Definitions of groove and hollowness of the infraorbital region and clinical treatment using soft-tissue filler

Treatment Algorithm for Surgical Correction of Lower Eyelid Bags and Tear Trough Deformity Based on Barton Grading System

Facial rejuvenation procedures for lower eyelid bags and tear trough deformity have recently gained increasing attention. This study introduced a treatment algorithm tailored to the severity of tear trough deformity, categorized using the Barton grading system, to tackle this concern effectively. One hundred seventy-six patients with combined lower eyelid bags and tear trough deformity underwent lower lid blepharoplasty at our center between 2018 and 2023. Preoperative assessment utilized the Barton grading system to categorize the severity of tear trough deformity, guiding personalized surgical approaches for each patient. Postoperative outcomes, including satisfaction levels, complications, and tear trough deformity improvement, were evaluated. Following surgery, 175 out of 176 patients achieved a reduction to Barton grade level of 0. Postoperative satisfaction scores averaged 4.4, with a satisfaction rate of 96.6%. Complications were minimal, including mild postoperative ectropion in patients and single occurrences of postoperative hematoma, infection, insufficient improvement, and recurrence. Our treatment algorithm offers a straightforward and effective approach for addressing tear trough deformity and lower eyelid bags. Further research is warranted to validate these findings.

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

Orbital fat graft retroseptal transconjunctival blepharoplasty for treatment of groove in the infraorbital region

PURPOSE

To investigate the efficacy of the retroseptal transconjunctival blepharoplasty together with tear trough ligament (TTL) and Orbicularis retaining ligament (ORL) release with orbital fat graft in the management of groove in the infraorbital region (GIR).

METHODS

A prospective study of 80 eyes of 40 patients that underwent retroseptal transconjunctival lower blepharoplasty together with TTL and ORL release and resected orbital fat grafting. An ophthalmic examination includes lower eyelid evaluation and Barton's Tear trough deformity grading was done at baseline, 2 weeks, 3 months, and 6 months after the surgery. Patient satisfaction was evaluated using Global aesthetic improvement scale (GAIS) and Blepharoplasty outcomes evaluation (BOE).

RESULTS

Baseline tear trough defects were graded into grade 1, 2, and 3 in 12 (15%), 39 (48.75%) and 29 (36.25%) eyes, respectively. While at 6 months follow-up, grade 0 was recorded in 63 (78.75%) eyes, and grade 1 was recorded in 17 (21.25%) eyes. The amount of fat removed was 0.52 ± 0.04 mL per eye, whereas the amount of injected fat graft was 0.24 ± 0.04. The mean operative time was 33.2 ± 4.1 min per eye. GAIS showed degree 1, 2, and 3 in 8 (20%), 29 (72.5%), and 3 (7.5%) patients at 6 months follow-up, respectively. The mean baseline BOE increased significantly from 36.5 ± 5.9 to 86.9 ± 5.5 at 6 months follow-up.

CONCLUSIONS

Our cohort highlights the beneficial effects of TTD/ORL release with resected orbital fat grafting in the management of GIR and infraorbital hollow.

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 .

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.

Lower eyelid blepharoplasty combined with ultrasound-guided percutaneous diode laser lipolysis: evaluating effectiveness with long-term outcome

Laser lipolysis may be considered for selective removal of excess orbital fat via minimally invasive lower blepharoplasty. To control the energy delivery to a precise anatomic location while avoiding complications, ultrasound guidance can be utilized. Under local anesthesia, a diode laser probe (Belody, Minslab, Korea) was introduced percutaneously to the lower eyelid. The tip of the laser device and changes in orbital fat volume were carefully controlled with ultrasound imaging. A 1470-nm wavelength was used for orbital fat reduction (maximal energy 300 J), and a 1064-nm wavelength was used to tighten the lower eyelid skin (maximal energy 200 J). From March 2015 to December 2019, a total of 261 patients underwent ultrasound-guided diode laser lower blepharoplasty. The procedure took 17 min on average. Total energy of 49 J-510 J (average = 228.31 J) was delivered in 1470-nm wavelengths or 45-297 J (average = 127.68 J) was delivered in 1064-nm wavelengths. Most patients were very satisfied with their results. Fourteen patients experienced complications, including nine cases of transient hypesthesia (3.45%), and three skin thermal burns (1.15%). However, these complications were not observed after strict control of the energy delivery below 500 J for each lower lid. Improvement in lower eyelid bags can be achieved using a minimally invasive approach in selected patients with ultrasound-guided laser lipolysis. It is a fast and safe procedure that can be performed in the outpatient setting.

