Static and Dynamic Filler-Associated Tear Trough Deformities: Manifestations and Treatment Algorithm

BACKGROUND

Fillers are popular substances for the correction of tear trough deformity. Despite well-documented complications increasing gradually, standardized treatment algorithm for deformity secondary to improper injection is still limited.

METHODS

Between April 2020 and April 2023, a total of 22 patients with filler-associated tear trough deformity with static bulges or dynamic swells after injection of tear trough were enrolled. For patients who received hyaluronic acid (HA) and unknown fillers, hyaluronidase dissolution was performed. For patients who received non-HA fillers and unknown fillers that failed to dissolve, a magnetic resonance imaging (MRI) examination was conducted. Surgical approaches were selected based on the filler distribution and the condition of the lower eyelid. Ligament releasement and fat transposition were accomplished when fillers were excised. Aesthetic outcomes were evaluated by double-blind examiners using the Global Aesthetic Improvement Scale after patients were followed up.

RESULTS

In total, the study included 3 patients with simple static deformities, 1 patient with simple dynamic, and 18 patients with both. Fourteen patients underwent transconjunctival surgery and 8 patients underwent transcutaneous surgery, among which 18 patients underwent hyaluronidase dissolution and 8 patients underwent MRI prior to surgery. A total of 4 patients with self-limited complications recovered after conservative treatment. 90.9% of patients expressed satisfaction or high satisfaction with the treatment results.

CONCLUSION

Filler-associated tear trough deformities could be classified into static and dynamic deformities, which could appear separately or simultaneously. Treatment of deformities should be based on characteristics of fillers, in which MRI could serve as a promising tool.

LEVEL OF EVIDENCE IV

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.

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

Infraorbital Rejuvenation Combined with Thread-Lifting and Non-cross-linked Hyaluronic Acid Injection: A Retrospective, Case-Series Study

BACKGROUND

Infraorbital aging develops during the natural aging process. Various treatment options offer unique benefits, accompanied by diverse side effect profiles, and can be synergistically combined to optimize results. This study aimed to evaluate the efficacy of a comprehensive approach involving non-cross-linked hyaluronic acid injection and smooth absorbable PPDO (poly p-dioxanone) thread insertion for infraorbital rejuvenation.

METHODS

This retrospective case series study enrolled ten female patients with infraorbital aging from March 2022 to April 2023. Clinical outcomes, patient satisfaction, and adverse events were assessed at 1, 3, and 6 months posttreatment.

RESULTS

The median Global Aesthetic Improvement Scale scores evaluated by the operator and blinded evaluator were 1.70 ± 0.42 and 1.80 ± 0.35, respectively, at six months posttreatment. The median Allergan Infraorbital Hollows Scale determined by the operator was 1.15 ± 0.34 at six months posttreatment, whereas the scores evaluated by the blinded evaluator were 1.15 ± 0.53. At six months after treatment, 50% of patients were satisfied, and an additional 40% reported strong satisfaction with the clinical improvement following treatment. No serious adverse events, such as infections, lumps, irregularities, Tyndall effect, hematoma, or skin necrosis, occurred during the treatment period.

CONCLUSIONS

The combination of PPDO thread insertion and non-cross-linked hyaluronic acid injection yielded satisfactory and effective clinical outcomes with no occurrence of serious adverse events for infraorbital rejuvenation. We anticipate that this study will contribute to the advancement of novel treatment options for infraorbital aging.

LEVEL OF EVIDENCE IV

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.

Decades of beauty: Achieving aesthetic goals throughout the lifespan

BACKGROUND

Several elements, including age, influence judgments of beauty and attractiveness. Aging is affected by intrinsic factors (e.g., genetics, race/ethnicity, anatomical variations) and extrinsic factors (e.g., lifestyle, environment).

AIMS

To provide a general overview of minimally invasive injectable procedures for facial beautification and rejuvenation to meet the aesthetic goals of patients across their lifespan, organized by decade.

