Tear trough rejuvenation

Tear trough filler rejuvenation
Technological advances in imaging techniques have led to greater insight into the physiology of facial aging. We know that atrophy, loss of facial volume and tissue elasticity, bone resorption and gravitational forces all combine to age the face. In the mid-face, loss of volume accentuates the bony orbital anatomy, leading to exposure of the infraorbital fat pads and accentuation of the tear trough depression. The descent and attenuation of the skin of the inferior orbital rim also contributes to the development of predominant lower eyelid tear trough hollows.

Surgery to address tear trough hollows is not always appropriate and counseling patients on the choice between surgery and other, less invasive techniques is a challenge to ophthalmic plastic surgeons. Although use of dermatological fillers in other areas of the face is well-documented and associated with high patient satisfaction, their use in the tear trough hollow is a relatively new procedure. Greater understanding of the role that volume loss plays in facial aging, together with a growing patient preference for more conservative options for rejuvenation, has led to consideration of soft tissue augmentation for the treatment of prominent tear trough hollows.

The published use of fillers in the tear trough hollow has been confined to nonanimal, stabilized hyaluronic acid (NASHA) to date. Its lack of immunogenicity, together with its stabilizing and hydrating properties, make it an ideal agent for use in this area of the face. Its duration of effect (6-12 months) is comparable to that achieved in other areas of the mid-face.

Reports of successful use of dermatological fillers in the tear trough hollows as a better alternative to blepharoplasty, the traditional approach to eyelid rejuvenation, continue to emerge. As an outpatient procedure for tear trough hollows that offers immediate cosmetic results, a reduced risk of complications and minimal recovery time it is one of the most exciting treatment options in aesthetic medicine today. The use of fillers also means that the option of surgery is retained for a later stage.
The technique used in the Orbitofacial clinic orbitofacial.org seating the patient upright with the head firmly resting against a solid headrest and asked them to look upwards in order to accentuate the appearance of the tear trough deformity and lower eyelid fat pads.

Standing at the same side to be treated, and using the standard 30-gauge needle supplied with the product on a luer-lock vial, the needle shaft is placed anterior to and along the infraorbital rim with the tip directed medially. Noting the position the tip would reach, the skin along the tear-trough was then gently stretched perpendicular to the direction of groove and the needle inserted transcutaneously. It is advanced in a sub-orbicularis plane, along anterior and just inferior to the inferior orbital rim, until the tip reached the pre-planned location. Small aliquot volumes of nonanimal, stabilized hyaluronic acid (NASHA ) are then injected into the preperiosteal space, deep to the orbicularis just inferior to the orbital rim with the needle-bevel face-down towards the bone. The needle is slowly withdrawn and further aliquots are injected along this tract, in the same plane and at the same time as it is withdrawn. The filler is introduced by using a serial puncture technique in this manner. Before each injection, the bevel-down needle-tip is lifted slightly away from the bone in order to confirm a deep sub-orbicularis location and minimize the risk of injection into a more superficial subcutaneous plane. At each site, approximately 0.1 ml of filler is injected. The needle is withdrawn and the filler moulded to achieve a desired contour and reduce any prominent localised lumps.

Further aliquots are injected along the tear trough groove with progressively less volume required when approaching the region of the lateral canthus. If a residual hollow remained following injection of the first `layer’ of filler, then a second injection is delivered in the same plane but superficial to the first layer. Care is taken to inject anterior to and not above the orbital rim, avoiding placement of significant filler in the preseptal lower eyelid location. Moulding or massaging of the product with the thumb is carried out where smoothing of irregularities over the bony rim is required. Botulinum toxin treatments given during the same session are limited to placement along the brow and lateral to the lateral orbital rim, just inferior to the lateral canthal angle (orbicularis oculi raphe) in order to reduce the likelihood of a significant effect on the tear trough hollow treatment. Patients are advised to avoid exercise for 24 hours and direct pressure on the lower eyelid region area for 72 hours. Regular ice packs and analgesia are recommended. Patients are also advised to expect swelling for 1 to 2 days and the potential for an increase in bruising over 24 hours. Antibiotic or antiviral prophylaxis is not routinely used. A 4-week follow-up is scheduled after treatment or sooner, if any concerns arises.

Although this region of the bony orbital rim is considered free of significant vascular structures, there is a risk of retrograde embolization when using fillers. There have been no reports of visual loss associated with occlusion of the ophthalmic artery with the use of NASHA in the tear trough hollow; however, there have been reports of such problems with other fillers, including micronized dermal matrix, bovine collagen, and autologous fat and silicone oil. These reports serve as a reminder to avoid injecting close to the angular and infraorbital vessels in all patients.
The complex contours and anatomy of the periorbital region present a challenge for soft tissue filling. The skin is extremely thin over the bone and any irregularities caused by injecting too superficially or over-correcting can be obvious. Similarly, superficial injection can lead to greater visibility of inflammation or the bluish-grey pigmentation seen with some fillers.
Also, occasional contour irregularities can and do occur. Massaging with the thumb can smooth out any “lumpiness” or, if the patient is unhappy with the result, the filler can be dissolved using hyaluronidase. Conservative use of hyaluronidase is always available to reduce “lumpiness” and over-correction. The need for hyaluronidase appears to reduce with experience and the author currently advises patients of a 10% chance of requiring this.

Credits

Details on this page have been contributed by Raman Malhotra Raman Malhotra Site:

He has expertise in orbitofacial surgery (specialist plastic surgery in the eyelid and orbital region of the face).

Mr Malhotra has expertise in both surgical and non-surgical approaches to orbitofacial rejuvenation including modern techniques for cosmetic eyelid surgery (blepharoplasty) and small incision forehead and browlifts.

Other areas of expertise include skin cancer management in the eyelid region with modern excision and reconstructive techniques, watery eye disorders, thyroid eye disease including orbital decompression, facial palsy rehabilitation and orbital tumours.

For further information on Tear Trough Rejuvenation / Tear trough fillers/ Facial contouring in the eyelid region please contact Mr Malhotra at

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