Filler-based correction of tear trough depressions and eye bags in Japanese patients: A classification system and treatment algorithm

BACKGROUND

Tear trough depressions are widely treated with fillers. However, it is questionable whether the same strategies can always be used for Caucasian and Japanese patients, owing to differences in bone and skin structures and epithelial thickness.

AIMS

To assess a novel classification system and treatment algorithm for correcting tear trough depressions and eye bags in Japanese patients.

METHODS

Tear trough depressions can be classified into three types according to the presence or absence of a "negative vector" based on retrusion of the maxilla relative to the anterior corneal surface, with or without eye-bag protrusion when smiling. Type 1 patients (without the negative vector) can be treated simply by filling the depression in the tear trough and the palpebromalar groove region. Type 2 patients (with a negative vector and no eye-bag protrusion on smiling) also require volume restoration in the mid-cheek (deep medial cheek fat, suborbicularis oculi fat, and pre-maxillary space); this not only enables volume recovery but also compensates for maxillary deficiency. Type 3 patients (with a negative vector and eye-bag protrusion on smiling) require an additional step, based on placing a filler in front of the eye bags and pushing orbital fat backward.

RESULTS

Case presentations demonstrate the utility of the techniques involved.

CONCLUSIONS

This system provides a simple and practical method for classifying and treating Japanese patients with tear trough depressions and eye bags. Further studies are warranted.

Tear Trough Filler Techniques Utilizing Hyaluronic Acid: A Systematic Review

BACKGROUND

Hyaluronic acid soft-tissue augmentation fillers are commonly injected into multiple areas of the face, including the tear trough. Despite well-documented risks, there is no standardized, evidence-based approach to inject filler in this area, be it using a hypodermic needle or a microcannula. The authors, therefore, sought to establish a preference between the two methods to facilitate progression toward standardization and prevention of adverse events.

METHODS

This is a systematic review of articles discussing hyaluronic acid tear trough injection techniques performed in vivo and related outcomes. Searches were conducted across The Cochrane Library, PubMed, Scopus, Web of Science, and Embase to yield relevant articles published before February of 2020. All selected articles incorporated discrete patient cases and were analyzed by a variety of variables assessing evidence strength, outcomes, technique, and patient safety.

RESULTS

After appraisal, 42 articles met eligibility criteria: 20 using needles, 12 using cannulas, and 10 focusing on adverse events. Level III was the most commonly awarded evidence grade, corresponding to retrospective, nonexperimental descriptive studies. There were no statistically significant differences in reported aesthetic results, patient satisfaction, or incidence of adverse events across the needle-based and cannula-based articles. Some technique trends, such as targeted anatomical plane and needle position, emerged in subsequent articles.

CONCLUSION

Given that there were no statistically significant differences in patient safety or outcomes, an evidence-based preference for needle or cannula injection into the tear trough cannot be made at this time. Current inconsistencies make tear trough injection procedures difficult to replicate, making standardization based on avoidance of adverse events not feasible.

Anatomical Characterization of the Tear Trough and the Lid-Cheek Junction: An Iodine Staining Technique Based on High-Resolution Micro-Computed Tomography

BACKGROUND

The literature presents the tear trough and lid-cheek junction's controversial anatomical explanations. In this study, the authors explored the anatomical characterization of the tear trough deformity and lid-cheek junction.

METHODS

Twelve human cadaver specimens were obtained from the authors' anatomy department. Iodine staining and high-resolution micro-computed tomography was used to observe the suborbital area's anatomy. Anatomical studies and histologic evaluation were performed.

RESULTS

The orbicularis retaining ligament is composed of a main septum right on the rim and multiple fibrous septa in the retro-orbicularis plain. The septum arises from the deep fascia of the palpebral part of the orbicularis oculi at approximately the level of the medial corneoscleral limbus, anchors the muscle to the orbital rim, and continues laterally as the lateral orbital thickening at the lateral canthus. Along the lid-cheek junction, multiple fibrous septa emanating from the deep fascia of the orbital part of the orbicularis oculi converge to the above septum. Using three-dimensional simulation, the skin-insert junction between the pre-palpebral part of the orbicularis oculi and pre-orbicularis oculi fibers precisely corresponded with the tear trough and the lid-cheek groove. Anatomical studies and histologic evaluation confirmed these observations.

