5 Techniques of Dermal Filler Injection for Tear Trough Augmentation

According to Dermal Fillers for the Treatment of Tear Trough Deformity: A Review of Anatomy, Treatment Techniques, and their Outcomes by Jaishree Sharad (2012) Tear trough deformity is a major concern in a lot of individuals seeking periorbital rejuvenation. A prominent tear trough deformity is characterised by a sunken appearance of the eye that results in the casting of a dark shadow over the lower eyelid, giving the patient a fatigued appearance despite adequate rest, and is refractory to attempts at cosmetic concealment.


The tear trough deformity is a natural consequence of the anatomic attachments of the periorbital tissues. A variety of techniques have evolved to address this cosmetic issue. Traditional techniques relied on surgical excision of skin, muscle, and fat as well as chemical peels. Treatment is now tailored towards specific anatomic abnormalities and often employs multiple modalities including surgery, botulinum toxin, and replacement of volume.


Tear Trough Anatomy


‘Tear trough” is the hollow line that develops from the inner corner of the eye that extends laterally across to the lower cheek. Having hollow areas under the eyes with flattened cheeks is one of the most significant changes sign of ageing. As the youthful plumpness of our cheeks slowly fades due to fat loss, the tear trough starts to deepen and lengthen. Eventually, the tear trough extends laterally across the lower cheek.



These are typically caused by the following:

  • Fixation of the orbital septum at the level of the inferomedial portion of the arcus marginalis.

  • Existence of a triangular gap limited by the lateral portion of the angular muscle on one side and the medial portion of the orbicularis oculi muscle on the other

  • Absence of fat tissue from the central and medial fat pads subjacent to the orbicularis oculi muscle in the area below the groove.



Dermal fillers are used under the eyes to dramatically improve deep tear troughs. By treating areas of lost volume, the hollows and shadows look less obvious. This is one of the most rewarding treatments. Patients often note that they look considerably younger and less tired afterwards.


In almost all cases, it’s essential to treat both the cheek and the tear troughs together as a combined procedure. A tear trough needs support from the lateral aspect of the cheek and eye areas before we can add filler to the under eye itself.


Dermal Fillers for Tear Trough

Under eye (tear trough) fillers are soft gels containing hyaluronic acid, which is a natural bio-degradable compound found in your connective tissues. Common brands of under eye fillers include Restylane, Juvederm, Belotero and Stylage. In the past, the only treatment options were surgical eye bag treatments if you wish to improve sunken eyes and remove eye bags.


Thankfully, non-surgical options are readily available nowadays. With under eye dermal fillers, the under eye areas can be treated safely and effectively to give both immediate and long lasting results.


Technique

The right technique can also make treatment more comfortable. Conversely, poor technique can be more painful, lead to complications, and leave you with undesirable results.


Lambros's technique


Lambros stressed that when one engages in nonsurgical treatment for tear trough correction, it is important to evaluate the following factors:

  1. Skin quality, as patients with thick, smooth skin will have better results than those with thin extremely wrinkled skin.

  2. Definition of the hollow, as a more defined hollow is more amenable to fillers.

  3. The orbital fat pad, as larger fat pads are more difficult to correct due to ‘puffiness’ caused by the injection.

  4. The colour of the overlying skin, as the filler may improve shadowing but will not improve dark pigmentation.

After application of an ice pack to the lower lid and cheek, a local anesthetic consisting of 0.5% lidocaine with epinephrine (0.2 to 0.4 mL) is injected into the orbicularis within the boundaries of the tear trough. Finger pressure is applied to flatten the area of injection. A half-inch, 30-gauge needle is inserted through the skin at the most lateral extent of the tear trough, advancing fully and potentially indenting the skin with the hub for full reach. The HA is then injected deep into the dermis as the needle is withdrawn.


This process is repeated above and below the original site of the injection. The area is then inspected, and additional passes are made as needed to yield a smooth contour. Last, the area is massaged lightly, compressed with finger pressure, and rolled with a cotton applicator. In his description of the technique, Lambros stressed the importance of not forcefully compressing the product during massage, as this can displace the product into the cheek and exaggerate the tear trough. Postinjection care involves applying ice to the area the night of the procedure, and patients are instructed to refrain from massaging the area.


Kane's technique


After evaluation and marking of the tear trough, betacaine topical anaesthetic ointment is applied to the lower eyelids at least 20 minutes before the injection. After preparation of skin with alcohol, a 30- or 32-gauge needle is inserted for injection.


The skin of the lower lid is spread and held at some tension with the noninjecting hand. The skin is inspected carefully for visible vessels before each needle stick. The deepest portion of the medial tear trough is treated first. The needle is threaded below the surface of the skin above the orbicularis oculi. A miniscule amount of hyaluronic filler is injected at each pass. Parallel threads of the filler are injected cephalad and caudal to the tear trough.


The raised area of the filler is then tapered off medially along the nasal sidewall superiorly at the most cephalad-significant rhytid, inferiorly at least abutting or immediately caudal to the thick skin of the cheek, and laterally to at least the junction of the medial and lateral third of the inferior orbital rim. If the tear trough is deep, the direction of the needle is changed throughout the injection so that the filler is applied in a cross-hatched fashion. The volume range is 0.1 to 0.45 mL per eyelid, with most patients requiring 0.2 to 0.3 mL.


