Introduction

Peri-orbital rejuvenation is one of the most sought after aesthetic treatments to correct sunken eyes due to infra orbital fat repositioning. Various theories have been postulated for formation of tear trough deformities, of which Loeb1  hypothesized the formation of ‘naso-jugal groove’ due to “fixation of the orbital septum at the level of the inferomedial portion of the arcus marginalis”.1

Another theory proposed to formation of tear troughs is loss of facial volume, gravitational descent of malar fat pads and muscular defects in orbicularis oculi muscle.2,3  

Besides anatomical grounds, several structural characteristics also contribute to the formation of tear trough deformities. These include: reduction of collagen, distortion of elastic fibers, dilated vasculature, and orbito-malar ligament laxity.4

Everything you need to know about tear trough fillers


Points to consider by the physician before performing Tear Trough Fillers:4

  • Having good anatomical knowledge of the orbital area
  • Identifying patients’ needs and carrying out thorough clinical assessment. 
  • Identifying the type and extent of tear trough deformity 
  • Discussing realistic outcomes
  • Choosing the right type of filler
  • Performing the right injection technique depending on the area to be corrected. 

Caution:4

  • Identifying the anatomical proximity of important vasculature around the orbit especially angular artery and angular vein is crucial.
  • The course of infraorbital nerve must be taken into consideration which emerges from the infraorbital foramen and correct injection techniques must be used to avoid any damage to it.
  • Lymphatics in the orbit run superficially and hence deep injections are preferred in outer thirds of lower orbital margins to avoid lymphatic damage. 
  • Care should be taken to NOT inject anterior and superficial to the malar septum as this area acts as a barrier and can cause edema due to improper lymphatic drainage. 

For correcting tear trough deformities, it is crucial to choose both, the right type of filler and injection technique, to achieve best results. Knowledge of crosslinking of Hyaluronic Acid (HA), product characteristics and structure of the material can help avoid complications such as edema. The use of cannula offers the highest level of safety taking into consideration the anatomical characteristics and vasculature in the tear trough area. 


Cannula Technique:4

  • Locate an entry point depending on the area to be corrected.
  • The skin on the point located is pierced with a 23G needle perpendicular to the skin.
  • A 25 or 27G cannula is inserted deep, making sure it is touching the periosteum.
  • While positioning the cannula to reach the tear trough or the deformity that has to be corrected, the finger of the other hand secures and confirms the cannula’s position.
  • The HA filler is deposited gradually in a retrograde manner till the defect is corrected.
  • A gentle massage is performed to spread the product out evenly. 

Needle Technique:4

  • The injection of the tear trough is preferred with a 27-30 G needle.
  • Locate an entry point depending on the area to be corrected and needle is inserted till it reaches the periosteum
  • Aspirate to ensure the needle is correctly placed to avoid any vascular complications. 
  • Deposit the HA filler slowly and gradually in micro-boluses or linear retrograde technique.
  • Second injection point is made to fill other defects in similar manner.
  • A gentle massage is performed to spread the product out evenly. 

Teosyal Redensity 2 PureSense

Teosyal Redensity 2 :5

Teosyal Puresense Redensity 2 is a monophasic HA based product with good visco-elasticity and biocompatibility offering long-lasting, natural looking results. 

It is a mixture of cross-linked (70%) and non-cross-linked HA (30%), gel which retains less water due to its low hygroscopic characteristics, and hence causes less edema.  The patented technology used in Teosyal ensures reduced levels of protein and bacterial endotoxins causing less hypersensitivity reactions.


Restylane

Restylane Lidocaine:6

Restylane uses a patented NASHA technology in its HA fillers which gives its product a unique particle size suitable for different indications. The HA is specially formulated to match body’s naturally formed HA and helps treated moderate to deep wrinkles including tear trough deformities. 


Stylage SStylage S: 7

Stylage S is a monophasic, crossed linked HA filler infused with anti-oxidants, offering a patented IPN (InterPenetrated Networks) technology. The IPN technology uses a unique combination of two mono-phasic cross-linked network of HA which determines the viscoelasticity of the product. Physiologically, injecting a needle into the skin provokes an inflammatory response that stimulates the release of free-radicals. The anti-oxidants in this filler neutralise the free radicals, and hence, shields the HA content from rapid degradation.

Available with lidocaine too.

 

What is neo-collagenesis?


References: 

  1. Loeb R. Naso-jugal groove levelling with fat tissue. Clin Plast Surg. 1993;20:393–400. [PubMed] [Google Scholar]
  2. Sharad J. Dermal Fillers for the Treatment of Tear Trough Deformity: A Review of Anatomy, Treatment Techniques, and their Outcomes. J Cutan Aesthet Surg. 2012;5(4):229-238. doi:10.4103/0974-2077.104910
  3. Flowers RS. Tear trough implants for correction of tear trough deformity. Clin Plast Surg. 1993;20:403–15. [PubMed] [Google Scholar]
  4. Anido, J, Fernández, JM, Genol, I, Ribé, N, Pérez Sevilla, G. Recommendations for the treatment of tear trough deformity with cross-linked hyaluronic acid filler. J Cosmet Dermatol. 2021; 20: 6– 17. https://doi.org/10.1111/jocd.13475
  5. Adapted from: https://www.teoxane.com/en/dermal-fillers/teosyalr-products
  6. Adapted from: https://www.restylaneusa.com/restylane
  7. Adapted from: https://vivacy.com/en/products/stylage/