CONCLUSIONS

The orbicularis retaining ligament's subtle anatomical features are clearly seen using the approach described. The tear trough and the lid-cheek junction's anatomical characterization is defined by a suborbital ligament-fascia system whose description has implications in designing lower eyelid cosmetic surgery.

Injection Guidelines for Treating Midface Volume Deficiency With Hyaluronic Acid Fillers: The ATP Approach (Anatomy, Techniques, Products)

Midface rejuvenation is among the most valuable indications of hyaluronic acid dermal fillers, because malar projection and full upper cheeks significantly contribute to a youthful appearance. Hyaluronic acid fillers have evolved over the past 2 decades to meet specific clinical needs such as strong projection capacity and adaptability to facial dynamism. As a result, they now represent the treatment of choice for midface rejuvenation throughout age ranges by offering the potential for noninvasive treatment, immediate results, and minimal downtime. Because the 5-layered structure of the midface plays a central role in the human face, injecting the midface area may also indirectly improve other aesthetic concerns such as infraorbital hollowing and nasolabial folds. Nonetheless, midface rejuvenation requires a tailored treatment approach and a thorough knowledge of anatomy to minimize procedural risks and achieve natural-looking results. This article provides an extensive anatomical description of the midface and of the usual course and depth of vascular structures circulating nearby to delineate a treatment area and minimize procedural risks. Furthermore, considering the differential mobility and mechanical constraints of each layer of the midface, a multilayer treatment algorithm is proposed for adapting the treatment strategy to patient specificities (including age, gender, skin type, and morphology). Emphasis is also placed on desirable filler properties to create deep structural support on the one hand and accompany facial movement on the other hand.

Corrective treatment for tear trough deformity in a young population utilizing two-dimensional fat injections

OBJECTIVES

Tear trough deformity (TTD) is becoming a growing concern for those seeking facial rejuvenation, and various treatment strategies have been reported. Among treatment options is micro-autologous fat injection, which appears to be an effective approach to recontour the tear trough in the young. The study we present here investigated the reliability and effectiveness of two-dimensional fat injections (TDFI) in the treatment of young patients with TTD.

METHODS

This study evaluated patients with TTD who underwent TDFI between December 2018 and December 2020. The proposed procedure involved ligament releasing and fat injection into the tear trough in two different directions.

RESULTS

The average age of the 102 enrolled patients was 25.9 ± 3.8 years. Significant improvement and maintenance of TTD were observed during the follow-up period (13.2 months average) with no major complications being observed. Improvement of dark cycles and enhanced aegyo sal were observed. Patient satisfaction based upon self-administered post-procedure questionnaires disclosed that 58.8% were very satisfied, 38.2% were satisfied, and 2.9% neutral with the results.

CONCLUSIONS

Two-dimensional fat injections is an effective and reliable method with high satisfaction and low risk of complication. Long-term results demonstrated its utility for young-type TTD.

Injectable Filler Technique for Face Lifting Based on Dissection of True Facial Ligaments

BACKGROUND

Strengthening weakened ligament tissues with injectable fillers to improve their supportive effect may achieve the aesthetic goal of face lifting.

OBJECTIVES

The aim of the study was to design an injectable technique for enhancing the true facial ligaments and dissect the ligaments to provide anatomical guidance for effective injection.

METHODS

Six true facial ligaments were chosen as target anatomical sites for injection. Specimens were dissected, and 3-dimensional (3D) images were reconstructed to confirm the exact location of each injection site and to confirm that the proposed injection routes will not cause dangerous vascular damage. A total of 5 patients received the injections; 3D images were taken before and after the injections for comparison and clinical outcome assessments.

RESULTS

The injection technique was designed to target 6 true facial ligaments, as follows. Site 1 targeted the temporal ligamentous adhesion region to lift the lateral ends of the eyebrows. Site 2 targeted the region of the lateral orbital thickening to lift the lateral canthus. Site 3 and site 4 targeted the zygomatic retaining ligaments and zygomatic cutaneous ligaments, respectively, to augment the soft tissues of the midface. Site 5 targeted the region of the maxillary ligament to lessen the nasolabial folds, and site 6 targeted the mandibular ligament to reduce the marionette line.

CONCLUSIONS

This site-specific injection technique targeting the true ligaments may lead to increased efficiency and accuracy of face rejuvenation and exert a lifting effect.

