Patients:
A. 53-year-old Hispanic woman complaining of “tired look.”
B. 46-year-old Caucasian woman complaining of “sunken eyes.”
Treatment Issue: Using a hyaluronic acid filler for soft tissue augmentation in the infra-orbital area, including:
A. infra-orbital “hollowing” of the lower eyelid itself.
B. tear trough “gutter” below the lower eyelid.
Introduction
Hyaluronic acid is a naturally occurring linear polysaccharide polymer consisting of repeating N-acetyl-glucosamine and D-glucuronic acid moieties. As part of the dermal ground substance, the charged molecule of hyaluronic acid is able to bind large amounts of dermal water.
Most currently available hyaluronic acid fillers are derived from recombinant bacterial cultures. The molecules are cross-linked to prevent very rapid degradation. Higher degrees of cross-linking lead to slower degradation but are also associated with higher viscosity, also known as gel hardness. In addition, certain products are formulated with higher initial water contents, resulting in decreased post-procedural swelling at the cost of less total active ingredient.
Hyaluronic acid fillers have been extensively used for facial rejuvenation, including correction of the nasolabial folds and marionette lines, lip augmentation, improvement of perioral and glabellar rhytids, correction of scarring, volume filling of the mid-cheek, rejuvenation within the orbital rim, and other indications. The popularity of hyaluronic acid fillers has led to an explosion in the number of products currently on the market or in various stages of development and testing.
Treatment of Our Patients
A. A 32-gauge needle was used to place tiny aliquots of hyaluronic acid product in the subcutaneous fat. The product was feathered into volume-depleted areas, staying just above the orbicularis oculi muscle.
B. A 30-gauge needle was used to place hyaluronic acid product sandwiched between the orbicularis oculi muscle and the periosteum.
Technique
The infra-orbital area is best treated by a very experienced injector and by one who has knowledge of the local anatomy, which is essential. It is critical to obtain proper informed consent from patients so that they are aware of the procedure’s risks, including but not limited to: bruising, swelling, nodularity, asymmetry, discoloration due to the Tyndall effect, and the potential for necrosis — or even the remote chance of intravascular injection leading to retrograde emboli of product to the ocular vessels and resulting in amaurosis (sudden blindness). Although sudden visual change is extremely rare, reports of products, including autologous fat and intralesional steroids, have led to this problem when injected in the periocular area.
Also essential before the patient comes to the office for the procedure is to give pre-treatment instructions so that they can avoid, if possible, anticoagulant agents (such as non-therapeutic aspirin and other NSAIDs) as well as certain vitamins and supplements. In addition, there are various reports, albeit mostly anecdotal, of potential benefit of arnica or bromelain supplementation. In our experience, a topical vitamin K preparation or topical arnica may be helpful for patients who have lots of oozing and for those who have significant swelling and bruising that becomes immediately apparent. For anesthesia, it is usually sufficient to have the patient apply a topical anesthetic cream under cellophane occlusion for approximately 1 hour before the procedure.
When treating the infra-orbital area, we think of the analogy of a down comforter with a duvet cover. For the infra-orbital hollow, we place tiny droplets below the skin to prevent them from showing, similar to hiding candies under the duvet cover. For the tear trough, larger threads of product are placed below the muscle — akin to hiding a tennis ball below the comforter.
Using a 32-gauge needle in the hollow area helps ensure that the amount of deposited product is small and that the injection is done slowly. In a recent study, slow injections were associated with a decreased risk of significant swelling. We typically employ a combination of fine linear threading and fanning techniques when correcting this problem.
The 30-gauge needle that comes with the package of Restylane and Juvederm Ultra is perfect for those larger threads of product required for product placement below the orbicularis oculi muscle. Retrograde tunneling of larger linear threads is typically utilized in this area for deeper placement in the trough itself.
Ice packs may help patients with excessive oozing and those with significant swelling and bruising during the procedure. After the procedure, patients should again be reminded of the expected edema and possible transient palpable nodularity. Patients should, however, notify the physician if issues persist, such as prominent or bluish nodules. These are caused by very superficial placement of the filler agent with subsequent discoloration due to the Tyndall effect. Treatment involves intralesional injections of the commercially available hyaluronidase. (See the January “Surgical Insights” column.)
Tips
1. Know the anatomy of the treated area.
2. Use a smaller-bore needle to superficially place small amounts of the filler for correction of the hollow.
3. Use a larger-bore needle to deposit larger amounts under the orbicularis oculi muscle along the tear trough deformity.
4. Warn patients about possible risks and complications and address post-treatment patient concerns as soon as possible.
5. The use of hyaluronidase should not be thought of simply as an antidote, but rather as an agent for a very experienced physician injector to use in very rare circumstances of prominent product nodularity or impending necrosis.
6. Other photorejuvenation techniques, including lasers and light-based or radiofrequency devices, may be used a few days following implantation, if desired.
Points to Remember
Hyaluronic acid products can provide significant lower eyelid rejuvenation. However, practitioners are advised not to undertake treatments with hyaluronic acid fillers at this particular location without extensive prior experience with these agents elsewhere on the face.
