Filler injection


Tear trough assessment


I would like to introduce you to our model, Sonal, who has come to us with the primary concern of hollows under her eye. She feels this gives her a dark eye appearance and makes her look tired. Her case is complicated by the fact that she has this malar edema, and therefore my teaching point here will be how to treat the infraorbital hollows in a patient who has pre-existing malar edema. If I turn Sonal to the oblique, we notice that she clearly has a tear trough deformity. She also has a little bit of volume loss in the anterior cheek. In this angle, we can clearly see the malar edema as a discrete mound, and we can also see that if we give her a bit of lateral support we will improve the tear trough and the anterior projection. We can also see that if we give her some anterior support by injecting the deep fat that this will also help to efface the tear trough. If I get her to close her eye and I press gently on the globe of the eye itself, it starts to make the infraorbital fat pads herniate through the orbital septum. This will then be the inferior limit of where we should be injecting our product. If we go any higher than this then we could inadvertently inject into the orbital septum. Our strategy here will be lateral lift and anterior support, followed by direct treatment of the tear trough.


Tear trough marking


Let’s review the markings that we will use for Sonal’s tear trough treatment. I will begin by marking off the tear trough itself with a black dotted line. Following this, I will mark out the border of her inferior orbital rim. Next, I will get Sonal to close her eyes, and when I gently press on the globe this will herniate her infraorbital fat forward, and the inferior limit of this, you will notice, comes just below the inferior orbital rim. This is an important consideration, and it is important not to inject too close to the upper border of the inferior orbital rim or we may inadvertently inject under the orbital septum. Next, I will mark out the malar edema, and this is a no go area. It is vital not to inject any product underneath this mound, or we may cause a worsening of the malar edema. I am now marking off a line in her medial limbus, and about 1 cm below the inferior orbital rim, in line with the medial limbus, is her infraorbital foramen. Next, I will mark out her upper and lower border of the zygomatic arch. This will give me two points that I can inject to give her lateral support along her lateral SOOF. Finally, there is an area in her anterior cheek that I will want to inject deep, and you will notice that I miss out the malar edema, so I inject laterally for the lateral support, anterior cheek, and finally the tear trough.


Tear trough treatment


Let’s now proceed to Sonal’s treatment. I am cleaning the skin but I will leave the marks on to guide my injection. I take my product, which is Juvederm Voluma with a needle, I retract the skin posteriorly, and I inject in front of the mark. I go deep and then I aspirate to ensure that I am not intravascular. After aspiration I will then proceed to slowly inject a bolus deep onto the zygomatic arch. I am injecting slowly because it is more comfortable for the patient, and I am maintaining posterior traction to help with the lift. My total amount of product that I will inject in this location is 0.2 ml of Juvederm Voluma. After injection, I will remove the needle, and on this occasion I have a small amount of bleeding so I will just gently apply a swab to compress. It is important, if you get this during treatment, to compress and not continue with the treatment, otherwise a small haemotoma can start to distort the symmetry, and therefore you may get a less aesthetic outcome. I then move on to the second point, and again I retract posteriorly, inject deep onto the zygoma, aspirate, and then inject a small bolus. This time, the total amount of product I will inject is 0.1 ml. After withdrawing, I will just apply a gentle mould. I do not want to over massage because I want to maintain the projection that those points will give me.


I now proceed to treating Sonal in the anterior cheek. If you are familiar with the MD Codes, the region I am going to now is called CK3, and my target here is the medial SOOF. I take the same product, Juvederm Voluma and I inject deep down onto the bone. I aspirate for a few seconds, and then I will slowly inject 0.1 ml of product. After withdrawing my needle and checking that there is no bleeding, I move slightly more medial, but I am still lateral to the mid-pupillary line and therefore I am happy to continue with the needle. I inject deep (aspiration in this region is mandatory), and after I have confirmed a clean aspiration I continue to inject a further 0.1 ml of product. After treating the lateral anterior aspect, we can look at the changes. Not only do we have better lift and projection of the cheekbone, which has had an incredible effect on the lower face, we can also see that this treatment has started to improve the hollow. If I turn her to the treated side, it has already improved the under eye hollow compared to the untreated side, where the hollow is still very visible.


We can now progress to treatment of the tear trough directly. For the tear trough, I will use a cannula. I use a 25 gauge needle to make my prehole and I will use a 27 gauge cannula and Juvederm Volbella. As I insert the cannula, you will notice that there is a small amount of bleeding. Therefore, I will take a sterile swab just to remove this blood. You must use a sterile swab and also be careful not to let the swab touch the cannula, so as to maintain sterility. I will take the finger of my non-injecting hand use that to protect the infraorbital foramen, and it also gives me an idea of where the tip of my cannula is. My first depth is deep, and in this depth I will start treating the middle aspect of the tear trough. I am laying microboluses of product along the orbital rim underneath the orbicularis oculi muscle. I am laying approximately 0.2 ml of product in total in discrete little boluses and then I am starting to advance a bit more medially. The non-injecting finger gives me a real idea of the amount of fill that I am managing to achieve. Once I am satisfied with the fill in the deep plane, I will need to adjust my cannula, so I withdraw it partially and I reintroduce it more superficially. You can actually make out the tip of the cannula as it is going through the dermis here. The idea now is to inject the medialmost part of the tear trough, and we cannot get under the ligaments in this region because it is very adherent to the underlying periosteum. Accordingly, I am in a more superficial plane, and I am injecting the product within the muscle, a total of 0.1 cc.


Following the treatment, we can see some quite impressive changes. If we compare the treated to the untreated, we can see that on her left side there is still a very obvious hollow, the obvious malar edema, and a deflated cheek, whereas on the treated side we can see a virtual eradication of the tear trough, a better projection of the anterior cheek, and a diminution of the malar edema, although it is still present. Because the malar edema is still quite obvious, I am interested in giving her a little bit of support underneath this region with a little drop of filler. Therefore, I will take a marker and just delineate the injection point. Remember, we cannot inject the edema itself so I will inject the product just below the area. I will use Juvederm Voluma and a needle. As she is lying down, you will see a quite obvious difference in the tear trough on both sides. I take the Juvederm Voluma on a needle, preclean the skin before the injection. Please note that as I am injecting I have omitted the aspiration, this is a genuine error and does not reflect good practice – I should have aspirated here because of the vascular risk. I lay a deposit of 0.1 cc bolus deep onto the zygoma, and with a very gentle mould we can assess her after treatment.


You will notice that after treating her right side there is a quite significant change, as we have a much better opening of the orbital aperture, better position of her eyebrow, better cheekbone projection, and an eradication of her tear trough compared to the untreated side. On Sonal’s left side, we see we have an obvious tear trough, a deflation in the mid cheek, and the malar edema is more obvious.


Tear trough outcome


After applying the identical treatment to Sonal’s left side, we can see a very satisfactory outcome. She has a good symmetrical result, the tear trough deformity is all but eradicated, and more importantly, not only has the malar edema not worsened, but it is arguably less obvious than it was pretreatment. Remember that the improvement will continue to sustain over the next 3 or 4 weeks, when we will view her again.