Nonsurgical Tear Trough Volumization: A Systematic Review of Patient Satisfaction

A Multicenter, Randomized, Evaluator-Blinded Study to Examine the Safety and Effectiveness of Hyaluronic Acid Filler in the Correction of Infraorbital Hollows

BACKGROUND

Hyaluronic acid injections are increasingly administered for correction of infraorbital hollows (IOHs).

OBJECTIVES

The objective of this study was to examine the effectiveness (IOH correction) and safety of Restylane Eyelight hyaluronic acid (HAEYE) injections.

METHODS

Patients with moderate/severe IOHs, assessed with the Galderma infraorbital hollows scale (GIHS), were randomized to HAEYE injections (by needle/cannula) (Day 1 + optional Month 1 touch-up) or no-treatment control. The primary endpoint was blinded evaluator-reported Month 3 response, defined as ≥1-point GIHS improvement from baseline (both sides, concurrently). Other endpoints examined investigator-reported aesthetic improvement on the Global Aesthetic Improvement Scale (GAIS), patient-reported satisfaction (FACE-Q satisfaction with outcome; satisfaction questionnaire), and adverse events.

RESULTS

Overall, 333 patients were randomized. Month 3 GIHS responder rate was significantly higher for HA-EYE (87.4%) vs control (17.7%; P < .001), and comparable between HA-EYE-needle and HA-EYE-cannula groups (P = .967). HAEYE GAIS responder rate was 87.5-97.7% (Months 3-12). Mean FACE-Q Rasch-transformed scores were 64.3-73.5 (HAEYE) vs 14.1-16.2 (control) through Month 12. Patients reported looking younger (≥71%) and less tired (≥79%) with reduced undereye shadows (≥76%) and recovered within 3-5 hours posttreatment. Efficacy was maintained through Month 12 (63.5% GIHS responders) and through Month 18, after Month 12 retreatment (80.3% GIHS responders; 99.4% GAIS responders; FACE-Q scores 72.5-72.8). Forty patients (12.7%) reported typically mild adverse events (4.9% HAEYE-needle; 20.9% HAEYE-cannula).

CONCLUSIONS

HAEYE treatment was effective in correcting moderate/severe IOHs at the primary endpoint (Month 3). Efficacy was sustained through Month 12 after first treatment for 63.5% and through Month 18 for 80.3% (after 1 retreatment) with needle or cannula administration. Safety outcomes were reassuring.

LEVEL OF EVIDENCE: 1

Lower Eyelid Dark Circles (Tear Trough and Lid-Cheek Junction): A Stepwise Assessment Framework

BACKGROUND

Despite increasing popularity, the use of hyaluronic acid (HA) fillers for the correction of dark under-eye shadows remains challenging. Specific guidance on patient assessment is limited.

OBJECTIVES

The aim of this study was to develop a stepwise assessment framework for lower eyelid dark shadows to help practitioners classify patients based on their underlying problems and facilitate a more strategic approach to treatment.

METHODS

Literature review and peer collaboration informed the current availability of educational material for use by experienced injectors when assessing patients presenting with dark circles. A practitioner survey provided insight into current practices. A focus group convened to review the survey results and discuss best practice approaches to patient assessment.

RESULTS

Surveyed practitioners (n = 39) reported patient concern about under-eye hollows (91%), dark eye circles (80%), and looking tired (60%). All (100%) agreed that midcheek volume was critical when treating tear-trough depression, and only 26% reported use of a tear-trough classification system. The focus group developed a framework for assessing tear-trough depression and the lid-cheek junction in patients presenting with dark circles. Key factors within this framework included the importance of appropriate lighting when conducting a visual inspection, regional inspection of the cheek and tear trough, palpation of the orbital rim and soft tissues, determination of the orbital vector, and assessment of lower eyelid pigmentation and skin quality.

CONCLUSIONS

Careful step-by-step assessment can reduce the challenges of treating dark circles by identifying patients in whom dark eye circles may be improved without the need to directly inject filler into the tear trough.

LEVEL OF EVIDENCE: 5

The Efficacy and Safety of Hyaluronic Acid Injection in Tear Trough Deformity: A Systematic Review and Meta-analysis

BACKGROUND

Hyaluronic acid (HA) injection is an effective method to correct tear trough deformity. Nevertheless, the quantitative data of cosmetic results and complications of HA injection in tear troughs remained unemployed. The purpose of this meta-analysis was to synthesize the current quantitative data on the aesthetic outcomes and adverse effects of tear trough deformity correction with HA injection.

METHODS

This meta-analysis consulted PubMed, Embase, Web of Science, Scopus and Cochrane databases based on the search terms published before September 2022. Data extracted was analyzed to evaluate the satisfaction rates and complications of HA injection. Meta-analysis was performed using the random-effect model for overall and subgroup analysis.

RESULTS

This meta-analysis comprised 31 reports involving 2556 participants. The pooled overall satisfaction rate was 91.0% (95% CI 84.9-95.7%). The pooled rates of swelling/edema and bruising/ecchymosis were 19.2% (95% CI 10.4-29.9%) and 18.4% (95% CI 10.1-28.4%), respectively. The pooled rates of redness/erythema, contour irregularity/lump and blue discoloration/Tyndall effect were 7.1% (95% CI 1.5-15.6%), 5.3% (95% CI 1.8-10.2%) and 0.9% (95% CI 0.0-2.5%), respectively.

