Filler injection




I’d like to introduce our next patient, Sheena. As you can see, Sheena is young and very beautiful, accordingly, she is only seeking some very subtle treatment. When I asked her what she was interested in having done, she said that she had three primary concerns; the under eye area, where she wanted a bit of improvement in the dark eye circles, her lips, and finally a very subtle improvement in her nose.


Tear trough assessment


If we start with the eye, we can see that there appears to be a slight darkening of the skin in the lower eyelid region, and this is something that we will often see in patients. It can be there for a number of reasons – the eyelid skin is the thinnest skin on the body, and often we can see structures underneath such as blood vessels and muscle. There is obviously a difference between the eyelid skin and the cheek skin, and the junction will often be in line with the tear trough. Some patients, especially those from the Middle East, the Indian subcontinent, and the Far East will have a true melanin deposition in this area, giving rise to pigmentation. Finally, some patients have a little bit of volume loss in the region, which exacerbates the appearance of the dark eye circles.


When we look at her from the side, we are aware of a little groove from the medial canthus moving inferiorly. We have an area of fullness above and below, leading to a hill-valley-hill appearance. Gentle pressure on the cheek eradicates this groove, meaning that she is a good candidate for treatment with filler. If we are proposing to treat her with filler, we just need to test the integrity of the lower eyelid skin. We can see already that there is no scleral show, and she has a youthful canthal tilt of about 3 degrees. When I look at the skin itself, it springs back with a good snap, and when I pick up the skin and release, we can see that there is good elasticity. This makes her a good candidate, as she has good skin quality, very little fat herniation above the groove, and the groove itself is very mild.


Tear trough treatment – right side


As we begin to treat Sheena in the tear trough region, I have demarcated the orbital rim with the upper green line. The lower green line lines up with her tear trough and the red marks have been located 40 mm away from the medial canthus. This is because I will use a 38 mm cannula, and by staying within the red marks, I know that I cannot proceed my cannula too far medially. I am now using a needle to make a prehole in the dermis, and I will use a 27 gauge cannula here with Juvederm Volbella. It is important to understand that when we use a larger gauge cannula, such as a 25 gauge, the product can flow out very rapidly. This is why I will often change to a 27 gauge cannula in the tear trough region.


Initially, I am under the muscle to lay the product between the orbital rim and the suborbicularis oculi fat. I want to make sure that I am not above the orbital rim, as it is very easy to get the product above the septum and into the infraorbital region. As I advance further closer to the medial canthus, I change the orientation of my cannula and become a little bit more superficial. This is because the muscle in this region is very closely adhered to the orbital rim, and to eradicate the medial most part of the tear trough we have to treat within the muscle fibres, as it is not possible to get below them. While we are treating, I am using my non-injecting hand to gently feel for the product and mould it as I continue. Once I withdraw the cannula, I then apply very gentle pressure to the treated area to mould and massage.


One side outcome and left side treatment


Following treatment to Sheena’s right eye, we can see that there appears to be a definitive improvement in the infraorbital hollow region, compared to the non-treated side. Also, we can see that her right lateral canthus appears to be lifted, and the canthal angle, or canthal tilt, is certainly improved compared to the untreated side on the left. We can see that there does not appear to be any transition now between the lid and the cheek compared to her left side, where we can still see an obvious hollow. When we turn her round and look at the side that we have treated, we see that the transition is smooth, going from the cheek straight into her lid. On downward gaze, we can see that on the untreated side the groove extends further down inferiorly, and on the treated side it is higher, shorter, and less deep.


Now, we will treat the left side. Again, we place a prehole for the 27 gauge cannula. Holding the cannula like a pen for control, we enter under the suborbicularis region and advance the cannula towards the tear trough, protecting the orbital rim with a finger. We have to make sure that we do not exert too much pressure, and if there is resistance at any time we can inject a bit of product to open up the tissue planes. We inject very little product here because it is an unforgiving region due to the overlying thin skin. Now that we have treated both sides, we can see that her result is very symmetrical. Both canthi now have an equal amount of tilt, which is upsloping and therefore very youthful. The under eye hollows appear considerably improved, and we can see that there is no longer a transition from cheek to to the lower eyelid. If we turn Sheena to the side, we notice first the original treatment side and then the newly treated side share a similar transition from mid cheek to the lower lid. Finally, on downward gaze, we can see that there is again an equal improvement in both sides.


Treatment outcome


We now see Sheena at the end of her treatments, so let’s just recap what we’ve done. We treated her under eye hollows, added refinement to her nose by decreasing the apparent width of her tip, and did a subtle rejuvenation of her lip to add definition and a little eversion. We can see that although our model is young and attractive, and presented with minimal treatment indication, we can use very subtle techniques to create an impactful result. If we look at Sheena from the side, we notice that we have eradicated the under eye hollows and created a pleasant eversion and projection of the lips, which are symmetrical from both sides. If I turn her completely towards me, we are aware of an improvement in her nasal profile and much better eversion and projection of the lip, which still conforms to the Rickett’s line analysis. I now turn her to the front, and we can test her animation. We notice that her smile is natural, she has a fuller lip during the smile, and when she pouts it is also symmetrical and not over-projected. This is the ideal lip rejuvenation result.