Filler injection


Tear trough assessment


I have my model, Debbie, here and I should just point out that her lip is a little bit swollen because she had some treatment a day previously which can be viewed in the lip masterclass section. In this video, I want to concentrate on the assessment of her infraorbital region. You will notice in this view that she has the appearance of eye bags. Because she is young, it is unlikely that they are true eye bags, and if we look closely we can see that she is very hollow beneath this region. It is, in fact, this infraorbital hollowing that is giving the appearance of the eye bag above. If I turn her slightly to the side, we will notice that she has what we would call a negative vector due to deflation in the midface, and this deflation gives the appearance of the eye bag above, or what we call pseudoherniation of the eye bag. We can see, if I turn her to the other side, that this deficit is approximately symmetrical on both sides. Finally, if I get Debbie to close her eye and I press gently on the globe, we can see that we can emphasise the herniation of the infraorbital fat through the septum, and it is important to stay below this level. Accordingly, the deficit that we can see in the anterior cheek will be the target for our rejuvenation.


Tear trough marking


Let’s now discuss the markings for Debbie’s infraorbital injection treatment. You will notice that I have drawn a white line here which denotes the height of the infraorbital rim, and I also have a blue line which is the line of the medial limbus. About 1 cm inferior to the orbital rim, we have the infraorbital foramen. If I get her to close her eye and press gently on the globe we can clearly see the herniation of the infraorbital fat through the orbital septum. Although this line is considerably below the level of the orbital rim, I want to avoid potentially getting product into this area, as it can cause persistent swelling. Therefore, our injection markings will be considerably inferior in the anterior cheek.


Tear trough treatment


I will now proceed to treat Debbie’s eye bags. We are going to begin by treating the deflation in the anterior cheek, and I am using Juvederm Voluma. I insert my needle deep until I am on the periosteum, and my target here is the medial part of the suborbicularis oculi fat, or SOOF. I aspirate and then slowly inject a bolus of 0.2 ml of product. The idea is to add some inferior support, which will improve the negative vector and reduce the appearance of the eye bag. Because I am lateral to the mid-pupillary line, I am happy to do this with a needle. After injecting the Voluma I apply a very gentle moulding but I am keen not to move the product too much. I will now use Volbella which has been decanted into a 0.3 ml, 32 gauge needle insulin syringe and I am injecting more medially, but again I am lateral to the mid-pupillary line, and I will inject a bolus of 0.15 cc here. I inject slowly and the idea of injecting a large bolus is that I can use some pressure with my finger to move the bolus more medially, which avoids the need to inject in a slightly riskier anatomical position.


At this point, I feel I may already have some degree of improvement, so I will remove the markings so that I can visualise this. If I compare the treated to the non-treated side, I am aware of a deeper trough and bulging on her left compared to her right, which is the treated side. If I view her from the foot of the bed, I can also see the improvement. On her left, I can see a deep depression underneath the eye bag, whereas on the right side there is a better convexity of the cheek and a better continuation from the cheek to the lower eyelid. If I sit her up, I can see that there appears to be a decent improvement on the treated side with a better continuation from the cheek towards the lower eyelid, and on the untreated side, there is still a considerable negative vector that can be observed. However, I do feel that we can improve the right side a little bit more. Accordingly, I will use another injection point slightly more medial than the one I used just to see if I can improve the appearance of the eye bag any further.


I will mark off the deficit that I can see with a white marker pencil and I am again using the Volbella decanted into the Botox syringe. I apply some lateral traction with my non-treating hand, then insert deep and I will inject slowly a small bolus of Juvederm Volbella. In total, I am injecting 0.1 ml with this injection, and I use gentle pressure just to dissipate the product. You can now see that following treatment to her right side using 0.2 ml of Voluma and 0.25 ml of Volbella there has been a considerable improvement in the appearance of her eye bag.




Let’s now review Debbie following all of her treatment. If we look at the infraorbital region, we are aware that there is less appearance of eye bag and an improvement in the infraorbital hollows. We can also see that there is an improvement in the shape of the nose and the symmetry of the lip with less appearance of the scar. Although there is still some eye bag visible, this is where I would stop the treatment because we know that she will continue to get an improvement. Ideally, I would see a patient like Debbie at 6 weeks. Here, I have got Debbie at her 6-week review. The first thing I will point out is that she does not have makeup in the before photo and she clearly has makeup in the after photo. That being said, we can see that now that we have given her the structure in the infraorbital region, a light covering of makeup gives her almost complete coverage of the infraorbital region. Accordingly, I do not feel she needs any more treatment.