METHODS

This case study review describes aesthetic considerations of females in their third to sixth decade of life (i.e., 20-60 years of age or beyond). Each case study reports the treatments, specifically botulinum toxin type A and soft tissue fillers, used to address aesthetic concerns.

RESULTS

Signs of aging, as well as aesthetic goals and motivations, vary by age groups, cultures, and races/ethnicities. However, there are overarching themes that are associated with each decade of life, such as changes in overall facial shape and specific facial regions, which can be used as a starting point for aesthetic treatment planning. Appropriate patient selection, thorough aesthetic evaluation, product knowledge, and injection technique, as well as good physician-patient communication, are essential for optimal treatment outcomes.

CONCLUSIONS

Nonsurgical facial injectable treatments can successfully enhance and rejuvenate facial features across different age ranges. A comprehensive understanding of facial aging and the aesthetic considerations of patients by the decade contributes to optimal treatment planning and maintenance.

Safety of infraorbital hyaluronic acid injections: Outcomes of a meta-analysis on prospective clinical trials

BACKGROUND

Hollowing of the infraorbital region represents a common concern among aesthetic patients. In the past decade, an increasing number of patients have resorted to noninvasive aesthetic procedures to treat these concerns. The objective of this study was to evaluate the safety profile of infraorbital hyaluronic acid injections for aesthetic rejuvenation.

METHODS

Through a systematic review and meta-analysis of prospective clinical trials, investigators sought to answer the research question "Does the use of needle versus cannula during infraorbital HA injections result in the same incidence rate of adverse events?" The primary outcomes of interest were the incidence rates of ecchymosis and edema in subject groups treated with a needle or cannula.

RESULTS

Subjects treated with needles had a statistically significant greater incidence rate of ecchymosis, compared to those treated with cannula. Conversely, subjects treated with cannula had a statistically significant greater incidence rate of edema, compared to those treated with needles.

CONCLUSIONS

The incidence rates of adverse events following the administration of hyaluronic acid injections in the infraorbital region vary depending on whether a needle or cannula is used; with needles being associated with a greater risk of ecchymosis and cannulas being associated with a greater risk of edema. These findings should be discussed with patients prior to treatment consultation. Finally, as with most techniques, it is usually prudent to develop expertise with one technique before using a second, especially in cases where both approaches can be used and have different adverse event profiles.

Validating the Reliability and Clinical Relevance of an Infraorbital Hollow Photonumeric Scale

Background

Infraorbital hollowing is a facial aesthetic issue for which a broad age range of patients seek treatment. Expanding treatment options for this region warrants the development of validated tools to objectively assess infraorbital hollow (IOH) severity before and after treatment.

Objectives

To validate a 4-point rating scale to assess depression of IOH, depression relative to the mid-pupillary line, and visibility of the lateral orbital rim.

Methods

The IOH scale described herein was developed and subjected to live validation with a total of 73 patients representing the full range of IOH severities. Scale validation was performed by board-certified plastic surgeons and dermatologists (3 raters) over 2 rounds, 2 weeks apart. Intrarater and interrater reliabilities were used to demonstrate test-retest reliability as quantitated with percentage of agreement, weighted kappa statistic with 95% confidence interval (CI), and intraclass correlation coefficient with 95% CI. The clinical relevance of a 1-grade difference was evaluated by comparing rater assessments of 77 photo pairs with their previously determined designation as "clinically different" or "not clinically different."

Results

The IOH scale demonstrated substantial to near-perfect intrarater and interrater reliabilities when utilized by trained raters to assess a diverse group of live patients. Furthermore, clinically relevant differences between grades were established, and detection of a 1-point difference could be achieved by trained evaluators using the IOH scale.

Conclusions

This highly reliable, clinically relevant, and validated IOH scale provides a user-friendly, standardized grading system to objectively evaluate and track changes in infraorbital hollowing in clinical practice and research.

