The approval of Juvéderm (Allergan) in 2006 brought another hyaluronic acid filler to the U.S. market. Questions regarding how it compares to hyalurons already approved were soon supplanted by answers suggesting that each of the major families of fillers — Restylane and Juvèderm — would find respective niches of excellence, with proponents in both camps.
One such area of excellence — the treatment of the tear trough, which is described below — takes advantage of Juvéderm’s unique properties. These include its homogeneous gel structure and perhaps its flow characteristics.
The technique presented here is deemed advanced in that it requires a high level of experience in injecting fillers and careful patient selection that considers previous surgery and specific aspects of the appearance of the periorbital area.
Who Benefits from Treatment
Patient who benefit from Juvéderm in the tear troughs generally include those with dark areas around their eyes from pigment that is not epidermal in origin or those who exhibit a bony periorbital appearance due either to surgery or the aging process.
Countering the Bony Look
Typical blepharoplasty patients have not only the extra skin of the eyelids removed but also some of the perioral fat pad as well. In cases where patients have had this fat pad entirely removed or they have deep set eyes, the post-operative results may be a periorbital area that looks like that of a skeleton. A similar bony appearance may develop in patients with deep-set eye who have not had the surgery as a result of the aging process when the subcutaneous soft tissue disappears. Without the buffering layer of fat, the bony ridge of the zygoma becomes visible and the skin, without any support, becomes wrinkled.
Inflating this area with a soft hyaluronic acid cushion will help hide the bones and fill the wrinkles of the skin.
For Dark Pigment and Shadows
Many patients have a deep pigment around their eyes that is caused by vascularity and shadows rather than epidermal or superficial dermal pigment.
They may benefit from a layer of hyaluronic acid to put some distance between the epidermis and the pigment or to diminish the light absorbing concavity that creates the shadow.
Treatment Approach
Injection Caveats
• When injecting this area, the needle should be inserted to the depth of the periosteum and then withdrawn slightly.
• It is imperative to aspirate the syringe to insure that intravascular placement does not occur.
• One should also take great care to avoid impaling the globe; it is helpful to use one finger from the non-dominant hand to protect the eye.
• Injections of Juvéderm in this area should be performed from the lateral aspect. Care should be taken to avoid orienting the needle in a manner that could cause it to poke the eye of a patient who, for example, sneezes or panics and grabs the injector’s arm.
• The injection should take place in the deep tissue plane, and the needle should be inserted into the periosteal plane and withdrawn slightly. Although this plane is relatively avascular, it is a good idea to aspirate the plunger to reduce the chance of an intravascular injection.
• When injecting in this location, use low pressure on the plunger and instruct patients to close their eyes.
Product volume and equipment
• Average amounts of volume used for filling the tear trough are between 0.5 ml and 1.0 ml per eye depending upon the size and the depth of the crease.
• Juvéderm Ultra or Juvéderm Ultra Plus can be used. The needles provided with these syringes are adequate for this injection.
Implanting the Juvéderm
• Small pearls of product (e.g., 0.02 ml to 0.05 ml) may be injected and then massaged into a confluent layer.
• One area that may require more superficial layers is the area of the medial eyelid as it nears the nose. This area needs to be treated gingerly and should be injected with minute amounts of product.
• The lateral aspect of the tear trough (which I define as the portion that is lateral to the mid-pupillary line) should be injected at the periosteal layer and followed laterally to the full extent of the concavity.
Proceed with Caution
The key to injecting the tear troughs with filler is to proceed with caution and inject small volumes until you have a sense for the patient’s aesthetic perspective and comfort level with the procedure. I have had the experience of injecting this location and having what I thought was a perfect result only to have a patient who was unhappy because of small bumps. (I am not sure it is possible to inject this location without some risk of bumps, and this is worth noting to the patient as well as putting into consent forms.)
Need for a Comparative Trial
Juvéderm has some characteristics that make it distinct from Restylane. Although in many areas of the face, these characteristics may not make a significant difference, there is little doubt that in other areas it can be significant. A clinical trial comparing these two products in the tear troughs would be beneficial.