LEVEL OF EVIDENCE: 4

Patient-reported Outcomes in Chinese Subjects Treated with OnabotulinumtoxinA for Crow's Feet Lines

BACKGROUND

Crow's feet lines (CFLs) can impact the emotional state, self-perception, and consciousness regarding appearance of patients.

OBJECTIVE

This study sought to assess patient-reported outcomes after onabotulinumtoxinA treatment for CFLs among Chinese subjects.

METHODS

A five-month, double-blind, randomized, parallel-group, placebo-controlled Phase III clinical study was conducted including Chinese adults with moderate-to-severe CFLs at maximum smile. Subjects were randomized 3:1 to 24 U of onabotulinumtoxinA or placebo and completed the 11-item Facial Line Outcomes (FLO-11) questionnaire and Facial Line Satisfaction Questionnaire (FLSQ) at baseline; on Days 8, 15, and 30; and monthly thereafter until Day 150. Item-level and/or domain analyses for the FLO-11 and FLSQ were conducted.

RESULTS

Of 417 treated subjects, 316 received onabotulinumtoxinA and 101 received placebo. For all 10 validated stand-alone FLO-11 items, there was a significantly greater proportion of responders in the onabotulinumtoxinA group versus placebo (P<0.001) at Day 30 that was maintained through Day 150. Significant improvements at Day 30 were reported for all FLSQ items and the FLSQ Follow-up Impact Domain (P≤0.01).

CONCLUSION

FLO-11 and FLSQ data indicated high satisfaction and significant improvements in appearance-related and emotional impacts through Day 150 in patients treated with onabotulinumtoxinA for moderate-to-severe CFLs in Chinese subjects.

TRIAL REGISTRATION

ClinicalTrials.gov identifier no. NCT02195687.

Consensus on the Use of Hyaluronic Acid Fillers from the Cohesive Polydensified Matrix Range: Best Practice in Specific Facial Indications

Background

As the treatment indications for the Cohesive Polydensified Matrix^® hyaluronic acid (CPM-HA) portfolio continue to expand and diversify, injectors new to the range or those who are expanding the treatments they offer may be unsure of the optimal product and injection technique for specific facial areas. Each product in the CPM-HA portfolio has been intentionally designed to provide the best physical properties for a specific indication and target tissue. This document has been developed to provide a comprehensive, one-stop reference for clinicians using the portfolio.

Methods

An international panel of experts in the field of aesthetic medicine convened to develop guidelines on effective and safe injection technique when performing treatments with the CPM-HA range of soft-tissue fillers.

Results

Consensus members considered treatment indications in the upper, middle and lower face. Landmark deficiencies and anatomical considerations are described for each indication and consensus recommendations provided on the optimal product, injection depth and treatment technique. This is supplemented by the experts advice on avoidance of complications. Throughout, an evidence-based approach to selection of products and injection techniques is provided. The result is a fully tailored approach to a range of indications covering the full portfolio of CPM-HA products, including the newest addition for skin revitalization.

Conclusion

The recommendations in this consensus document are provided to assist clinicians in the selection of CPM-HA products, administration techniques and depths of injection with the aim of providing seamless and natural treatment results, enhanced safety and patient satisfaction.

Use of Buried Guide Needle to Fix Inferior Eyelid Orbital Septum Fat for Tear Trough Depression Filling

ABSTRACT

Fat fixation is a key step in filling tear trough depression with inferior eyelid orbital septum fat. The ideal position for inferior eyelid fat fixation is to cross the tear trough ligament causing tear trough depression and the orbicularis retaining ligament, with the distal end fixed at the farthest end of the dissected lacuna deep down the inferior orbicularis oculi muscle. Traditional suturing is difficult in the deep narrow lacunae, but a buried guide needle can be used to suture and fix the fat in the deepest lacuna. In this study, 264 patients who underwent tear trough filling using a buried guide needle to fix the released inferior eyelid orbital septum fat from 2017 to 2020 were followed up. The preoperative and postoperative imaging findings were compared to evaluate the effectiveness of the operation and postoperative complications. The inferior eyelid bulging, loose skin, and tear trough depression significantly improved than that before the operation. None of the patients had any severe complications, such as inferior eyelid ectropion, lagophthalmos, scar hyperplasia, and diplopia, in the long term (6 months) postoperatively. Five patients showed mild eyelid-eyeball separation and recovered in 1 month. Four patients had diplopia, and 3 patients had chemosis; all recovered in 7 days. The tear trough depression was not corrected completely in 2 patients. The operation showed satisfactory results in the improvement of tear trough depression in addition to alleviation of inferior eyelid bulging and loose inferior eyelid skin that is caused by the traditional inferior eyelid pouch removal.

