Novel technique of non-surgical rejuvenation of infraorbital dark circles

Fat or fillers: The dilemma in eyelid surgery

The aging of the periocular region has always aroused great interest. A fresh, young, and attractive sight determined an ever-greater attention to surgical and non-surgical techniques to obtain this result. In particular, the change in the concept of a young look, considered then "full", led to the increasing use of surgical (fat grafting) or medical (hyaluronic acid) filling techniques. Eyelid rejuvenation became increasingly popular in the field of cosmetic treatments, with a focus on achieving a youthful and refreshed appearance. Among the various techniques available, the choice between using fat grafting or fillers presented a clinical dilemma. In particular, what surgery considered of fundamental importance was a long-lasting result over time. On the other hand, aesthetic medicine considered it fundamental not to have to resort to invasive treatments. But what was the reality? Was there one path better than the other, and above all, was there a better path for patients? The minireview aims to explore the physiopathology, diagnosis, treatment options, prognosis, and future studies regarding this dilemma. We analyzed the literature produced in the last 20 years comparing the two techniques. Current literature reveals advancements in biomaterials, stem cell research and tissue engineering held promise for further enhancing the field of eyelid rejuvenation. The choice between fat grafting and fillers in eyelid cosmetic treatments presented a clinical dilemma. Understanding physiopathology, accurately diagnosing eyelid aging, exploring treatment options, assessing prognosis, and conducting future studies were essential for providing optimal care to patients seeking eyelid rejuvenation.

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 .

Analysis of the efficacy of blunt separation combined with uncrosslinked sodium hyaluronate composite solution for the treatment of tear trough deformity in Asians

BACKGROUND

Filling therapy is becoming increasingly popular for correcting tear trough deformities (TTD). However, its therapeutic effect and retention time are limited.

AIMS

To improve the clinical efficacy and safety of TTD treatment in Asians, we used a blunt separation technique to break the adhesion site of periorbital subcutaneous tissue, and while repairing skin dermis after injury, it was combined with uncrosslinked hyaluronic acid compound solution to promote collagen regeneration and treat TTDs.

PATIENTS/METHODS

Twenty-six Chinese patients (21 women and 5 men) with TTD, with a mean age of 34.54 ± 9.21 (range, 20-56) years, were enrolled. Symptom improvement, recurrence rates, treatment safety, and patient satisfaction were evaluated.

RESULTS

All patients' tear trough rating scale (TTRS) scores decreased significantly immediately after treatment. The TTRS scores at 1, 3, and 6 months, and 1 year after treatment demonstrated significant differences from those before treatment (all p < 0.05). All patients' experienced mild pain, erythema, and swelling during the treatment. Three patients developed postinjection bruising after treatment, which lasted for 6-7 days and subsequently disappeared. No other adverse reactions were observed during the follow-up. There were no recurrent cases, and patient satisfaction was very high.

CONCLUSIONS

Blunt separation combined with an uncrosslinked sodium hyaluronate composite solution is safe and effective for treating TTDs in Asians with few side effects and has good clinical application prospects.

In vitro, ex vivo and clinical approaches to evaluate the potential effect of Gentiana lutea extract on skin

BACKGROUND

Dark circles affect subjects of all ages and in all skin types. They can be treated by various methods, particular by topical solutions. This investigation was directed towards exploring the effect of gentiopicroside (GP) on the skin around the eyes. For this, an extract of Gentiana lutea (GIE) containing GP (65% by dry matter) was evaluated on oxidant and angiogenesis parameters using in vitro and ex-vivo studies. A clinical experimentation was also realized.

METHODS

The effect of GIE at different concentrations on antioxidant gene was evaluated in vitro by RT-qPCR after treatment of NHDF. The effect of 2.93 μg mL-1 GIE on the release of VEGF-A and VEGF-C by NHDF was also studied. The effect of 87.9 μg mL-1 GIE was also evaluated on pseudotube formation in a coculture system of normal dermal microvascular endothelial cells (HMVEC-d)-NHDF stimulated or not with VEGF as pro-angiogenic factor. Prior to these assays, preliminary cytotoxicity assays were performed using a standard WST-8 reduction assay. The expressions of carboxymethyl-lysine and glyoxalase-1 were quantified on skin explants topically treated with 147 μg mL-1 GIE in basal and UVA-irradiated conditions. A clinical study was conducted in 22 subjects using topical twice daily for 14 days on eye area (split-face application: cream containing 147 μg mL-1 GIE versus placebo). 3D image acquisition and skin colour measurement were performed at D0 and D14.

RESULTS

Treatment of GIE upregulated the gene expression of NFE2L2 and downregulated the expression of CXCL8. GIE targeted AGEs pathways and reduced the formation of pseudotubes. A total of 147 μg mL-1 GIE gel cream significantly reduced significantly the average roughness and relief of the upper eyelid skin as well as the redness of dark circles after 14 days of application.

