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Complete Reflection


Dark eye circle


In this video, I would like to demonstrate one contributing factor to dark eye circles. If I reflect the skin back, you will notice that we can see the orbicularis oculi muscle in both the pretarsal and preseptal regions, and there is no subcutaneous fat overlying this muscle, so we just have skin and then muscle. However, in the orbital section, we have quite considerable subcutaneous fat. Accordingly, when we look at the pretarsal and preseptal regions, we notice the appearance of the muscle and blood vessels through the skin, and this may lead to the appearance of a darker region in the eyelid skin, compared to the thicker skin in the cheek region, which has some fat over the orbital part of the orbicularis oculi. This is one of the contributing factors to the tear trough deformity and dark eye circles.


Tear trough anatomy


In this video, I want to explore important structures when contemplating tear trough treatment. We have here the pretarsal and preseptal part of the orbicularis oculi muscle, and also the orbital part of the orbicularis oculi muscle. This muscle has an attachment in the underlying maxilla and infraorbital rim, by means of the orbicularis retaining ligament. This ligament has an attachment which is a little bit more loose in the middle and lateral sections, as demonstrated here, however when we go more medial we will notice that the ligament is more closely adherent to the bone. Accordingly, when we want to inject in this region we can get under the muscle in the middle and lateral sections, but when we inject more medially we need to place our product more superficially because it is not possible to inject product under the muscle, but we have to inject more within the muscle.


If I now reflect the muscle up, we can see an important structure in blue, and this is the angular vein. This is a large structure which will then drain into the facial vein. Also, if I take a line down from the medial limbus and follow about a centimetre below the infraorbital rim we can see the infraorbital artery exiting the infraorbital foramen. Please note that although we always take care to avoid the foramen itself, the infraorbital artery will course out of the foramen and be potentially subject to damage, and here we can see it coming out laterally. Because of all of these high risk structures, it will be highly advisable to use a cannula when treating the tear trough region.


Tear trough injection strategy


In this video, I would like to explore the depth and target tissue for tear trough injections. We have the superficial fat compartments, and remember that this is not one confluent layer but a series of discrete compartments bounded by septae. You will see that the fat only covers the orbital section of the orbicularis oculi muscle – the preseptal and pretarsal parts of the muscle do not have any superficial fat covering them, and this contributes to the appearance of the tear trough deformity. Also note that the superficial fat is mobile, and therefore if it is injected during a tear trough treatment we can get a strange animation when the patient smiles due to excessive projection of this tissue. After reflecting the superficial fat, we can see the full extent of the orbicularis oculi muscle. This muscle has an elliptical shape, and both an upper and lower portion. We can see that this muscle extends to a considerable distance inferiorly, and is almost in line with the alar base. The muscle itself has a pretarsal and preseptal portion and also an orbital section.


If we reflect the orbicularis oculi muscle superficially, we will notice the presence of a deep fat compartment known as the SOOF, or suborbicularis oculi fat. You will notice that in comparison to the superficial fat, this is very densely adherent to the periosteum below, therefore it is not mobile and provides excellent support for filler injected into this region. Therefore, when we are injecting the tear trough, this is our target tissue. Notice how the muscle is attached to the infraorbital rim by means of an orbicularis retaining ligament, and this is the superior boundary for the SOOF and prevents filler migration superiorly. The ligament is relatively lax in the middle and lateral sections, however when we get more medial in this region the ligament is very closely adherent to the underlying bone. Accordingly, it will not be possible to inject any filler under the muscle in this area. So if we are injecting the product in the medial most section, we need to inject in a superficial plane, or within the muscle itself. However, as the ligament is more lax laterally, when we inject the tear trough in the middle and lateral sections, we can place the filler directly under the muscle.


SOOF injection


In this video, we are looking at the SOOF being injected with product using a soft tissue cannula. As I am injecting, you may notice that the SOOF is expanding, and we can demonstrate this a little bit more clearly if we look at the same footage just slightly sped up. You will notice here that as product is injected the SOOF is expanding in all directions. The reason for this is that the suborbicularis oculi fat here is very densely adherent to the bone and is immobile. It has a superior boundary, which is the orbicularis retaining ligament, and therefore any product that is injected into this region will be compartmentalised. Treating the SOOF is an excellent way of diminishing the appearance of the tear trough in the lateral and medial aspects.


Medial tear trough injection


I would like to demonstrate an injection into the medial most part of the tear trough. For ease of demonstration, I will do this with a needle but in real life I would have done this with a soft tissue cannula. Because the ligament is so adherent to the bone, it is not possible to get underneath the muscle in this region and therefore we inject in a more superficial plane. Following injection, if we dissect out the muscle, we can see quite clearly that the product is placed within the fibres of the orbicularis oculi muscle , and this is the ideal placement in this region. More medially and laterally, of course, we would be under the muscle.