Fan-Shaped Thin Fat Pedicles for Tear Trough Correction Through a Layer-Level Fixation: A Modified Transconjunctival Blepharoplasty

ABSTRACT

Fat repositioning is an effective way to treat tear trough deformity (TTD) in Asians. Recent techniques mainly focused on the fixation technique, whereas how to precisely shape and individually quantify the fat pedicle has been ignored. This article introduced an individualized, targeted, and tension-free technique to fabricate a fan-shaped thin septum fat pedicle for repositioning. Furthermore, a layer-level fixation method was advocated to provide sufficient, continuous, uninterrupted filling of the TTD. From January 1, 2009, to December 31, 2018, 492 patients underwent this procedure. Through a transconjunctival incision, a continuous fan-shaped, tension-free, customized septum fat pedicle was precisely designed to match the TTD anatomy. The pedicle could either be elongated, or thickened, or debulked, or translocated, to meet the patients' individual needs. At the same time, a layer-level fat pedicle fixation technique was applied to fully interrupt the TTD. The mean operation time was 60 ± 9.3 minutes. All patients demonstrated a significant improvement with elimination of both eye bags and TTD. High satisfaction was noted among the patients. No obvious resorption of the fat pedicles was observed, and the lower lid contour improvements were durable. One infection occurred after 3 days of surgery, and was resolved by removal of the suture followed by topical application of iodine and oral antibiotics for 3 to 5 days. No other complications were observed. Precisely repositioning transconjunctival fat using a layer-level fixation technique with a fan-shaped thin fat pedicle under a subperiosteal plane is an effective, lasting, and safe approach for individually treating TTD.

Measurement Method to Determine the Difference in Tear Trough and Palpebromalar Groove Distribution After Transconjunctival Fat Reposition

PURPOSE

This study designed an efficient measurement method to evaluate the outcome of transconjunctival fat reposition in the tear trough and palpebromalar groove.

METHODS AND TECHNIQUES

A total of 41 patients (82 eyes) who underwent transconjunctival fat reposition surgery between January 2016 and March 2019 were retrospectively analyzed. Preoperative and postoperative (at least six months) standardized digital images were taken from the patients. A satisfaction survey was conducted on all patients. Their images were analyzed by using the Adobe Photoshop CS5 software. Ratios of the tear trough and palpebromalar groove were calculated. These data were analyzed by SPSS 20.0.

RESULTS

The overall satisfaction rate was 90.2%. With a partition in the infraorbital region, a line graph showed that the location of the tear trough and palpebromalar groove moved to the upper squares postoperatively. The number of patients whose end points of the tear trough and palpebromalar groove located outside the midline of the pupil decreased by 30.5%. When we processed all the parameters of the preoperative and postoperative groups by profile analysis, a significant difference in the tear trough and palpebromalar groove before and after surgery was observed (right: F = 79.844, P = 0.000 < 0.01; left: F = 161.799, P = 0.000 < 0.01).

CONCLUSIONS

Digital image analysis is feasible and useful in investigating the improvement of the tear trough and palpebromalar groove. The tear trough and palpebromalar groove shifted up and became shortened, which provided a more reliable evidence for lower eyelid rejuvenation.

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.

Three-Dimensional Computed Tomography of the Detoured Facial Artery: Variations and Implications for Nasojugal Groove Correction

BACKGROUND

When performing filler injection procedures to the nasojugal groove, there is the risk of iatrogenic damage to the detoured facial artery.

OBJECTIVE

To determine the 3-dimensional location of the detoured facial artery.

MATERIALS AND METHODS

The branches of the facial arteries from 118 cadaveric hemifaces were scanned using computed tomography and reconstructed using the Mimics software program.

RESULTS

Detoured facial arteries were found in 47 of the 118 hemifaces (39.8%). Two main arterial patterns were identified: in Type I (29 of 47 cases), there were both detoured and nasolabial trunks where the facial artery originated, whereas in Type II (18 of 47 cases), there was only a detoured trunk. The detoured trunk originated 32.0 ± 5.3 mm from the midsagittal line, 5.0 ± 2.8 mm from the occlusion plane, and 5.9 ± 3.5 mm below the skin layer; the inflection of the detoured trunk was located 30.0 ± 5.6 mm laterally, 26.2 ± 4.4 mm superiorly, and 5.7 ± 2.6 mm deep. The meeting point with the inferior orbital rim plane was located 17.1 ± 3.4 mm laterally, 43.4 ± 3.1 mm superiorly, and 2.8 ± 1.7 mm deep.

