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Page 4 of 9 Lee et al. Plast Aesthet Res 2018;5:43 I http://dx.doi.org/10.20517/2347-9264.2018.39

Figure 2. Botulinum toxin injection for crow’s feet. It is important not to extend medial to the mid-pupillary line to avoid lower lid
ectropion. Lateral injection should be placed approximately 1 cm lateral to the lateral canthus. Volumes referenced are independent
of neurotoxin variety and assume dilution as specified in the body of the text (i.e., 1 mL saline per 100 unit vial of Botox® or Xeomin®
and 3 mL per vial of Dysport®). While these figures offer a guide, dosing may vary between patients according to their musculature
and anatomy

to avoid bruising and avoid untargeted muscles. A small welt should be visible after injection similar to a
tuberculin skin test. Potential concerns with injections of this area include bruising, as mentioned above, as
well as iatrogenic lower lid ectropion if injections are positioned medial to the mid-pupillary line. Injections
in this area may also exacerbate symptoms of dry eye in patients with a known history. Finally, if injected too
deeply or too inferiorly, muscles of the mid-face may be affected, which may cause an asymmetrical smile.

The shape of the brow may also be subtly modified with toxin injection. Lateral injection of the orbicularis
may give 1-2 mm of lift to the lateral brow [Figure 3]. This may be combined with filler to further shape
and fill out this region. The appearance of larger eyes may also be achieved by injection of the pretarsal
orbicularis, which widens the palpebral fissure by weakening the pretarsal muscle [Figure 3]. This injection
should also target a superficial plane. Again, one must use caution in patients with a history of dry eye, as
this may exacerbate their symptoms.

NON-SURGICAL REJUVENATION OF THE PERIOCULAR AREA: FILLERS
Overview
Facial aging is also characterized by soft tissue volume loss of the periorbital area. Although neurotoxins
in isolation may be sufficient to ameliorate dynamic rhytids in younger patients, it is insufficient to address
static changes caused by volume loss in the dermis and underlying soft tissue. Thus, botulinum toxin in
combination with dermal fillers is an excellent option for non-invasive rejuvenation in patients with deep,
static rhytids. The use of fillers in combination with neurotoxins has the added benefit of approximately
[8]
doubling the half-life of the filler .
Dermal fillers are used to restore facial fullness and volume. Common materials include hyaluronic
[9]
acid, calcium hydroxylapatite, poly-L-lactic acid, polymethylmethacrylate, and autologous fat . For
periorbital rejuvenation, we almost exclusively use hyaluronic acid products. Hyaluronic acid is a naturally
occurring polysaccharide found in the connective tissue of all living species and so is very well tolerated.
It is hydrophilic, and this ability to bind water molecules enables its natural contribution to skin turgor
[8]
and dermal volume. With aging, natural levels of dermal hyaluronans diminish . In terms of cosmetic
injectables, of particular value is the ability to dissolve this material with hyaluronidase in the event of the
rare but very real potential complication of vascular occlusion. This may also be useful if there is need for
revision in the case of suboptimal cosmetic outcome, such as irregular surface contour or Tyndall effect,
especially important in the delicate and unforgiving periocular region. Given these factors, hyaluronic
acid is our filler of choice in this area. There are a variety of types of hyaluronic acid fillers commercially
available [Table 2]. The three major brands in the United States are the Restylane® family, Juvederm® family