Filler injection




I’d like to introduce you to Clare, who is 29. She has two concerns, and the first one relates to her under eye area. She feels she has a darkness here, which is possibly more apparent if we tilt her head down, and you will notice that she has a groove extending from her medial canthus to the mid-pupillary line, so she has a very early tear trough. This gives the eye darkness, and makes her look a little bit more tired. She can, however, cover this up with makeup. Her second concern relates to her chin, she feels that she has an excessive shadow beneath her lip, because the chin is rotated up. If we look at her face, we notice that this gives her a shortened chin, and as the chin rotates up, the shadow below the lip deepens.


Tear Trough Assessment


Let’s examine Clare’s periorbital region. If we start with the eyebrow and look at the head of the brow, we notice that it ascends up at about a 30 degree angle to the apex. The apex is the highest point and lies above the lateral canthus, and then the tail of the brow drops down to be just slightly above the head of the brow. This is the ideal brow shape for a young, female patient. We can then move laterally and see that she has a nice fullness in the periorbital region, as we would expect. She is, however, a little bit hollow in the lateral region below the lateral canthus, and if we look closely, you will notice she has some scleral show in this region. Looking at the eye, it appears that she has a degree of vertical dystopia on her right side. This does mean that she has lost some lateral support for the base of the eye and her right periorbital region looks more open. When we tilt her head down, we can then accentuate the hollowness below the eye on both sides. From this angle, we can see that she also has some volume loss in the anterior cheek, which accentuates the hollowness. If I apply pressure with my finger to simulate filling, you will see that the hollow improves. Accordingly, one aspect of her treatment will be cheek augmentation.


If we are planning to treat a patient in the under eye region, we should test the skin, and you will notice that she has a very normal elasticity, as we would expect. However, the distraction test is a little sluggish, especially if we compare it with the other side. Accordingly, we need to be cautious when treating in this region. In summary, Clare’s treatment will involve treatment to the lateral cheek, the anterior cheek, and finally the tear trough to give her the overall improvement that she needs.


Tear Trough Marking And Strategy


I have now marked the area that we will treat in Clare’s infraorbital region. It is worth just reviewing the causes of this hollowing. In some patients, we have very thin skin overlying the pretarsal and preseptal portions of the orbicularis oculi muscle. The skin overlying the cheek is thicker, and we get a boundary at the two. There is often some deflation of the fat structures in this region, and in some patients there is a tightness of the orbicularis retaining ligament. These three factors in combination will contribute to the hollow. We can see that by adding some lateral support along the cheekbone, we can already influence an improvement in this region.


Tear Trough Treatment


We begin the treatment by injecting onto the cheekbone. I insert my needle onto the periosteum and aspirate to ensure that I am not inside a vessel, then inject a bolus of Voluma onto the zygomatic arch, and my target here is the lateral portion of the SOOF, or suborbicularis oculi fat. I deposit a bolus of 0.1 ml of Voluma to give lateral support. After injecting in this region, I will withdraw the needle, and just apply very gentle massage. I am keen not to remove the projection that we have created with the first injection. I then move on more anteriorly, and again my injection depth is deep, I aspirate, and this time I will inject slightly more product. In this location, I will inject 0.2 ml, and again, I will give a very gentle massage while preserving the projection created by this injection. Having treated the cheekbone, I then move on to treating the anterior cheek and tear trough. For this, I will use a cannula at a deep depth. Accordingly, I pinch the skin and insert my pre needle, which is a 23 gauge needle. After removing the needle, I insert my cannula, which is 25 gauge. My product of choice here is Juvederm Volbella. I inserted the cannula, holding it like a pen, and then readjust my grip, and use the finger of my non-injecting hand to protect the orbital rim and also guide me as to the location of the infraorbital foramen. It is vital in this delicate area not to overinject, and I’m careful to inject my product under the orbicularis oculi muscle. At the most medial aspect, the muscle is very adherent to the bone and my depth is more within the muscle. Following treatment, I apply a gentle massage. After this treatment, we can see an improvement in the infraorbital hollow, and a better transition from cheek to the lid junction. On the non-treated see, we still have a deep groove. You will also see that the scleral show has improved on the treated side.


We will now treat the left side with exactly the same sequence: first, a bolus of 0.1 ml onto the cheekbone. Secondly, we repeat this a bit more anteriorly on the zygoma with a bolus of 0.2 ml of Voluma. After this, we move on to treatment of the anterior cheek and tear trough with a cannula and Juvederm Volbella. Remember that the depth here is deep under the orbicularis oculi muscle, but slightly more superficial at the lateral canthus. Accordingly, we protect the rim of the orbit with the finger of the non-injecting hand. Finally, do remember not to over inject in this delicate under eye region.


Treatment outcome


Following treatment to both infraorbital regions, we can see that Clare’s eyes appear brighter and more refreshed, and she has a better smoothness in the lid cheek junction. If we observe her from the oblique side, we can see that we have now managed to reduce the groove effect that she had before the treatment.