CONCLUSION

The 3-dimensional location of the detoured facial artery as reported here will help clinicians to avoid iatrogenic damage when they are performing filler injection procedures.

Supraperiosteal application of hyaluronic acid with cannula: Is it possible?

INTRODUCTION

The aging process occurs in all anatomical layers of the face; therefore, rejuvenation should not be limited to the dermic signs of aging (Aesthet Surg J. 2018;38:73) The treatment with fillers in strategic points can reconstruct young anatomy, providing natural results (Aesthet Surg J. 2018;38:73). There are two instruments used for facial application of hyaluronic acid: cannula and needle. Both of them have advantages and disadvantages.

OBJECTIVE

In this study, we aim to compare the limitations of application with cannula by cutaneous ultrasound when compared to the needle by ultrasound, since some injectors suggest that one of the disadvantages would be the inability to reach certain application plans (periosteum).

MATERIALS AND METHODS

A 52-year-old female patient was treated with 22 mg/ml hyaluronic acid (Juvéderm® Voluma), guided by high-frequency ultrasound (LogicE device, Logic brand (GE Healthcare), with high-frequency linear probe (L8-L18i-RS). The left hemiface was treated with a 27G needle and the right hemiface with a 5 cm 22G cannula (SoftFil®).

CONCLUSION

This study proved that, in the malar/zygomatic and the chin region, it is possible the cannula and needle reached the supraperiosteal region. In the temporal region, the cannula did not reach the supraperiosteal plane.

Tear Trough Treatment with Orbicularis Oculi Muscle Suspension

BACKGROUND

Blepharoplasty is a very requested surgery for aesthetic rejuvenation of the eyes with grateful results. Lower blepharoplasty involving a variety of different techniques can be considered to refresh the oculopalpebral area. The approach of the treatment of the tear trough as releasing the tear trough ligament and plication of orbicularis oculi muscle in the palpebral portion to fill the tear trough concavity is essential in our surgical technique demonstrated here.

METHODS

From July 2014 to January 2020, 435 patients were submitted to blepharoplasty surgery for rejuvenation of the eyes. Lower blepharoplasty was performed with releasing of the tear trough ligament and suspension and fixation of the palpebral part of the orbicularis oculi muscle in the medial part of orbital bone corresponding to the tear trough area. The follow-up was 12 months.

RESULTS

Patient satisfaction was high, and no complications were observed. Ten patients (2.2%) needed the addition of hyaluronic acid fillers in the tear trough 12 months after the surgery.

CONCLUSION

We conclude that the use of the orbicularis oculi muscle suspension improves the long-term aesthetic results for the tear trough and the technique is easy to perform.

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 .

Whole-Face Approach with Hyaluronic Acid Fillers

The use of hyaluronic acid fillers in aesthetic medicine has changed over the years and the procedure became one of the most common in the world. Understanding the ageing process of the face and the anatomical interrelationships in the face have dramatically influenced the use of the hyaluronic acid fillers and the assessment of the patient. It was supported by a new technology of products and by the delivery of tools (eg, blunt cannulas), face imaging, and innovative injection techniques. The whole-face approach challenges the practitioner to look at the face as a whole, and the patient to trust and rely on the treatment plan. Over the years, we have understood, that the most important outcome of aesthetic procedures is what does the whole face look like not static but in motion, and how do people read emotions from it. Nowadays, the result changes "the face information" and makes aesthetic procedures more satisfactory. In this manuscript, we reviewed essentials of the current treatment approach including patient's consultations, product selection and injection techniques used in different parts of the face. One size fits none; thus, we provided a general overview of hyaluronic acid fillers used in different indications and presented several treatment approaches to each region of the face.

Complications associated with infraorbital filler injection

Soft tissue augmentation with injectable fillers is increasingly being performed, and providers must be prepared to understand and treat complications. Periorbital skin presents unique challenges due to its thin nature, easily evident pigmentary and textural irregularities, and anatomical considerations including vasculature and subcutaneous layers. The most common complications of infraorbital filler include ecchymosis, malar edema, blue-gray hue, and contour irregularities. Uncommon complications include infection and biofilm formation, skin necrosis, and blindness. This purpose of this review is to highlight the infraorbital anatomy, complications of filler injection in this region, and techniques to avoid these complications.