The approval of Juvéderm (Allergan) in 2006 brought another hyaluronic acid filler to the U.S. market. Questions regarding how it compares to hyalurons already approved were soon supplanted by answers suggesting that each of the major families of fillers — Restylane and Juvèderm — would find respective niches of excellence, with proponents in both camps.
One such area of excellence — the treatment of the tear trough, which is described below — takes advantage of Juvéderm’s unique properties. These include its homogeneous gel structure and perhaps its flow characteristics.
The technique presented here is deemed advanced in that it requires a high level of experience in injecting fillers and careful patient selection that considers previous surgery and specific aspects of the appearance of the periorbital area.
Who Benefits from Treatment
Patient who benefit from Juvéderm in the tear troughs generally include those with dark areas around their eyes from pigment that is not epidermal in origin or those who exhibit a bony periorbital appearance due either to surgery or the aging process.
Countering the Bony Look
Typical blepharoplasty patients have not only the extra skin of the eyelids removed but also some of the perioral fat pad as well. In cases where patients have had this fat pad entirely removed or they have deep set eyes, the post-operative results may be a periorbital area that looks like that of a skeleton. A similar bony appearance may develop in patients with deep-set eye who have not had the surgery as a result of the aging process when the subcutaneous soft tissue disappears. Without the buffering layer of fat, the bony ridge of the zygoma becomes visible and the skin, without any support, becomes wrinkled.
Inflating this area with a soft hyaluronic acid cushion will help hide the bones and fill the wrinkles of the skin.
For Dark Pigment and Shadows
Many patients have a deep pigment around their eyes that is caused by vascularity and shadows rather than epidermal or superficial dermal pigment.
They may benefit from a layer of hyaluronic acid to put some distance between the epidermis and the pigment or to diminish the light absorbing concavity that creates the shadow.
Treatment Approach
Injection Caveats
• When injecting this area, the needle should be inserted to the depth of the periosteum and then withdrawn slightly.
• It is imperative to aspirate the syringe to insure that intravascular placement does not occur.
• One should also take great care to avoid impaling the globe; it is helpful to use one finger from the non-dominant hand to protect the eye.
• Injections of Juvéderm in this area should be performed from the lateral aspect. Care should be taken to avoid orienting the needle in a manner that could cause it to poke the eye of a patient who, for example, sneezes or panics and grabs the injector’s arm.
• The injection should take place in the deep tissue plane, and the needle should be inserted into the periosteal plane and withdrawn slightly. Although this plane is relatively avascular, it is a good idea to aspirate the plunger to reduce the chance of an intravascular injection.
• When injecting in this location, use low pressure on the plunger and instruct patients to close their eyes.
Product volume and equipment
• Average amounts of volume used for filling the tear trough are between 0.5 ml and 1.0 ml per eye depending upon the size and the depth of the crease.
• Juvéderm Ultra or Juvéderm Ultra Plus can be used. The needles provided with these syringes are adequate for this injection.
Implanting the Juvéderm
• Small pearls of product (e.g., 0.02 ml to 0.05 ml) may be injected and then massaged into a confluent layer.
• One area that may require more superficial layers is the area of the medial eyelid as it nears the nose. This area needs to be treated gingerly and should be injected with minute amounts of product.
• The lateral aspect of the tear trough (which I define as the portion that is lateral to the mid-pupillary line) should be injected at the periosteal layer and followed laterally to the full extent of the concavity.
Proceed with Caution
The key to injecting the tear troughs with filler is to proceed with caution and inject small volumes until you have a sense for the patient’s aesthetic perspective and comfort level with the procedure. I have had the experience of injecting this location and having what I thought was a perfect result only to have a patient who was unhappy because of small bumps. (I am not sure it is possible to inject this location without some risk of bumps, and this is worth noting to the patient as well as putting into consent forms.)
Need for a Comparative Trial
Juvéderm has some characteristics that make it distinct from Restylane. Although in many areas of the face, these characteristics may not make a significant difference, there is little doubt that in other areas it can be significant. A clinical trial comparing these two products in the tear troughs would be beneficial.
