Dr. Robyn Siperstein shares her experience with more than 1,000 infraorbital filler cases and how to overcome challenges and achieve optimal results when injecting this inherently difficult facial area.
Robyn Siperstein, MD, board-certified dermatologist, Boca Raton and Boynton Beach, Florida
“The area under the eye is a very difficult location to inject for many reasons—mostly because it’s a tight space bound by a lot of ligaments,” said Robyn Siperstein, MD, who presented “Treatment of Infraorbital Hollows” at the ODAC Dermatology Conference 2023 in Orlando, Florida.
Among the hurdles of infraorbital filler injection are the orbital retaining ligament above and zygomatic cutaneous ligament below it, said Dr. Siperstein.
“If that weren’t enough, we have a malar septum which is an impermeable membrane. The infraorbital area holds on to any swelling and bleeding, which makes it a very difficult area to treat. Additionally, there are lymphatics in the area that can get clogged.”
Dermatologists injecting under the eyes should be aware of important blood vessels including the infraorbital artery, which is below the medial pupillary or line, said Dr. Siperstein.
“You can usually feel it. It’s right under the tear trough, about 1 cm down from the orbital rim.”
The zygomaticofacial foramen is not present in all people but when it is, it’s about a finger width outside the bony orbital rim, then another centimeter down. The zygomaticofacial foramen feels like a slight depression and hurts a little when pressed, she said.
“Lastly, there is the transverse facial artery that comes across under the zygoma and most of the time connects to the infraorbital artery. The infraorbital artery has a branch that connects the majority of the time to the angular artery, which comes up from the facial artery.”
Injection Technique Tips
Injection points away from the foramens and the malar mound help to reduce bruising and swelling, said Dr. Siperstein.
“My injection point is usually under the malar septum because if you inject above the malar septum, on the malar mound, you might get more swelling. I pick a point with my vein finder to reduce the risk of bruising underneath the malar septum and come up medial to it. I start as deep as possible. If you’re deep under the muscle you’re less likely to get swelling and the lymphatic flow is better.”
To address contour differences, Dr. Siperstein places some filler in all layers, with very little (0.1 cc filler) in a superficial or middle plane, she said.
“I did a retrospective study in my practice and the less filler you put in the less swelling….”1
Half syringes, or .055 cc or less, are perfect to use under both eyes, said Dr. Siperstein.
Preventing, Fixing Side Effects
Thin skin, vascularity, and swelling make the under eyes hard to treat. Dr. Siperstein has infraorbital filler patients sign a separate consent form because there are unwanted side effects in the infraorbital area post-injection that don’t occur as often in other facial areas, she said.
Despite the increased complexity of infraorbital injections, when done correctly, treatment can be a practice “gamechanger,” and she has never encountered a problem she couldn’t fix, said Dr. Siperstein.
“If somebody is prone to swelling (and it makes sense because this is a small, confined space), you can mix 0.1 cc of triamcinolone in with your under-eye filler, and it cuts the swelling by more than half….”2
By asking patients prior to injection if they get a lot of swelling with bug bites, putting them on antihistamines might also help decrease post-procedure swelling, said Dr. Siperstein.
“If it’s severe, you can do oral steroids, but I have never needed that.”
Do not use hydrophilic fillers in the under-eye area, said Dr. Siperstein. Those include Restylane (Galderma), Belotero (Merz Aesthetics) and Volbella (Juvéderm), which Dr. Siperstein has compared retrospectively in practice and found that all three result in about the same amount of post-procedure swelling, she said.2
“You never want to use a filler like Juvedérm Ultra and Ultra Plus around the eyes because those bring in water.”
Severe late onset edema is also possible with infraorbital filler treatment, as well as veins around the eyes that appear as lumps, said Dr. Siperstein.
“I’m going on 12 years with under eye filler patients and still get surprises. You will get swelling after 8 years of perfection out of nowhere. We still don’t know why that happens in the eye area, but it happens. You don’t have to get rid of all the filler; you just have to lower it a little bit. You can do what I call ‘microdose’ hyaluronidase, so anywhere from 5 to 15 units at most in any area with a little bit of cortisone. Basically, I just want to lower that swelling level, not get rid of the filler.”
To decrease the risk of eye bruising, Dr. Siperstein said she uses a vein finder for her entry point and then a cannula, which she redirects if she feels resistance. She also applies immediate post-procedure pressure on the entire area.
“If they do bruise… we offer complimentary treatments in our office with intense pulsed light (IPL), pulsed-dye laser (PDL) or Nd:YAG.”
To address skin laxity after infraorbital filler injections, Dr. Siperstein might use laser resurfacing to tighten that skin, she said.
Finally, some patients notice veins or lumps popping up around the eyes after injection, said Dr. Siperstein.
“I show them with my vein finder that it is a vein, and there are a lot of things you can do. Often it’s not a big deal. Usually it looks natural, and they’re happy. If they’re not, you can inject around [the vein] to camouflage. Or you can treat the vein with an Nd:YAG laser, as long as it is not within the orbital rim.”
Most importantly, educate patients that if anything doesn’t look right to come back because it can be fixed, she said.
References:
- Siperstein R. Infraorbital Hyaluronic Acid Filler: Common Aesthetic Side Effects With Treatment and Prevention Options. Aesthet Surg J Open Forum. 2022 Jan 15;4:ojac001. doi: 10.1093/asjof/ojac001. PMID: 35386936; PMCID: PMC8982019.
- Siperstein R, Montes JR, Speranza A. A Retrospective Review of the Safety and Efficacy of Low-dose Triamcinolone Mixed with Hyaluronic Acid Fillers to Reduce Post-injection Infraorbital Swelling. J Clin Aesthet Dermatol. 2022 Apr;15(4):13-19. PMID: 35465031; PMCID: PMC9017664.
Disclosures: Dr Siperstein is a primary investigator, consultant, and lecturer for Allergan and Galderma.