Level of Evidence 3

A Prospective, Multicenter, Single-Blind, Randomized, Controlled Study of VYC-15L, a Hyaluronic Acid Filler, in Adults for Correction of Infraorbital Hollowing

BACKGROUND

Rejuvenation of the under-eye area is a popular facial aesthetic treatment option.

OBJECTIVES

This study evaluated the safety and effectiveness of VYC-15L for the correction of moderate or severe infraorbital hollowing.

METHODS

This was a randomized, controlled, single-blind study with a primary endpoint defined as the proportion of participants with ≥1-grade improvement at Month 3 assessed by an evaluating investigator employing the Allergan Infraorbital Hollow Scale. Three-dimensional imaging was conducted to assess infraorbital volume up to Month 12. Procedure pain and injection-site responses (ISRs) were documented, and safety was monitored throughout the study.

RESULTS

At Month 3, the difference between treatment (83.1%) and control (15.6%) was 67.5% (95% CI = 52.9 to 82.0, P < 0.0001). 3D imaging showed a mean volume increase from baseline of 0.733 mL (left) and 0.777 mL (right) at Month 12. Mean pain scores were ≤1.7 (scale of 0 to 10). Most ISRs with initial treatment were mild/moderate and resolved in ≤1 week, including tenderness (49.5%), bruising (42.7%), and swelling (41.7%). Thirty-four participants had treatment-emergent adverse events (TEAEs), of which 14 (10.3%) had treatment-related TEAEs, including bruising (3.8%) and swelling/edema (2.9%), which resolved in ≤2 weeks. Three participants had swelling/edema starting >30 days posttreatment; 2 resolved in ≤4 days, 1 by 45 days. No treatment-related serious AEs were reported.

CONCLUSIONS

VYC-15L was safe and effective for the correction of moderate or severe infraorbital hollowing and lasted through 1 year.

LEVEL OF EVIDENCE: 2

Nonsurgical Tear Trough Volumization: A Systematic Review of Patient Satisfaction

BACKGROUND

Nonsurgical rejuvenation of the tear trough area via the use of injectable filler material has become a popular procedure in facial rejuvenation. This procedure offers immediate, albeit temporary, results with minimal recovery time.

OBJECTIVES

The aim of this systematic review was to report on patient satisfaction and complication rates to further guide practitioners.

METHODS

PubMed, Cochrane, and Scopus libraries were queried for articles containing relevant terms. Articles with more than 5 patients who reported on satisfaction and/or complications from the procedure were included for review. In addition to these variables, we noted other aspects of injection, including filler material, technique, and needle or cannula delivery. Studies that did not otherwise fulfill inclusion criteria for statistical analysis but reported on intravascular injection-related complications were cited.

RESULTS

Initial query resulted in 1655 studies which were assessed for duplicates and inclusion/exclusion criteria. After screening, 28 articles were included for analysis. In total, 1956 patients were captured who had been injected with 1 of 4 materials: hyaluronic acid (1535), calcium hydroxyapatite (376), autologous fibroblast/keratin gel (35), and collagen-based filler (10). Short- and long-term satisfaction rates were 84.4% and 76.7%, respectively. Minor complications were common (44%). Secondarily, we found the use of cannula for filler injection of this region to be associated with a lower rate of ecchymosis (7% vs 17%, P < 0.05).

CONCLUSIONS

Filler injection volumization of tear trough deformity is an effective technique for facial rejuvenation associated with high patient satisfaction. Multiple filler materials offer acceptable satisfaction and complication profiles.

LEVEL OF EVIDENCE: 4

Correction of tear trough deformity by hyaluronic acid soft tissue filler placement inferior to the lateral orbital thickening

Tear trough deformities can be a sign of facial aging and exert a negative impact in facial attractiveness. Surgical techniques and adipose tissue transfer have been used to improve tear trough deformity. In recent years, minimal invasive procedures such as soft tissue filler injections became more popular. We report a retrospective evaluation of 45 Caucasian female patients ≥40 years (mean age of [58.8 ± 8.9] years). Severity of tear trough was classified according to Hirmand: 3 as grade I, 28 as grade II, and 14 grade III tear trough deformities. We used a monophasic hyaluronic acid, low G prime filler placed inferior to the lateral orbital thickening. On average, 0.4 ml of hyaluronic acid (HA) filler were injected per side. The improvement was I grade 29 patients and II grades in 16 patients. The improvement lasted (10.8 ± 2.3) months. No severe adverse events were noted. Vascular danger zones can be avoided.

