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I have Gale here, and her only concern really is that she has noticed she is developing some hollowness under her eyes. We can understand that she doesn’t really want to have any other part of her face treated, because overall she has a beautiful face with great structure and beautiful features. Accordingly, we will assess her under eye region. We can see that there is a groove originating from the medial canthus and running down laterally. We call this the tear trough, and there are a number of theories as to why people develop the tear trough, one being that the pretarsal and preseptal orbicularis oculi muscle is not covered by any subcutaneous fat. Accordingly, it has a darker appearance. The orbicularis oculi over the cheek, however, does have some subcutaneous fat, and therefore appears thicker. In some younger patients, there is a tightness of the orbicularis retaining ligament, which also creates the appearance of a depression in this region. In some older patients, there may be separation of the fibres in this region.
In some patients, particularly those from the Middle East or Indian subcontinent, there can be some pigmentation in the lower eyelid skin, and patients should be examined carefully to make sure that there isn’t excessive pigmentation which is not amenable to improvement from an injection procedure. As she has great lateral support in the cheek and good anterior volumes, we will proceed to a direct tear trough treatment. Tear trough anatomy markings and treatment strategy Let’s have a look at the markings and strategy for treating Gale’s tear trough region. The first thing to note is that, in a black dotted line, I have delineated the course of the tear trough. You will see that from the medial canthus up to the mid-pupillary line we have what we would call the tear trough. From the mid-pupillary line, extending out laterally, conventionally referred to as the lateral mid-cheek junction, we see the palpebromalar groove. In some patients, particularly those who may be older, there is a third line, which continues inferolaterally, and we call that the mid-cheek groove, however Gale clearly does not have this. You will also see that, in a white dotted line, I have delineated the course of the bony orbital rim, and it is important to note that the tear trough will always be below the level of the bony orbital rim, and therefore we must never inject above this area. The green line refers to the mid-pupillary line, which is an important landmark. Medial to the mid-pupillary line, in line with the medial limbus and about a centimetre below the orbital rim, you will notice my red dot, and this is the infraorbital foramen, through which we have the infraorbital artery, nerve, and vein.
As we will be injecting in the close vicinity of this area, it is important to use a cannula. There are also numerous other blood vessels in this area, so a cannula, although it is less precise than using a needle, does offer us considerable safety. The final caveat when injecting in the tear trough region is to ensure that we make our entry point at a sufficient distance to enable us to reach the medial canthus. Accordingly, I have made a marking about 4 centimetres distance from the medial canthus, or the point that I want to inject to ensure I have adequate distance for my cannula.
Injection site markings and treatment
We are now proceeding to treat Gale in the tear trough region, so I begin by pinching the skin and making an entry hole with a 23 gauge needle for my 25 gauge cannula. Pinching the skin allows me to ensure that I am entering at a deep depth. I then adjust my grip on the cannula, which allows me to reach the most inferior part of the tear trough roughly in the mid-pupillary line. There can be some resistance from the septae between the fat pads, so never force the cannula, but simply maneuver it to reach the correct depth. The finger of my non-injecting hand will guide me as to how far I reach with the tip of my cannula. At the base of the tear trough, roughly where the mid-pupillary line is, the orbicularis retaining ligament is relatively lax, and we can easily inject the product underneath the orbicularis oculi muscle. I am injecting very small amounts of product close to the bony orbital rim, but not extending below it. I then change the orientation of my needle and syringe so I can reach the lateral lid-cheek junction.
Finally, I will orientate my cannula to go more medially to reach the most medial part of the tear trough, and you will notice that I am now slightly more superficial. This is because the orbicularis retaining ligament is tightly adhered to the periosteum at this level, and we cannot really get underneath the muscle. Accordingly, we are probably injecting the product within the muscle fibres in this region. Again, you will see the tip of my cannula just peeping out through the skin, so it is vital to ensure that you inject slowly, and the second caveat is that we should ensure that we don’t inject too much product. The under eye area is very unforgiving, and if we have too much product it can give us a lumpy appearance.
Following the treatment, we can apply a very gentle mould. If we look at Gale following the treatment to her right side, we are already aware of a significant improvement as compared to the non-treated side. As Gale is relatively symmetrical, we will treat her left side in exactly the same way, with the same quantity of product, which is 0.5 ml of Juvederm Volbella. Again, I make the pre-entry hole with a 23 gauge needle and insert my 25 gauge cannula. I adjust my grip on the cannula so that I can insert it with ease, and then I will change it to inject. I’m using the fingers of my non-injecting hand to protect the orbital rim and also guard over the infraorbital foramen. At the same time, my fingers give me some feedback as to how much fill we are creating. Following the treatment, we can just give a little wipe and a soft mould with a finger just to make sure that the product is symmetrical and even.
We now have Gale at the end of her treatment, and you will notice that, because we used the cannula, we have avoided any major unsightly bruises or swellings, and you can see that her eyes now have a very relaxed and refreshed appearance, and this is in keeping with the rest of her face. If we look at Gale from one side and then the other, we can see that we have virtually eradicated the tear trough, and have a much better junction from cheek to lid. If we compare her treatment with her pre-treatment photo, you will notice that before treatment, she had very deep troughs from the medial canthus to the mid-pupillary line, with a fair amount of hollowness above, but after treatment, she has a much more youthful convexity, and a much higher lid-cheek junction.