Tear trough anatomy: how not to inject filler within the orbit

Tear trough treatments are relatively common, yet they can be a risky aesthetic treatment when using dermal fillers to replace lost volume in sub-orbicularis oculi fat. Get it wrong, placing filler within the orbit, and the resulting problem can be long-lasting and difficult to reverse, hence prevention is paramount.

In this blog, Dr Tim Pearce discusses the incorrect placement of dermal filler within the orbit of the eye instead of into the pre-zygomatic space when treating tear troughs. He explains the critical anatomy around the eye, and ways to be a safer injector to avoid injecting within the orbit.

Do you feel anxious about causing complications? Many clinicians feel so overwhelmed with the thought of causing a vascular occlusion that it stops them growing their aesthetics business. Dr Tim is currently hosting a webinar series to help you overcome your fear of complications so that you can uplevel your knowledge, and increase your CPD-certified learning to build a successful aesthetics business. Sign up here >>

Tear trough complication: dermal filler in the orbit

Raised by Australian radiologist and aesthetic doctor, Dr Mobin Master during an online interview with Dr Tim in 2020, a rare complication occurs when dermal filler gets into the orbit of the eye instead of into the pre-zygomatic space.

Tear trough treatments are technically challenging and can result in complications including oedema which presents as a visible ‘bag’ requiring dissolution if product remains and/or migrates, causing unforeseen swelling long after it was expected to have been metabolised.

Dr Master’s MRI studies established that the reason for this was because the filler had been placed behind the orbital septum. The orbital septum is a very thin membrane that forms a natural barrier, protecting the orbit from external factors like infections which may be present on the surface of the skin. Therefore, if dermal filler is placed behind this membrane, it may remain for many years. In fact, Dr Master has shown with MRI studies that filler product can remain up to twelve years after placement.

Dr Master’s findings were also discussed by Dr Tim when he asked, should we stop injecting tear troughs with dermal filler?

Without a good understanding of the anatomy, and the various compartments within the face that a needle can pass through in the tear trough area, it can be very easy to place the filler gel into the wrong place. If that happens, reversal is risky, requiring specialist knowledge and potentially ultrasound guidance, with a possible onward referral to an oculoplastic surgeon, because there is a need to go through the orbital septum and very close to the globe of the eye to administer the hyaluronidase to break down the hyaluronic acid gel.

Tear trough anatomy: understanding ligaments and fat pads

Knowledge of the anatomy is your primary concern when designing your injection technique and treatment – safety first – followed only then by the aesthetic result you seek to achieve, explains Dr Tim. To ensure the injection technique you choose is more likely to minimise the risk of ending up in the wrong place, we must start with understanding the anatomy.

Important structures include the zygomatic retaining ligament which runs on the anterior surface of the zygoma. This is followed by the orbicularis oculi retaining ligament which runs around the orbit, above the orbital rim. Underneath the orbicularis oculi retaining ligament is the SOOF or sub-orbicularis oculi fat. The SOOF is usually the area where volume replacement is taking place by injecting the dermal filler, because the fat pad reduces in size with ageing.

The SOOF protrudes outwards in some patients which is also important to understand when treating tear troughs. The aim is to harmonise the three fat pads – the medial cheek fat pad, the SOOF, and the intraocular fat pad, all of which can create undesirable shadows due to lost volumes, or where protrusions occur (which may require surgical intervention to remove excess fat).

The superficial, infraorbital fat pad sits on top of orbicularis oculi and underneath the muscle is the orbital septum. The orbital septum bridges over these two areas, connecting with the lower eyelid and the orbicularis oculi retaining ligament, with the intraorbital fat beneath it. This is precisely where we do not want dermal filler placement, but it is the main complication from treatment in this area and is very easily done.

If you are aiming to inject the SOOF using a cannula and insert it just superior to the zygomatic ligament heading in the direction of the SOOF, it is very easy to be a little too high and enter the space underneath the orbital septum. This places the tip of your cannula or needle within the orbit, maybe only by a millimetre or so, but any filler deposition would be into the orbit.

Tear trough injection techniques: preventing getting dermal filler in the orbit

When injecting dermal fillers into the tear trough, there are different, but commonplace techniques used by aesthetic clinicians. The approach is to treat the tear trough or the small space between the zygomatic retaining ligament and the orbicularis oculi retaining ligament to replace lost volume in the SOOF.

Angles of entry are important; if using a cannula, and trying to position deeply, it is very easy to pop through a thin membrane and find yourself in the orbit. To avoid this risk, others choose to treat using a needle which allows for placement on the periosteum, to give certainty that they are not within the orbit, although again, a slight miscalculation on angles of the needle can make all the difference to being in the wrong place. Slow injecting, after just touching the periosteum before injecting, maintaining stability, delivering small amounts of product at a time add to the safety of the method.

To be safer injectors, Dr Tim advises feeling the area before you inject. This way you can ensure you know the location of the orbital rim, on an individual patient. Similarly, you can feel as you inject, and perhaps place your finger over the area to protect the orbit, particularly when using a cannula to stop it from going too deeply or superiorly and into the orbit.

Dr Tim loves to hear from his followers, so why not drop him a comment on social media if you have further questions on tear trough treatments or other topics you want him to discuss; you can find Dr Tim Pearce on Instagram.

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Aesthetics Mastery Show

Vital Tear Trough Anatomy Tutorial

In this episode, Dr Tim explain the vital anatomy which can cause the unfortunate tear trough complication after injectors place filler into the orbit instead of the pre zygomatic space. The effects of this problem can be nasty, long lasting, and very hard to reverse. Tim explains the injection technique you need to avoid injecting within the orbit. Watch the full Aesthetics Mastery Show here.

The show has had over 30k views on youtube and many viewers have left comments to share their own experiences and thoughts on the issue.

Read more and join in the debate on youtube.

Dr Tim Pearce eLearning

Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.

Our exclusive video-led courses are designed to build confidence, knowledge and technique at every stage, working from foundation level to advanced treatments and management of complications.

Thousands of delegates have benefited from the courses and we’re highly rated on Trustpilot. For more information or to discuss which course is right for you, please get in touch with our friendly team.