CONCLUSION

By acting on the pathway of AGEs, VEGF-A and VEFG-C, GIE seems to allow a rejuvenation of the skin resulting, among others, in a decrease in redness. It now would be interesting to evaluate the efficacy of GIE on skin around eyes microbiota, antibacterial gentiopicroside property being well-established.

Treatment of Periorbital Vascularity, Erythema, and Hyperpigmentation

Periorbital hyperpigmentation (POH) is a common aesthetic concern that impacts patients' emotional well-being and quality of life. POH can be difficult to manage as the etiology is often multifactorial or difficult to elucidate. An understanding of different contributing factors and ability to classify hyperpigmentation can aid in the management of POH. Classification of POH is divided into pigmented, vascular, structural, and mixed subtypes. A wide array of treatment options has been proposed belying the challenges inherent to improving POH. Modalities vary from topical therapies, chemical peels, dermal fillers, and lasers, to surgical intervention. Because POH can be multifactorial, successful management of POH will depend on elucidating the etiology and often requires a combination of therapies.

Tear Trough Filler Using the Three-point Tangent Technique: Lessons from 1452 Tear Trough Applications

This study describes a novel three-point tangent technique for tear trough filler and the results from the largest series to date.

Methods

A retrospective case review was performed for all patients treated between 2016 and 2020. Patient demographics, filler details and complications were recorded. The injection technique involves using a blunt cannula to deliver filler along three linear tangents bespoke to each patient.

Results

A total of 1452 applications of filler to the orbits of 583 patients were recorded. The median patient age was 41 years (range 19-77), and 84% were women. The mean volume of applied filler at the first appointment was 0.34 mL to each orbit (range 0.1--1.5); 82% reported no complication, 10% reported swelling with a median duration of 4 weeks (range 1-52), 4.3% experienced bruising, 4.6% reported contour irregularities, and 3.3% experienced a Tyndall effect. Retrobulbar hemorrhage occurred in one patient (0.17%), which was managed immediately with no lasting visual compromise. Volume of filler injected was significantly associated with a risk of edema (P < 0.00001) and contour irregularities (P = 0.012). In total, 50% of cases of edema resolved spontaneously after 4 weeks. Filler was dissolved in 1.9% of orbits. Patients with a history of dissolving were significantly more likely to require dissolving after subsequent reinjection (P = 0.043).

Conclusions

The three-point tangent technique is a safe and effective method. Increasing volume of filler administered is associated with complications of edema and contour irregularities. Edema is the most common complication and resolves spontaneously in half of patients by 4 weeks.

Surgical Correction of Tear Trough Deformity (TTD) with Orbicularis Retaining Ligament Release and Volume Augmentation for Periorbital Rejuvenation: Review of the Literature

BACKGROUND

Tear trough deformity is a hallmark of periorbital aging. It is not, however, an exclusive feature of old age. While protruding orbital fat results in lower lid bags that are traditionally corrected by excision, correction of TTD can constitute a real challenge requiring volume enhancement in addition to addressing prolapse of orbital fat and descent of cheek tissues. Described therapeutic options include minimally invasive soft tissue augmentation with fillers or structural autologous fat transfer as well as invasive surgical procedures concomitantly with lower lid blepharoplasty or other facial rejuvenation procedures.

MATERIAL AND METHODS

Six eponyms have been used in the literature to describe the condition: (1) naso-jugal fold, (2) naso-jugal groove, (3) naso-jugal ditch, (4) tear trough, (5) tear trough deformity, and (6) tear trough depression. A separate PubMed database search of each of the 6 terms was conducted in addition to an advanced literature and systematic PICO searches to identify all described clinical retrospective or prospective, comparative or simple cohort studies related to surgical correction of TTD. An additional screening of references of retrieved clinical studies was performed to identify any missed reports.

RESULTS

A total of 435 publications were identified with the initial search. After excluding all none relevant studies, 44 papers were selected for review. 6 additional studies were identified by screening relevant references.

CONCLUSION

Almost all authors agree on the necessity to release the tear trough retaining ligament together with volume enhancement. Transconjunctival and transcutaneous incisions are reported. Most recommend repositioning of the protruding orbital fat for volume enhancement to mostly subperiosteal, or pre-periosteal pockets. Other reported options include pedicled buccal fat pad transposition, segmental fat grafting, and minced micrografts. Internal as well as external fixation of repositioned fat flaps have been described. Despite lack of solid objective evidence, several of these techniques when properly executed for the proper indication in selected patients are reported to result in a rewarding and long-lasting outcome. Unfortunately, it is difficult to determine the most appropriate technique that would universally yield the most pleasant and harmonious facial contour without creating an unnatural puffy appearance. It remains for the surgeon to identify the safe surgical approach that does not compromise lower eyelid function and achieves the most pleasing aesthetic outcome with the least complications and downtime.