Technique of stutman and codner


With the patient seated, the tear trough deformity and lid-cheek junction are marked with easily removable white eyeliner. The patient is advised to apply ice packs to the area several minutes before injection to minimise bruising and for anaesthetic purposes.


After the markings are confirmed by the patient, HA is injected deep in the preperiosteal plane, to reduce visibility of the product. The HA is placed beneath the insertion of the medial orbicularis muscle at the maxilla and continues laterally inferior to the orbicularis retaining ligament. A combination of crosshatching and linear threading is utilised with a 30-gauge needle with care not to inject superficially. The product is lightly massaged with cotton-tipped applicators to disperse any visible irregularities.


After injection, the patient is instructed to apply ice to the area over the next 24 hours as needed to decrease oedema and ecchymosis.


The technique of Kenneth and Samantha Steinsapir

Kenneth and Samantha reported a technique of deep HA filler injections in 164 patients with tear trough. The mean dose of filler per session was 1.53, 0.8, 0.84 and 0.38 mL divided between the two lower eyelids.


The goal was to place aliquots of the filler in the preperiosteal tissues just inferior to the orbital rim. It was sometimes necessary to digitally elevate the inferior orbital fat in the lower eyelid to expose the desired injection site. The bony orbital rim is free of significant vascular structures from the base of the anterior lacrimal crest to the lateral canthal tendon. The filler was introduced by using a serial puncture technique. Patients were permitted to close their eyes. The orbital rim was digitally palpated and the needle rotated so that the bevel was parallel to the skin and advanced to be flush on the periosteum.


Before injection, the impaled soft tissue was digitally pulled over the needle like curtains over a curtain rod (curtain manoeuvre). This decreased the risk of backflow of the filler in a more superficial plane. At each site, approximately 0.1 mL was injected. The needle was withdrawn and the filler moulded to the desired contour.

Technique of Patel and Glaser


Patel and Glaser have described a similar technique. HA filler was injected by using a serial point injection or linear threading technique and massaged using a cotton-tipped swab or a digit.


Small aliquots of filler just inferior to the orbital rim at a plane between the periosteum and the orbicularis oculi muscle were also injected to correct loss of volume in the lower eyelid area due to pseudoherniation, orbital septal laxity and atrophy of the midface. The filler material was carefully massaged to allow even distribution.


Results

Significant improvement is typically observed immediately after the dermal fillers at injected in under eye region. Advantages of choosing tear trough fillers include, total eye rejuvenation, no more hollowed out look, brightens up gloomy under eye shadows & plumps up ageing eye wrinkles.



The effect of the procedure tends to become more natural as the swelling reduces between 1-3 days after the non-surgical eye bag removal treatment and is estimated to last between 9 and 12 months, depending on individual as results may vary. Factors that affect how long the under eye filler will last include: Smoking, Lifestyle, Metabolism or Medical conditions.


Post care management includes avoid strong or extended pressure within the treated area, strenuous physical activity, exposure to extreme cold or heat for up to six hours post treatment & schedule follow-up sessions to assess the clinical result.


Touch-ups may be performed in the follow-up sessions if required.


Conclusion

HA is an attractive choice for midface augmentation due to its high patient satisfaction, long-lasting effects, and low side-effect profile.


Due to the variability in technique, level of expertise, and subjective measurements across studies, one optimal regimen could not be concluded. However, midface augmentation treatment should be personalized to each patient. Additional clinical trials are required to more conclusively determine the most appropriate approach for this procedure.


Understanding the complex anatomy and proper injection techniques can help avoid complications, but are no guarantee. Only injectors with the understanding of the tear trough anatomy and its complications should inject this complex region.


Therefore, education of both patients and injectors of these procedures is critical to designing the best individualised plan to achieve the most optimal result for the patients.


Reference

Dermal Fillers for the Treatment of Tear Trough Deformity: A Review of Anatomy, Treatment Techniques, and their Outcomes by Jaishree Sharad (2012)

Delayed Complications following Dermal Filler for Tear Trough Augmentation: A Systematic Review by Lily Nguyen Trinh, Kelly C McGuigan, Amar Gupta (2022)

Hyaluronic Acid Fillers for Midface Augmentation: A Systematic Review by Lily Nguyen Trinh, Amar Gupta (2021)

Dermal fillers: an update by Annelyse Cristine Ballin , Fredric S Brandt, Alex Cazzaniga (2015)

Tear trough fillers: Treating tired-looking eyes by KL Cosmetic Clinics (2022)

Dermal Fillers by Restylane, Juvederm, Radiesse, and Sculptra (2022)

Under Eye (Tear Trough) Fillers in Singapore: Reviews, Prices by Sozo Aesthetic Clinic (2022)

Tear Trough Fillers by Freia Medical (2022)

CosmeTalk By Cosmetic Doctors: Tear Trough Filler Before And After — From Lights Out To Lights Up! By Dr Ahmed Haq (2022)

What Technique Will My Injector Use? Injection Techniques for Optimal Outcomes by Gregory Buford (2020)

 

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