarsal plate (a), palpebral arcade (b), Mullers muscle (c), nasal fat pad (d), central preaponeurotic orbital fat pad (e), retro-orbicularis oculi fat (ROOF) (f), transverse artery of the ROOF, a branch of the supraorbital artery (g), angular artery (h), dorsal nasal artery (i). B, Arteries. Supratrochlear arteries (a), supraorbital arteries (b), and large transverse artery (c), which is a branch of the supraorbital artery that travels through the ROOF.

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Figure 2.
Before and After Photographs of Patient Shown in Video Demonstration

A, Before injection of hyaluronic acid filler to the upper periocular area. B, Immediately after injection. A 30-gauge needle was used to inject filler into the superior sulcus space subcutaneously and posterior to the orbital septum (0.1 cm3 per side) (Belotero; Merz). A 27-gauge cannula was used to volumize the roof (0.1 cm3 per side) (Belotero). A 30-gauge needle was used to inject filler in the periosteal plane at 3 injection points above the lateral corrugator (0.2 cm3 per side) (Restylane Silk; Galderma). A 27-gauge cannula was used to introduce filler diluted 1:1 with saline to the pregaleal plane and massaged into place (0.2 cm3 per side (Restylane Silk). C, One week after treatment to the superior periocular area, the bilateral temple hollowing was treated with filler introduced to the preperiosteal plane with a 27-gauge needle and the subcutaneous plane with a 27-gauge cannula (about 0.7 cm3 per side) (Juvéderm Voluma; Allergan).

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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Filler Technique for Rejuvenation of the Upper Periocular Area

Hyaluronic acid filler is used to rejuvenate the upper periocular area by volumizing the eyebrow, filling a hollow superior sulcus, and smoothing the forehead contour.

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