The approval of Juvéderm (Allergan) in 2006 brought another hyaluronic acid filler to the U.S. market. Questions regarding how it compares to hyalurons already approved were soon supplanted by answers suggesting that each of the major families of fillers — Restylane and Juvèderm — would find respective niches of excellence, with proponents in both camps.
One such area of excellence — the treatment of the tear trough, which is described below — takes advantage of Juvéderm’s unique properties. These include its homogeneous gel structure and perhaps its flow characteristics.
The technique presented here is deemed advanced in that it requires a high level of experience in injecting fillers and careful patient selection that considers previous surgery and specific aspects of the appearance of the periorbital area.
Who Benefits from Treatment
Patient who benefit from Juvéderm in the tear troughs generally include those with dark areas around their eyes from pigment that is not epidermal in origin or those who exhibit a bony periorbital appearance due either to surgery or the aging process.
Countering the Bony Look
Typical blepharoplasty patients have not only the extra skin of the eyelids removed but also some of the perioral fat pad as well. In cases where patients have had this fat pad entirely removed or they have deep set eyes, the post-operative results may be a periorbital area that looks like that of a skeleton. A similar bony appearance may develop in patients with deep-set eye who have not had the surgery as a result of the aging process when the subcutaneous soft tissue disappears. Without the buffering layer of fat, the bony ridge of the zygoma becomes visible and the skin, without any support, becomes wrinkled.
Inflating this area with a soft hyaluronic acid cushion will help hide the bones and fill the wrinkles of the skin.
For Dark Pigment and Shadows
Many patients have a deep pigment around their eyes that is caused by vascularity and shadows rather than epidermal or superficial dermal pigment.
They may benefit from a layer of hyaluronic acid to put some distance between the epidermis and the pigment or to diminish the light absorbing concavity that creates the shadow.
Treatment Approach
Injection Caveats
• When injecting this area, the needle should be inserted to the depth of the periosteum and then withdrawn slightly.
• It is imperative to aspirate the syringe to insure that intravascular placement does not occur.
• One should also take great care to avoid impaling the globe; it is helpful to use one finger from the non-dominant hand to protect the eye.
• Injections of Juvéderm in this area should be performed from the lateral aspect. Care should be taken to avoid orienting the needle in a manner that could cause it to poke the eye of a patient who, for example, sneezes or panics and grabs the injector’s arm.
• The injection should take place in the deep tissue plane, and the needle should be inserted into the periosteal plane and withdrawn slightly. Although this plane is relatively avascular, it is a good idea to aspirate the plunger to reduce the chance of an intravascular injection.
• When injecting in this location, use low pressure on the plunger and instruct patients to close their eyes.
Product volume and equipment
• Average amounts of volume used for filling the tear trough are between 0.5 ml and 1.0 ml per eye depending upon the size and the depth of the crease.
• Juvéderm Ultra or Juvéderm Ultra Plus can be used. The needles provided with these syringes are adequate for this injection.
Implanting the Juvéderm
• Small pearls of product (e.g., 0.02 ml to 0.05 ml) may be injected and then massaged into a confluent layer.
• One area that may require more superficial layers is the area of the medial eyelid as it nears the nose. This area needs to be treated gingerly and should be injected with minute amounts of product.
• The lateral aspect of the tear trough (which I define as the portion that is lateral to the mid-pupillary line) should be injected at the periosteal layer and followed laterally to the full extent of the concavity.
Proceed with Caution
The key to injecting the tear troughs with filler is to proceed with caution and inject small volumes until you have a sense for the patient’s aesthetic perspective and comfort level with the procedure. I have had the experience of injecting this location and having what I thought was a perfect result only to have a patient who was unhappy because of small bumps. (I am not sure it is possible to inject this location without some risk of bumps, and this is worth noting to the patient as well as putting into consent forms.)
Need for a Comparative Trial
Juvéderm has some characteristics that make it distinct from Restylane. Although in many areas of the face, these characteristics may not make a significant difference, there is little doubt that in other areas it can be significant. A clinical trial comparing these two products in the tear troughs would be beneficial.