Patients:
A. 53-year-old Hispanic woman complaining of “tired look.”
B. 46-year-old Caucasian woman complaining of “sunken eyes.”
Treatment Issue: Using a hyaluronic acid filler for soft tissue augmentation in the infra-orbital area, including:
A. infra-orbital “hollowing” of the lower eyelid itself.
B. tear trough “gutter” below the lower eyelid.
Introduction
Hyaluronic acid is a naturally occurring linear polysaccharide polymer consisting of repeating N-acetyl-glucosamine and D-glucuronic acid moieties. As part of the dermal ground substance, the charged molecule of hyaluronic acid is able to bind large amounts of dermal water.
Most currently available hyaluronic acid fillers are derived from recombinant bacterial cultures. The molecules are cross-linked to prevent very rapid degradation. Higher degrees of cross-linking lead to slower degradation but are also associated with higher viscosity, also known as gel hardness. In addition, certain products are formulated with higher initial water contents, resulting in decreased post-procedural swelling at the cost of less total active ingredient.
Hyaluronic acid fillers have been extensively used for facial rejuvenation, including correction of the nasolabial folds and marionette lines, lip augmentation, improvement of perioral and glabellar rhytids, correction of scarring, volume filling of the mid-cheek, rejuvenation within the orbital rim, and other indications. The popularity of hyaluronic acid fillers has led to an explosion in the number of products currently on the market or in various stages of development and testing.
Treatment of Our Patients
A. A 32-gauge needle was used to place tiny aliquots of hyaluronic acid product in the subcutaneous fat. The product was feathered into volume-depleted areas, staying just above the orbicularis oculi muscle.
B. A 30-gauge needle was used to place hyaluronic acid product sandwiched between the orbicularis oculi muscle and the periosteum.
Technique
The infra-orbital area is best treated by a very experienced injector and by one who has knowledge of the local anatomy, which is essential. It is critical to obtain proper informed consent from patients so that they are aware of the procedure’s risks, including but not limited to: bruising, swelling, nodularity, asymmetry, discoloration due to the Tyndall effect, and the potential for necrosis — or even the remote chance of intravascular injection leading to retrograde emboli of product to the ocular vessels and resulting in amaurosis (sudden blindness). Although sudden visual change is extremely rare, reports of products, including autologous fat and intralesional steroids, have led to this problem when injected in the periocular area.
Also essential before the patient comes to the office for the procedure is to give pre-treatment instructions so that they can avoid, if possible, anticoagulant agents (such as non-therapeutic aspirin and other NSAIDs) as well as certain vitamins and supplements. In addition, there are various reports, albeit mostly anecdotal, of potential benefit of arnica or bromelain supplementation. In our experience, a topical vitamin K preparation or topical arnica may be helpful for patients who have lots of oozing and for those who have significant swelling and bruising that becomes immediately apparent. For anesthesia, it is usually sufficient to have the patient apply a topical anesthetic cream under cellophane occlusion for approximately 1 hour before the procedure.
When treating the infra-orbital area, we think of the analogy of a down comforter with a duvet cover. For the infra-orbital hollow, we place tiny droplets below the skin to prevent them from showing, similar to hiding candies under the duvet cover. For the tear trough, larger threads of product are placed below the muscle — akin to hiding a tennis ball below the comforter.
Using a 32-gauge needle in the hollow area helps ensure that the amount of deposited product is small and that the injection is done slowly. In a recent study, slow injections were associated with a decreased risk of significant swelling. We typically employ a combination of fine linear threading and fanning techniques when correcting this problem.
The 30-gauge needle that comes with the package of Restylane and Juvederm Ultra is perfect for those larger threads of product required for product placement below the orbicularis oculi muscle. Retrograde tunneling of larger linear threads is typically utilized in this area for deeper placement in the trough itself.
Ice packs may help patients with excessive oozing and those with significant swelling and bruising during the procedure. After the procedure, patients should again be reminded of the expected edema and possible transient palpable nodularity. Patients should, however, notify the physician if issues persist, such as prominent or bluish nodules. These are caused by very superficial placement of the filler agent with subsequent discoloration due to the Tyndall effect. Treatment involves intralesional injections of the commercially available hyaluronidase. (See the January “Surgical Insights” column.)
Tips
1. Know the anatomy of the treated area.
2. Use a smaller-bore needle to superficially place small amounts of the filler for correction of the hollow.
3. Use a larger-bore needle to deposit larger amounts under the orbicularis oculi muscle along the tear trough deformity.
4. Warn patients about possible risks and complications and address post-treatment patient concerns as soon as possible.
5. The use of hyaluronidase should not be thought of simply as an antidote, but rather as an agent for a very experienced physician injector to use in very rare circumstances of prominent product nodularity or impending necrosis.
6. Other photorejuvenation techniques, including lasers and light-based or radiofrequency devices, may be used a few days following implantation, if desired.
Points to Remember
Hyaluronic acid products can provide significant lower eyelid rejuvenation. However, practitioners are advised not to undertake treatments with hyaluronic acid fillers at this particular location without extensive prior experience with these agents elsewhere on the face.