CONCLUSIONS

The present meta-analysis manifested a low risk of complication rate and a high satisfaction rate in tear trough rejuvenation with HA injection.

LEVEL OF EVIDENCE I

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Needle versus Cannula to Treat Tear Trough: A Prospective Study Comparing both Methods

Background

We aimed to clinically compare needle and cannula techniques in vivo with ultrasound and magnetic resonance imaging, to better understand the best technique and adverse events.

Methods

Ten adults without previous fillers in the area were injected with hyaluronic acid (CPM 22.5 HA mg/mL) with a 25G cannula on one side and a Becton Dickinson syringe needle (31G 0.3 mL) on the other. The product was fractionated among two visits. Assessment was made at time 0d, 14d, 30d, 60d, 90d, 180d, and 365d with standard camera, Vectra H2, ultrasound, and magnetic resonance imaging. Level of satisfaction was also evaluated.

Results

All the patients showed natural results with both techniques and a high satisfaction index. Cannulas were minimally less traumatic in terms of bruises. However, the product was applied in a more superficial layer and in a less precise manner, despite the fact that a deep technique was used with cannulas, depositing the product on the orbital bone. Patients reported a more noticeable change immediately after the procedure on the side treated with cannulas but less edema and a more comfortable procedure on the Becton Dickinson syringe treated side. None of the patients required hyaluronidase to dissolve overcorrection of the area, and no severe complications were observed. The product remained in most of them at day 365.

Conclusions

Cannulas seem to be less traumatic regarding bruises, but less precise in vivo. Thin needles seem to be more precise with minimal trauma. However, this difference disappears during patient's evolution.

Nonsurgical lower eyelid rejuvenation using injectable poly-D,L-lactic acid in Asian patients

BACKGROUND

Filler injection for lower eyelid rejuvenation remains a difficult subject due to many complicated anatomic changes as the face ages.

OBJECTIVES

To propose an alternative, simple, and effective filler injection method in lower eyelids for Asian patients.

METHODS

Any patient who has tear trough deformities, infra-orbital hollows, nasojugal grooves, dark eye circles, as well as mild eyebags is a potential candidate for this method. Our filler choice is injectable poly-D,L-lactic acid (PDLLA; AestheFill; REGEN, Seoul, South Korea). PDLLA must be reconstituted with sterile water for injection (SWFI) before administration. When the patient's troughs, grooves, or volume deficit are class II to III, 3-4 mL of SWFI and 1 mL of lidocaine are used. When the deficits are class I, 5-7 mL of SWFI and 1 mL of lidocaine are used. With fanning injection technique, a wide region that covers all the deficits is evenly injected. The depth is under the dermis layer. Total amount of filler injection is not more than 2 mL on each side.

RESULTS

Since 2019, we have injected more than 100 patients by following these steps in Taiwan. The level of patient satisfaction is high. Only some mild and transient post-injection complications such as edema, erythema, and ecchymosis were found.

CONCLUSIONS

We propose an alternative, simple and effective method for non-surgical lower eyelid rejuvenation for Asian patients. However, anyone who wants to perform this procedure should be well-trained and knowledgeable about the anatomy, product and procedure to prevent the adverse events.

Facial Aesthetic Priorities and Concerns: A Physician and Patient Perception Global Survey

Background

Minimally invasive and noninvasive facial aesthetic treatments are increasingly popular, and a greater understanding of patient perspectives on facial aesthetic priorities is needed.

Objectives

The authors surveyed facial aesthetic concerns, desires, and treatment goals of aesthetically conscious men and women, and physicians, in 18 countries.

Methods

This was a global, internet-based survey on desired appearance and experiences with, or interest in, facial aesthetic treatments. Eligible respondents were aesthetically conscious adults (21-75 years). Eligible aesthetic physicians were required to see ≥30 patients per month for aesthetic reasons, have 2 to 30 years of experience in clinical practice, and spend ≥70% of their time in direct patient care.

Results

A total of 14,584 aesthetically conscious adults (mean age, 41 years; 70% women) and 1315 aesthetic physicians (mean age, 45 years; 68% men) completed the survey. Most respondents (68%) reported that aesthetic procedures should be sought in their 30s to 40s; physicians recommended patients seek treatment earlier. Respondents expressed greatest concern over crow’s feet lines, forehead lines, facial skin issues, hair-related concerns, and under-eye bags or dark circles; in contrast, physicians tended to underestimate concerns about under-eye bags or dark circles, mid-face volume deficits, and skin quality. Although both physicians and respondents cited cost as a major barrier to seeking aesthetic treatments, respondents also emphasized safety, fear of injections or procedure-related pain, and concern about unnatural-looking outcomes.

Conclusions

This global survey provides valuable insight into facial aesthetic concerns and perspectives that may be implemented in patient education and consultations to improve patient satisfaction following aesthetic treatments.