"WAY": A practical means to identify and treat the aging process

Background

Many patients consult a specialist in esthetics to improve certain aspects of their face that are altered by aging. To ensure optimal results and to define the best approach for such interventions, it is important that specialists have a comprehensive understanding of facial anatomy and of the aging process in the regions of interest.

Aims

The main purpose of this article was to provide a practical approach for managing aging process in the mid‐ and lower face. Additionally, this paper also aimed to describe the processes associated with aging that may affect the morphology and the appearance of jaw contour (“W”); prejowl (“A”); tear trough, palpebromalar area, and nasojugal groove (“Y”) (“WAY”) signs.

Methods

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

Results

In this study, the anatomy and the changes associated with aging of the mandibular line and that of the tear trough, palpebromalar area, and nasojugal groove was described. The important anatomical changes in these facial regions can be considered through the “WAY” paradigm, signs of aging that can be treated through a variety of surgical and nonsurgical approaches. Although surgical procedures may obtain good results, patients generally prefer less invasive treatments, which have a good efficacy profile, but are safer and have a shorter recovery time.

Conclusions

The “WAY” signs identify anatomical changes in the mandibular line and tear trough, palpebromalar area, and nasojugal groove associated with aging that can be corrected by different procedures, preferably minimally invasive ones.

Recommendations for the treatment of tear trough deformity with cross-linked hyaluronic acid filler

Background

Recent years have seen a growing interest in the appearance of the eyes among the concerns expressed by patients in cosmetic clinics. This has led to an increase in the frequency of diagnosis of tear trough deformity, and, as a result, the number of treatments performed by specialized professionals has also risen. Hyaluronic acid filler injection is a rapid, nonsurgical technique that gives good long‐lasting, but not permanent, results. However, to achieve optimal results, the attending physician must have good anatomical knowledge of the area and involvement of the structures in the tear trough, carry out proper clinical assessment of the patient, and use an appropriate injection technique with the right product.

Aims

To support good practice among the professionals who carry out these procedures, this interdisciplinary consensus document describes the relevant issues and recommendations, in order to improve safety standards and to help successfully resolve this aesthetic problem.

A Prospective Study on Safety, Complications and Satisfaction Analysis for Tear Trough Rejuvenation Using Hyaluronic Acid Dermal Fillers

Background:

Tear trough (TT) treatment with hyaluronic acid soft tissue fillers is an increasingly popular aesthetic procedure. The traditional needle technique is cited many times in the literature with no studies looking at the results, complications and satisfaction rate with the use of the cannula device instead. The aims of this study are to describe the experience of 4 aesthetic doctors in the treatment of TT deformity and assess complications and side effects, overall satisfaction and improvement.

Methods:

Twenty-four patients were included (48 TTs) that fulfilled the inclusion and exclusion criteria and they were assessed over a 4-week period, looking at the complications, side effects, satisfaction rate, and others with the cannula technique for the medial TT.

Results:

Twenty-two women and 2 men each had the medial TT filler supra-periosteally using a cannula device. They were all reviewed at the 2-week stage +/− the 4-week stage. 100% of patients noted an overall improvement to the TTs and 75% were satisfied with their results with the other 25% requiring further filler to be satisfied. There were no major complications and only a small number of minor side effects like mild bruising and swelling that lasted up to 4 weeks.

Conclusions:

TT treatment, if performed using a cannula with a maximum of 1ml used in one sitting between both eyes, according to this study, is a safe treatment with a very low pain rating and with no major complications and high patient satisfaction.

Location of the infraorbital foramen with reference to soft tissue landmarks for regional nerve blocks during midface surgery

PURPOSE

An infraorbital nerve (ION) block is widely used to accomplish regional anesthesia during surgical procedures involving the midface region. This study aimed to elucidate the exact location of the infraorbital foramen (IOF) in relation to clinically useful soft-tissue landmarks for achieving an effective ION block.

METHODS

Forty-three hemifaces from 23 embalmed Korean cadavers were dissected. The lateral canthus, peak of Cupid's bow, medial limbus, and midline were used as reference points. The distances from the IOF to the midline and the lateral canthus were measured.