LEVEL OF EVIDENCE III

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 .

Surgical Management of Polymethylmethacrylate-Collagen Gel Complications in the Lower Eyelid: A Case Series

BACKGROUND

As nonsurgical rejuvenation with fillers continues to grow in popularity, patients are increasingly interested in more durable results. Polymethylmethacrylate (PMMA)-collagen gel is unique among fillers in that the PMMA microspheres are not completely absorbed and phagocytosed by the body. This durability coupled with the biophysical properties of PMMA makes it a poor choice for periorbital rejuvenation, an unforgiving and highly complex anatomic area.

METHODS

Between 2011 and 2018, 14 patients with PMMA granulomas in various facial areas self-referred to the senior author's practice. Of these patients, 11 were managed nonsurgically; however, all 3 patients who presented with granulomas in the infraorbital area required surgery to remove the filler and restore a natural aesthetic.

RESULTS

The 3 patients with significant swelling and PMMA filler nodules in the infraorbital area with unacceptable cosmetic appearance were females between the ages of 50 and 55 years. Nonsurgical protocols were unsuccessful, and surgical removal was required. All subjects have been followed for a minimum of 2 years with no immediate- or long-term postoperative complications secondary to PMMA removal. Patients remain satisfied with the outcome of the surgery.

CONCLUSIONS

Despite the evidence that the periorbital area is prone to adverse events when injected with particulate fillers, misguided enthusiasm for PMMA-collagen gel as a durable treatment continues to lead to unnecessary and severe complications in patients. The case studies presented here highlight that this product should not be introduced into the periorbital area. We also describe a surgical treatment approach for its removal if complications arise.

Optical characteristics of the skin with dark circles using pump-probe imaging

Pump-probe imaging was first used for quantitative analysis of melanin in dark circles' skin to improve the ability to diagnose and treat dark circles on human skin. This study aimed to compare the distribution characteristics in melanin of lower eyelid skin tissues and to determine whether pump-probe imaging has potential for the classification of dark circles in vivo. Specimens obtained from 15 patients undergoing blepharoplasty were examined using pump-probe imaging. Furthermore, adjacent slices were respectively treated with hematoxylin-eosin (HE) and ferrous sulfate (FeSO₄) staining for cross-references. Subsequently, the melanin content index (MCI) and mean fluorescence intensity (MFI) were quantitatively analyzed by the pump-probe imaging. The distribution of melanin granules in the pump-probe image and FeSO₄ staining was consistent. Meanwhile, the tissues of the skin with dark circles and normal skin demonstrated significant differences in MCI and MFI. These differences can be used to distinguish the skin with dark circles from the normal skin. Pump-probe imaging could be used for the analysis of the microstructure and spectral characteristics of melanin granules in skin with dark circles. Significant differences were noted between the pigmented type of dark circles and the other two groups (normal skin and the vascular type of dark circles), while no significant differences were found between normal skin and the vascular type of dark circles.

Dermal Fillers for Tear Trough Rejuvenation: A Systematic Review

There is significant variation in treatment parameters when treating the infraorbital region. Thorough knowledge of these pertinent factors, choice of the optimal filling material, and proper understanding of the anatomy of this unforgiving region will contribute to a safe, effective, and natural result. We aim to conduct a systematic review of published literature related to soft tissue fillers of the tear trough and infraorbital region. A search of published literature was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and included PubMed, Embase, and Science Direct databases. The Medical Subject Headings (MeSH) terms used were "tear trough" OR "infraorbital" AND "dermal filler" OR "hyaluronic acid" OR "poly-L-lactic acid" OR "calcium hydroxyapatite" OR "Restylane" OR "Radiesse" OR "Perlane" OR "Juvéderm" OR "Belotero." Different combinations of these key terms were used. The initial search identified 526 articles. Six additional articles were identified through references. Two-hundred twenty-five duplicates were removed. A total of 307 studies were screened by title and abstract and 258 studies were eliminated based on inclusion and exclusion criteria. Forty-nine articles underwent full-text review. The final analysis included 23 articles. Patient satisfaction was high, and duration of effect ranged from 8 to 12 months. Restylane was most commonly used. Injection technique varied, but generally involved placing filler pre-periosteally, deep to orbicularis oculi muscle, anterior to the inferior orbital rim via serial puncture or retrograde linear threading with a 30-gauge needle. Topical anesthetic was most commonly used. Side effects were generally mild and included bruising, edema, blue-gray dyschromia, and contour irregularities. Nonsurgical correction of the tear trough deformity with soft tissue filler is a minimally invasive procedure with excellent patient satisfaction with long-lasting effects. It is essential to have a fundamental understanding of the relevant anatomy and ideal injection technique to provide excellent patient outcomes and prevent serious complications.