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I have here with me Siobhan, who has come complaining of an appearance of dark eye circles. We notice if we look at her that the appearance is worse on her left than on her right. When we assess her full face, we can see she has excellent lateral cheek projection, and therefore good lateral support. However, she is quite clearly hollow in the anterior cheek, and this is exacerbating her condition. If I tilt her head back we can see that she has a decent projection of the cheek at the apex, however, there is an obvious concavity medially in the anterior aspect of the cheek, leading to a lack of inferior support. If she smiles, we notice that this does not improve and therefore she needs volume in this region.
We can also see that, if we tilt her head down, the infraorbital hollow is exacerbated, and therefore we can delineate the tear trough and the mid cheek groove. I can simulate the effect of filling by applying a little bit of gentle pressure, and we can see that this would improve the hollows. If I turn Siobhan’s head to the oblique angle, we can see a very obvious mid cheek groove inferiorly, and we can see that this improves with gentle filling. Accordingly, our idea in treating Siobhan will be a two step technique: first, we will replace the volume in the mid cheek deep fat compartments, and then we will follow this with a direct tear trough treatment.
Injection site markings
Let’s have a look at the strategy and markings for treating Siobhan. You will see that I have lined this area in white, and this delineates the area we will fill to target both the deep medial cheek fat and the medial part of the suborbicularis oculi fat, or SOOF. The area I have marked out with the black dotted line is the orbital rim, and the white line is the mid pupillary line. As we will be crossing medial to the mid pupillary line, we will use a cannula as this avoids inadvertent damage to the infraorbital foramen. Finally, I have outlined a larger area on the left because it is more severe, and accordingly we will start on this side.
Tear trough direct treatment – left side
We begin by treating Siobhan in the anterior part of the cheek, to target the deep medial cheek fat and the medial part of her SOOF. Holding my cannula like a pen, I insert a 25 gauge, 38 mm cannula, and the product of choice here for me is Juvederm Volift. I am using the finger of my non-injecting hand to guide and protect, holding it over the infraorbital foramen and also the orbital rim to ensure that I do not inject above the orbital rim. The depth here is deep, and we can often feel some resistance from the septae between the fat compartments. It is important, if you feel resistance, not to force the cannula, however you can make the passage of the cannula easier by injecting a little bit of product. All the time that you are injecting, use the non-injecting hand to guide your product replacement. It is important in the anterior cheek not to overinject, as otherwise we can get asymmetries and also distortions of the smile. The advantage of the cannula is that we can cover a wide area with much less risk to the vascular structures compared with using a needle. After treating the medial part of the anterior cheek, I can then orientate the syringe and cannula to treat the more lateral part, which will target the medial and lateral SOOF. The whole time you will notice that I will ensure that I am not over injecting by using my non-injecting finger. I give this a gentle wipe just to check that the product has been injected in a smooth manner. Finally, I can just massage the product. At the end of the treatment, you will notice that she appears more lifted on the treated side, and when she smiles you can see some increased anterior projection.
As I turn Siobhan to the side, the base of the mid cheek groove is improved, but she still has a residual tear trough, so having treated the mid cheek deep fat compartment, we will treat the tear trough directly now. When I treat Siobhan in the tear trough I have changed the product to Juvederm Volbella. I can use the same cannula entry point, and I am still using a 25 gauge, 38 mm cannula. It is even more important to guide your cannula placement with the finger of the non-injecting hand. You will notice that when I am in the most medial part of the tear trough, my depth is superficial; it is practically within the muscle, and you can see the tip of the cannula here. The reason for this is that at the most medial portion of the tear trough, the orbicularis oculi muscle is very densely adhered to the periosteum at the arcus marginalis. After injecting the product, I will use a cotton-tipped swab just to gently milk the product along the tear trough. It is important not to over massage or mould in this region, otherwise we can lose the clinical result of injecting in this area. If she had greater deficit more laterally, we could be at a deeper level.
We can now see Siobhan following treatment to her left side. We can immediately see that the groove and the darkness have both improved moderately. She could get greater improvement with further treatment, however, in the infraorbital region it is very important not to over correct. One of the reasons for this is that the product will continue to improve over a 3-4 week period, and she could end up with an over correction. I always tell my patients that some degree of hollowness in the infraorbital region can be a variant of normal, however, any lumpiness is always abnormal, and accordingly we are better off under treating and being satisfied with an 80-90% improvement. When we compare her to the untreated side, we can see that there is enough improvement for us to finish on her left and now treat the right.
Tear trough direct treatment – right side
When we treat Siobhan on the right side we will employ the same strategy, and we begin by using the cannula to treat the deep medial cheek fat and the suborbicularis oculi fat. Again, I am using a 25 gauge, 38 mm cannula, and you will notice that I hold the cannula like a pen and bracing my hand against her face. You will notice that there was a little bit of resistance on entering with the cannula, and by bracing my hand, it prevents me from inadvertently causing damage in case I had inserted the cannula too far. As always, I will use the finger of my non-injecting hand to let me know the location of the infraorbital foramen and the orbital. I can also use my left hand to assess the amount of fill that we are getting and ensure that the product is being placed in an even distribution. After I have treated the medial aspect of the anterior cheek, I can also angle the cannula so that I can target the lateral area and the junction between the malar eminence and the anterior cheek. Because her right side was not as severe as her left side, we will use less product. I injected a total of 0.5 ml of Volift on her left anterior cheek and on her right we will use 0.35 ml.
We now have Siobhan at the end of her treatment, and we can immediately see that the under eye area looks brighter and less hollow. At the same time, we are aware of a better fill in the anterior cheek with a smoother transition from the malar eminence to the front aspect of her cheek bi-laterally. The effect of this is that she now has a diminished groove on both sides. As mentioned during the treatment, we could have treated her a little bit more, however, she runs the risk of then getting an over correction. Accordingly, we will review her in 4 weeks.
If we have a look at Siobhan before treatment, we notice that she had two quite obvious tear troughs, which have improved considerably. The learning points from her treatment are that, first of all, we appreciated there was significant volume loss in the anterior cheek, and we had to replace this before moving on to her tear trough. The second learning point is that we need to stop before a full correction, otherwise the patient may present with over correction at review.