RESULTS

The IOF was located approximately 25 mm below the lateral canthus and 27 mm lateral to the midline. In all cases, the IOF was situated within 9.0 mm of the crossing point of the oblique line connecting the lateral canthus to the peak of Cupid's bow and the vertical line through the medial limbus.

CONCLUSION

Considering the spread of an anesthetic agent, injecting it into the crossing point of the oblique line through the lateral canthus to the peak of Cupid's bow and the vertical line through the medial limbus would successfully block the ION in most patients.

Novel technique for infraorbital groove correction using multiple twisted polydioxanone thread

BACKGROUND

The infraorbital groove can be corrected by lower blepharoplasty, microfat grafting, and soft tissue filler injection. Recently, multiple twisted polydioxanone threads were developed for facial rejuvenation.

OBJECTIVE

This study aimed to examine the efficacy and associated risks of the use of new synthetic threads for infraorbital groove correction.

METHODS

From March 2018 to June 2019, 40 patients (mean age: 43.4 years; range: 25-56 years) underwent transcutaneous multiple twisted thread insertion to correct the infraorbital groove. Three threads were inserted along the infraorbital groove on each side. The outcomes were assessed based on a comparison between preprocedure and postprocedure findings. Barton's grading and Global Aesthetic Improvement Scale scores were assessed by two physicians. Patient satisfaction with the aesthetic outcome of the procedure was evaluated at the end of the procedure and after 3 months. Ultrasonographic evaluation was performed to confirm that the threads had been properly placed. The anatomical layer in which the threads were placed was evaluated in a cadaveric study.

RESULTS

The mean Barton grade improved significantly (P < .001) without decline throughout the 12-week period. Improvement was found in all patients who were designated with a score >2 ("improved"). More than 77.5% of the patients were satisfied with the outcomes, and the rest of the patients reported some extent of correction with little satisfaction.

CONCLUSIONS

The findings indicate the benefits of the multiple twisted polydioxanone thread insertion in the treatment of patients with infraorbital groove without septal protrusion. This evaluation raised no major safety concerns.

Prolonged Periorbicular Edema After Injection of Hyaluronic Acid for Nasojugal Groove Correction

The injection of hyaluronic acid (HA), a naturally occurring biopolymer, is a common cosmetic procedure. Despite their efficacy and growing adaptation by the medical community, HA fillers occasionally give rise to adverse events. Adverse events from HA fillers range from temporary, such as edema and erythema, to more long-term effects, including granulomas or, in rare cases, sequelae from vascular occlusion. Here, we present a case of a 61-year-old Caucasian woman with prolonged infraorbital hollow edema after injection of HA filler for nasojugal groove correction. We review the anatomy of the nasojugal area and differing injection techniques as a possible explanation for the development of prolonged edema. Similarly, the rheological properties of the specific hyaluronic acid used during this procedure might be crucial in the development of this complication.

Periocular hyaluronic acid fillers: applications, implications, complications

PURPOSE OF REVIEW

The use of dermal filler in the periocular area is increasing - both for functional and aesthetic indications. Hyaluronic acid fillers dominate the market; these treatments offer an alternative to some surgical procedures with the advantage of instant results, minimal healing time and low complication rates. However, success depends on judicious selection of patients, products and procedures to achieve favourable outcomes. This article reviews current understanding of the principal complications in the periocular area and their management.

RECENT FINDINGS

Hyaluronic acid is a ubiquitous, biodegradable, nonspecies-specific molecular substrate with limited potential for immunogenic reactions. However, in the periocular area, such products can migrate and last significantly longer than the expected filler lifespan. Contamination or subsequent immune stimulation can trigger delayed-onset inflammatory reactions. Though minor vascular occlusions are not uncommon, cases of blindness secondary to facial filler injections are thought to be rare. Timely enzymatic degradation with injectable hyaluronidase can be effective in the treatment of some such complications. But recent studies demonstrate lack of penetration through arterial walls and optic nerve sheath, casting doubt on the role of retrobulbar hyaluronidase in the management of vision loss because of embolism with hyaluronic acid filler.

SUMMARY

Hyaluronic acid fillers represent an emerging and important addition to the armamentarium of the oculofacial plastic surgeon with their use in the aesthetic field also expected continue to rise. The oculoplastic facial surgeon, armed with a thorough knowledge of facial anatomy, safe injection planes and the means of minimizing and treating complications is in the best position to lead clinically in the use of this well tolerated and effective treatment modality.