Use of Hyaluronic acid fillers in treatment of periorbital melanosis induced by tear trough deformity: Anatomical considerations, patient satisfaction, and management of complications

BACKGROUND

Periocular melanosis (POM) due to shadow effect of tear trough deformity (TT) does not respond to the conventional treatment modalities. Hyaluronic acid (HA) fillers are a favurable treatment modality. This area is a high risk for injectables due to its unique anatomy.

AIMS

To find role of HA fillers in treatment POM due to TT deformity with special emphasis on practical anatomy, patient satisfaction rate, and management of complications. A correlation of the grade of TT, age of the patient, and patient satisfaction was done. A follow-up at 1 year was done to assess longevity of results.

METHODS

Retrospective study of 60 cases of clinically diagnosed POM (120 TT) due to TT deformity was performed. Each patient was injected with 1 ml, cross-linked HA 22.5 mg/ml in under-eye area using 30 G needle or a 25 G cannula. Follow-up was done at 2 weeks, 4 weeks, and 1 year.

RESULTS

Mean age of patients was 36.4 years. Majority of patients, that is, 31 (52%) were in the age group of 30-40. As per Hirmand's classification, 46.6% (28/60) had grade 2 TT which was most common. We graded results in the form of VAS and 80% patients had VAS > 7. There were no major side effects.

CONCLUSION

Hyaluronic acid fillers are promising treatment modality without any major side effects. Both needle and cannula can be used effectively. Patient satisfaction is higher in younger patients with low grade of TT and results persisted in all cases for a minimum of 1 year.

Management of Tear Trough with Hyaluronic Acid Fillers: A Clinical-Practice Dual Approach

INTRODUCTION

Tear trough deformity (TTD) is currently a major concern for many individuals that seek periorbital rejuvenation. Among the different options currently available for treating TTD, hyaluronic acid (HA) filler injections have become increasingly popular.

PURPOSE

To provide a dual approach, direct and indirect strategies for treating TTD with HA fillers according to patient facial structure.

METHODS

The current paper combined the authors' experience with the currently available scientific evidence.

RESULTS

The current study presents the authors clinical experience regarding TTD treatment and serves as a guide on the best therapeutic approach with HA fillers. For achieving good aesthetic outcomes, especially in TTD, it is crucial to have a detailed understanding of both facial anatomy and the individual characteristics of the HA fillers. Proper management of full-face facial rejuvenation should have into consideration three main pillars: structure, contour, and refinement.

CONCLUSION

Treatment of TTD should be addressed from a comprehensive perspective, including potential lack of structural support, as well as interventions on the dynamic processes involved in the problem. Additionally, HA fillers can be used to modulate mechanically muscle movement by either facilitating their action or decreasing contractility by reducing their movement. Clinicians can benefit from ongoing guidance on the use of these products in order to tailor and optimize treatments to patient's requirements. Although HA filler injections have low rates of side effects, TTD was listed as the most challenging area to treat with HA. Therefore, TTD treatment should be performed only by well-trained and experienced specialists.

Eyelid and Periorbital Dermal Fillers: Products, Techniques, and Outcomes

A retrospective observational case study and a literature review were conducted to evaluate how anatomic findings, especially those related to the periorbital zone, serve as a guiding compass for injectable implants. Treatment techniques and product selection will be discussed for patients with negative vector, shallow orbit, and deep set eyes. Versatility of injectables will be demonstrated on patients with peanut face, iatrogenically altered anatomy (after surgery), and trauma.