REVIEW THE AESTHETIC HEALTH OF THE EYES.
LANATOMY APPLIED TO INJECTIONS IN THE PERIORBITAL REGION
THE EXAMPLE OF THE CHEMICAL EYEBROW LIFT
Jad BISSAR, MD
The "Fox eyes", "foxy eyes" or "cat's eyes" is one of the new aesthetic trends, currently very fashionable and increasingly mediatized on social networks by influencers like Bella Hadid and Kendall Jenner. More and more patients are asking for it, with a majority of younger patients between the ages of 20 and 40.
The desired effect is to rejuvenate the eyes with a "fine eye", giving the face a soft yet "fatal" appearance.
There are many ways to achieve this, either invasively, such as canthopexy "or temple/brow liftor non-invasively, such as with absorbable tensor threads, the botulinum toxin injections and hyaluronic acid and the "ponytail lift.
Botulinum toxin is currently the simplest and least risky technique.
The aim of this paper is to review the basic anatomy that is essential to understanding the " chemical eyebrow lift "To optimize results and avoid complications.
Anatomy of the periorbital region
The face is broken down into different layers, in succession from surface to depth:
The cutaneous plane, the skin.
The superficial fat plane.
Ligaments of the face.
The muscular plane represented by the skin muscles.
These muscles are characterized by fixed bony insertions on one side, and mobile cutaneous insertions on the other. They are generally arranged around the orifices, with a dilating or constricting action.
They are often continuous with neighboring muscles, which explains why botulinum toxin injections can be dangerous by diffusion.
The deep, sub-muscular fat layer.
The face is analyzed under 5 views: from the front, from ¾ and from the side, distinguishing different subunits in a staggered manner from top to bottom (or from bottom to top, depending on preference):
- The periorbital region
With the fronto-orbital unit
And the infraorbital region,
The mid-facial region
And the perioral unit.
A- The fronto-orbital unit:
There are 4 muscles of major clinical interest in this zone:
1- Frontalis muscle: large, flat, quadrilateral muscle, which inserts itself into the eyebrow region by intertwining its fibers with neighboring muscles, notably the corrugator muscle. It is digastric with the occipital muscle via an intermediate aponeurosis: the galea. It is the only eyebrow elevator muscle.
2- The procerus (pyramidal) muscle : small, vertical, very thin medial muscle, with a lower bony insertion molded to the bones proper of the nose and an upper dermal insertion in the interbrow area. It is an antagonist of the frontal muscle, allowing the eyebrow head to be lowered. Its contraction is responsible for interbrow transversality at the root of the nose.
3- The corrugator muscle of the eyebrow: horizontal muscle with fronto-nasal bony insertion at the root of the nose and cutaneous insertion on the skin of the inner ½ of the eyebrow. This muscle enables the eyebrows to be frowned, and is responsible for the vertical glabellar wrinkles known as frown lines.
4- The upper part of the orbicularis oculi muscle : Large muscle that completely surrounds the orbital orifice and extends into the eyelids.
It is divided into two parts:
the outermost part of the orbit, which surrounds the orbital frame
and the palpebral, internal part, at the level of the eyelids.
The latter is divided into 3 parts:
marginal, flush with the lashes;
pre-tarsal, adherent to the tarsus
and pre-septal septum.
These three parts converge on the external and internal canthal ligaments.
B- Suborbital region:
Simpler than the fronto-orbital unit, the suborbital region comprises several muscles:
The lower part of the orbicularis oculi muscle,
The upper part of the greater zygomaticus, lesser zygomaticus, levator labi superioris and levator angulis oris muscles.
This region features ligaments of major clinical interest:
The orbito-malar ligament (or orbicular retention ligament), which represents the ring, very solid
The zygomatico-cutaneous ligaments, above which the malar pouch develops.
The cutaneous-maxillary ligament
Chemical eyebrow lift
It's essential to understand that the layout of the eyebrow tail is simply the result of a balance of fronto-orbital muscles, with the eyebrow elevator muscles (frontal muscle complex) on one side, and the eyebrow depressor muscles (procerus, corrugators, orbicularis orbicularis) on the other.
Female Brow Vs Male Brow
It's essential to understand that the female eyebrow is not the male eyebrow.
Indeed, the female eyebrow has an upwardly oblique appearance: positioned above the supraorbital rim, it has a gull-wing shape, with more lateral than medial elevation, and maximum arch at or lateral to the lateral limbus.
The male eyebrow, on the other hand, is quasi-horizontal, sloping slightly downwards to the glabella and, above all, not rising too much.
It's important to respect the shape of the eyebrow and use botulinum toxin to modify its shape in an aesthetic and gender-appropriate way, otherwise there's a risk of feminizing the look or Mephisto.
The evolution of facial beauty can be described by the theory of inverted triangles.
In fact, beauty can be represented by a triangle with a higher base and more volume in the upper and middle thirds of the face.
With time and aging, the skin loses elasticity, fat atrophies and the face becomes ptose, with an inversion of the triangle, which becomes lower-based with more volume at the bottom.
The eyebrow and the appearance of the eyes are intimately linked. It's one of the first signs of aging in both men and women. A drooping eyebrow accentuates the tired, sad and aged appearance of the eyes. Injecting botulinum toxin to raise the tail of the eyebrow gives a more youthful, stealthy look.
Botulinum toxin injection techniques
Elevation of 2 to 3 mm of the tail of the eyebrow by relaxation of the external portion of the orbicularis muscle under the eyebrow combined with relaxation of the corrugator muscle.
Injection is based on bone markers, not eyebrow markers, especially for women who wax or tattoo their eyebrows, which can be misleading.
- Locating the orbit
- Stitch with a needle into the orbicularis under the tail of the eyebrow
- Direct upward injection of 2 IU of botulinum toxin
Ptosis is the main possible complication of botulinum toxin injection in the eyebrows. It results from diffusion of the toxin to the levator of the upper eyelid.
However, it is becoming increasingly rare as the injection technique becomes better mastered.
If this occurs, a drug can be used: iopidine at 0.5% morning and evening for 15 days.
This will correct the ptosis.
It remains essential to see the patient again at 48 hours and after 15 days of iopidine to monitor progress.
How to avoid complications?
A few tips:
- Rigorous injection technique and good anatomical knowledge
- Needle orientation: Injection upwards, not the other way round
- Avoid injection near the levator of the upper eyelid
- Maintain a distance of 1.5cm above the brow bone
- Do not inject below the floor of the orbit
- Avoid massaging