Patients:
A. 53-year-old Hispanic woman complaining of “tired look.”
B. 46-year-old Caucasian woman complaining of “sunken eyes.”
Treatment Issue: Using a hyaluronic acid filler for soft tissue augmentation in the infra-orbital area, including:
A. infra-orbital “hollowing” of the lower eyelid itself.
B. tear trough “gutter” below the lower eyelid.
Introduction
Hyaluronic acid is a naturally occurring linear polysaccharide polymer consisting of repeating N-acetyl-glucosamine and D-glucuronic acid moieties. As part of the dermal ground substance, the charged molecule of hyaluronic acid is able to bind large amounts of dermal water.
Most currently available hyaluronic acid fillers are derived from recombinant bacterial cultures. The molecules are cross-linked to prevent very rapid degradation. Higher degrees of cross-linking lead to slower degradation but are also associated with higher viscosity, also known as gel hardness. In addition, certain products are formulated with higher initial water contents, resulting in decreased post-procedural swelling at the cost of less total active ingredient.
Hyaluronic acid fillers have been extensively used for facial rejuvenation, including correction of the nasolabial folds and marionette lines, lip augmentation, improvement of perioral and glabellar rhytids, correction of scarring, volume filling of the mid-cheek, rejuvenation within the orbital rim, and other indications. The popularity of hyaluronic acid fillers has led to an explosion in the number of products currently on the market or in various stages of development and testing.
Treatment of Our Patients
A. A 32-gauge needle was used to place tiny aliquots of hyaluronic acid product in the subcutaneous fat. The product was feathered into volume-depleted areas, staying just above the orbicularis oculi muscle.
B. A 30-gauge needle was used to place hyaluronic acid product sandwiched between the orbicularis oculi muscle and the periosteum.
Technique
The infra-orbital area is best treated by a very experienced injector and by one who has knowledge of the local anatomy, which is essential. It is critical to obtain proper informed consent from patients so that they are aware of the procedure’s risks, including but not limited to: bruising, swelling, nodularity, asymmetry, discoloration due to the Tyndall effect, and the potential for necrosis — or even the remote chance of intravascular injection leading to retrograde emboli of product to the ocular vessels and resulting in amaurosis (sudden blindness). Although sudden visual change is extremely rare, reports of products, including autologous fat and intralesional steroids, have led to this problem when injected in the periocular area.
Also essential before the patient comes to the office for the procedure is to give pre-treatment instructions so that they can avoid, if possible, anticoagulant agents (such as non-therapeutic aspirin and other NSAIDs) as well as certain vitamins and supplements. In addition, there are various reports, albeit mostly anecdotal, of potential benefit of arnica or bromelain supplementation. In our experience, a topical vitamin K preparation or topical arnica may be helpful for patients who have lots of oozing and for those who have significant swelling and bruising that becomes immediately apparent. For anesthesia, it is usually sufficient to have the patient apply a topical anesthetic cream under cellophane occlusion for approximately 1 hour before the procedure.
When treating the infra-orbital area, we think of the analogy of a down comforter with a duvet cover. For the infra-orbital hollow, we place tiny droplets below the skin to prevent them from showing, similar to hiding candies under the duvet cover. For the tear trough, larger threads of product are placed below the muscle — akin to hiding a tennis ball below the comforter.
Using a 32-gauge needle in the hollow area helps ensure that the amount of deposited product is small and that the injection is done slowly. In a recent study, slow injections were associated with a decreased risk of significant swelling. We typically employ a combination of fine linear threading and fanning techniques when correcting this problem.
The 30-gauge needle that comes with the package of Restylane and Juvederm Ultra is perfect for those larger threads of product required for product placement below the orbicularis oculi muscle. Retrograde tunneling of larger linear threads is typically utilized in this area for deeper placement in the trough itself.
Ice packs may help patients with excessive oozing and those with significant swelling and bruising during the procedure. After the procedure, patients should again be reminded of the expected edema and possible transient palpable nodularity. Patients should, however, notify the physician if issues persist, such as prominent or bluish nodules. These are caused by very superficial placement of the filler agent with subsequent discoloration due to the Tyndall effect. Treatment involves intralesional injections of the commercially available hyaluronidase. (See the January “Surgical Insights” column.)
Tips
1. Know the anatomy of the treated area.
2. Use a smaller-bore needle to superficially place small amounts of the filler for correction of the hollow.
3. Use a larger-bore needle to deposit larger amounts under the orbicularis oculi muscle along the tear trough deformity.
4. Warn patients about possible risks and complications and address post-treatment patient concerns as soon as possible.
5. The use of hyaluronidase should not be thought of simply as an antidote, but rather as an agent for a very experienced physician injector to use in very rare circumstances of prominent product nodularity or impending necrosis.
6. Other photorejuvenation techniques, including lasers and light-based or radiofrequency devices, may be used a few days following implantation, if desired.
Points to Remember
Hyaluronic acid products can provide significant lower eyelid rejuvenation. However, practitioners are advised not to undertake treatments with hyaluronic acid fillers at this particular location without extensive prior experience with these agents elsewhere on the face.
