I’m going to introduce our next patient here, Andy, who is particularly troubled by his under eye region. If we zoom in, we will be able to see that he has the appearance of grooves under both eyes. Let’s take a moment just to analyse his periorbital region in a little bit more detail. Starting with the head of the brow, we can see he’s got some ptosis of both the head and tail of the brow, and he has some degree of excess skin in the upper lid below the brow. In the sides, he has some lateral canthal lines, or crow’s feet, and underneath both eyes he has a groove that runs from the medial canthus down towards the mid-pupillary line, which is known as the tear trough. This groove then continues laterally as the lateral lid-cheek junction. We can see that if we tilt his head down, this hollowing under the eye is exacerbated.
Moving Andy to the side, we can also see that he is very hollow and flat, both in the lateral part of his cheek, and especially the anterior part of his cheek. It is this lack of support in the midface that is also leading to the drawn and sunken appearance in his under eye region. Accordingly, when we treat him, we will have to reintroduce support both in his lateral cheek, and in his anterior cheek underneath the eye. As we’re contemplating treating Andy in the periorbital region with dermal filler, it is worth testing his skin for its integrity. I will pinch the skin and release, and you will notice that he has got just a very slightly delayed return, indicating a slight decrease in elasticity, but his distraction test is normal.
We will begin the treatment of Andy’s periorbital rejuvenation by treating his lateral cheek to give him some extra support in this region. I’m pinching the skin so I can introduce my cannula at a deeper level, using a 25 gauge cannula, and my product of choice here is Juvederm Voluma. My target here is the lateral portion of the suborbicularis oculi fat, also known as SOOF. I will use my non-injecting hand just to palpate the product as I inject to ensure that I am filling the correct area, and that the filler is being placed in a very regular pattern without any obvious lumps. You’ll notice that there is a depression just under my finger, which I am looking to fill. The advantage of a cannula is that we can change the course of the cannula many times without exiting the skin, which is clearly very useful in the midface, where we need to put the product down in multiple locations. After I’m happy with the amount of fill in the lower part of the zygoma, I change the orientation of the cannula and I inject the slightly more superior part. As I’m injecting, I’m already aware of a better fill in this region, which will give the support that he requires. My total amount of product used in this region has been 0.5 ml of Voluma. After treatment, we can just apply a gentle massage and mould to ensure that the product is even.
Anterior cheek treatment
We now proceed to treating the anterior cheek in Andy, and I’m pinching the skin to enable me to introduce my cannula deep. I then will insert a 25 gauge cannula, and my target here is the deep cheek fat; both the medial SOOF and the deep medial cheek fat pad. I’m using the non-injecting hand to protect the orbital rim and the infraorbital foramen, and also to let me know how much filler I’m injecting, as well as gauge the tissue response to treatment. It is important not to overfill the anterior cheek because the lip elevators are found in this area and if we over augment this area, it can lead to a strange appearance when the patient is smiling. After filling in the medial part of the anterior segment of his cheek, we also need to swing the cannula round and augment the lateral area so that we get a more harmonious transition from the lateral to the anterior. In this region, there are some retaining ligaments like the zygomatic cutaneous ligament, which may hinder the easy passage of the cannula. Never force the cannula, as it can cause damage, and it is better to slowly manipulate it, or if necessary inject a small amount of product, which can open up tissue planes and facilitate easier passage of the cannula. I’m already aware that we are getting substantial improvement in the projection of the anterior cheek even though he’s lying down, so at this point I will stop injecting and just apply a little bit of mould and manipulation to allow the product to settle more regularly.
After treating the lateral and anterior cheek, we can see the result, and already we are aware that, compared to the non treated side, we have better lateral support and the filling at the front means we have an improvement in the periorbital region even though we haven’t treated it yet. Clearly he still has the groove more obvious in the lateral portion than the medial portion, and therefore we will now proceed to direct treatment of his tear trough and the lateral junction. Just looking at the improvement in the anterior cheek, we can see that he is now more projected than on the untreated side.
Tear trough treatment
Again, I will use a cannula here because there is a number of vascular structures in this region, and I am changing my product to Juvederm Volbella. I am using a 25 gauge cannula, and you have to be careful because the product can escape very rapidly through a large bore cannula. I am protecting the orbital rim, as I don’t wish to inject above the rim or even in its most superficial aspect as otherwise product may enter below the orbital septum. I’m injecting small amounts of product in the middle, medial, and lateral aspects of the tear trough. As you noticed, he had a deep groove laterally, so it’s important that we make sure that we inject enough product in the lateral lid-cheek junction to help efface the deep groove that we could see there. You’ll notice that I’m injecting slowly and in very small amounts, as the infraorbital area is a very unforgiving region, due to the fact that the skin in this location is very thin, therefore we will always be better off undertreating this area, and adding more product later if required.
There are a number of patients who complain that, after treatment, they notice that they have got swellings or obvious visible deformities in this region, and this can be avoided by always adhering to the principle of under treating. Remember, hyaluronic acid is hydrophilic, and it will attract water, so even on the day of treatment it is ok not to get a complete correction, as the patient may improve over the next few days and weeks. I will continue to massage, and now when we look at Andy after his treatment, we can see quite a considerable improvement in the groove that he had under his eyes. We could not have done this had we not given him the lateral and anterior support in his cheek, but now that we have done that, we have managed to make good effacement of the deep groove.
Left side combined treatments
We will treat his left side in exactly the same way: begin by using the cannula and the Juvederm Voluma to add the lateral cheekbones support. Again using the non-dominant hand, just allow it to guide your injection, so you can feel for the areas that need more support and inject the product deep onto the zygoma. After treating the lateral area and applying a little bit of manipulation, proceed to the anterior cheek. Remember, the product being used here is Volift, and we’re using the non-injecting hand to protect the orbital rim and the infraorbital foramen, and also guide our product placement. Having treated the anterior cheek, we can finally move on to treatment of the tear trough. Just to recap, we used Voluma for the lateral cheek support, Volift for the anterior cheek, and we’re changing to Volbella for treatment of the tear trough itself. You will notice that the cannula can pass right up into the lateral lid-cheek area, and we deposit the product along the orbital rim in a deep plane. We can prevent inadvertent eye injury by constantly knowing where the tip of our cannula is, and the best way to do this is by using the non-injecting hand feeling for the tip. You can see that I’m doing this as I’m injecting. Once we have finished the tear trough treatment, we can just gently mould and manipulate the area.
Here we have Andy after treatment of both sides. I’m sure you’ll agree that his immediate result following treatment is a significant improvement to his pre-treatment, even though the head position is not exactly the same. We can see that the trough appears to have diminished considerably, leading to a younger and more rejuvenated appearance within the midface and also in the periorbital region.