Fig. 53.1 Hyaluronic acid is a glycosaminoglycan disaccharide composed of repeating units of D-glucuronic acid and N-acetyl-D-glucosamine

n

of hyaluronic acid renders it soluble and allows it to bind water extensively. The average 70 kg man has roughly 15 g of hyaluronic acid in his body, one-third of which is turned over every day [12–14].

Pure hyaluronic acid, even in its longest polymeric form, degrades quickly in tissues. HA derivates have been developed with modified physical and rheological characteristics, making it suitable for tissue augmentation [12–14]. At physiologic pH, hyaluronic acid exists mostly as a sodium salt; this is the most common form of commercially available hyaluronic acid [12–14].

Restylane® is a modified hyaluronic acid. It is nonanimal-derived product obtained by bacterial fermentation of Streptococcus strains (S. equi or S. zooepidemicus) and stabilized by chemical cross-linking process. It has approximately 100,000 particles of gel per millimeter [11–14].

a

53.3 Patient Marking and Preparation

Before treatment, patients are advised to avoid medications that tend to interfere with platelet function for 2 weeks before treatment. Standard digital photographs are taken with all visits, and informed consent is obtained.

Makeup is removed, the skin is prepped with alcohol, and the morphology of the eyelids is studied. The area to be treated is marked delimiting to the lower and upper borders of the tear trough. When correction of the eyelid–cheek groove is required, the lower and upper limits are marked (Fig. 53.2). As a precaution, the author tends to define the position of the lower bony orbital rim. The lower eyelid area is anesthetized by the topical application of 2.5% lidocaine and 2.5% Prilocaine cream. After 20–30 min the ointment is cleaned off with alcohol.

b

Fig. 53.2 (a) Yellow arrow: location of the anterior lip of the bony orbital rim. White arrow: the area to be treated is marked delimiting to the lower and upper borders of the tear trough and

the eyelid–cheek groove. (b) White arrow: the area to be treated is marked delimiting to the lower and upper borders of the tear trough

53.4 The Injection

Under a bright overhead light and with patient’s chair reclined 30° from vertical position, and with the head firmly resting against a solid headrest, the injections begin. The patients are permitted to close their eyes. The goal is to place aliquots of filler in the preperiosteal tissues just inferior to the orbital rim. The filler is introduced by using a serial puncture technique with a 30 gauge needle supplied with the medication (Fig. 53.3). Approximately 0.1 ml is injected at each pass. The needle is withdrawn and the filler is molded to the desired contour. The deepest part of the medial tear trough is treated first and, as the depression becomes less deep, parallel amounts of fillers are injected cephalad and caudal to the first injection until all area is corrected (Fig. 53.4).

If a bruise is noted to be forming, the needle is quickly withdrawn and a gentle pressure is applied to the local area with a cotton tip applicator. If the needle is placed too superficially, visible lumps or wheals of the hyaluronic acid gel will form. It is important to avoid depositing large volumes of the filler in one location. Rather, a gentle continuous pressure is applied to the syringe plunger after the needle touches the periosteal tissue and slowly withdrawn, creating multiple fine vertical stacked deposits, creating smooth three-dimensional contour.

At the conclusion of the procedure, determined by the end points of a successful accomplishment of the goal of artistic filling of the hollow contours, a massage of the treated areas is performed by the surgeon

Fig. 53.4 White arrow indicates the side treated with HA gel filler. Black arrow shows the tear trough before injection

to mold to the desired contour. Afterwards the patient is discharged, and the postoperative instructions consisted of a massage of the treated areas if the patient notices any irregularity in the contour, cold compress on the eyelids for 2 days, makeup to conceal any bruising, and no restrictions on activities is imposed. The patient is scheduled to return to the office in 7 days. When the treated area is reevaluated and if required a touch-up is done.

53.5 Complications

Complications included some degree of bruising, 52% (78/150); erythema, 50% (75/150); local swelling, 8% (12/150); pain at injection site, 4% (6/150); and migraine, 1.3% (2/150). Transient swelling in the lower eyelid is expected for 1 or 2 days. In five cases, persistent swelling was related to bruising and did not resolve until the bruise disappeared. In seven additional cases, swelling subsided after an additional day of observation with no intervention.

Fig. 53.3 Injection of the hyaluronic acid gel filler below the orbital rim

53.6 Discussion

The results of this technique are primarily visual (Figs. 53.5–53.8). Approximately 150 subjects have been treated, with the effect of treatment lasting up to

18 months. Patients are told that they will be improved but not perfect. The older and more crepe-like the skin, the less well the treatment works. The mean age was 46.1 (26–62) with 2% male.

The total injection volume per side (baseline + touchups) needed to achieve correction of the tear trough was on the right side was 0.63 ml (SD = 0.37) and on the left side 0.6 ml (SD = 0.3). There was a large range in the amount of product used to correct the tear trough, spanning from 0.1 to 2 ml on the right side and on the left side from 0.2 to 1.2 ml. Of the 150 subjects, 15 received a touch-up injection 1 month later. Flowers [15] was the surgeon who described the tear trough saying that, “The deep groove that commonly occurs near the junction of the eyelid and the cheek is the most consistently ignored major deformity of the orbital region. With a characteristic length of about 2 cm, it extends downward and lateral from the inner canthus of the eye…whether limited or extended it gives the face a dissipated, unhealthy, and tired – even haggard-appearance” [15].

The cause of the tear trough deformity is multifactorial, and separating its components exactly may be difficult. The main components of the tear trough are the hollow itself, the fat bulge just superior to it, and the very distinct change of skin quality, color, and thickness between the lid and the cheek [7, 16].

Injectable dermal fillers are rapidly challenging and complementing the market of more invasive cosmetic surgical procedures. Dermal fillers have different tissue-compatibility characteristics that determine their suitability. Thus, no single filler is “ideal” for

applications, but certain desirable filler qualities are generally accepted, such as safe and effective; it should be biocompatible, nonimmunogenic, easily obtainable, nonreabsorbable, low in cost, and easily stored. It should be easy to remove if necessary [12–14].

A number of investigators have explored the use of cross-linked stabilized nonanimal hyaluronic acid gel filler to treat the tear trough [7, 9, 16, 17]. Kane described his personal method that places HA gel filler (Restylane®) between the skin and the orbicularis oculi muscle [7]. Goldberg and Fiaschetti demonstrated a method in which they use multiples threads of HA gel filler (Restylane®) injected under the orbicularis oculi muscle [9]. Lambros showed his experience of treating the tear trough with HA gel filler placed in the orbicularis oculi muscle and at the periosteum (1q6) [16]. Steinsapir and Steinsapir reported a 2-year experience of treating the naso-jugal groove (tear trough) with Restylane®, using a deep-fill method [17]. All these methods require considerable experience to achieve acceptable result. The superficial method can easily produce skin irregularities while the deep-fill method places a premium on the skin, maximizing tissue covering and minimizing the risk of intravascular injection. The author prefers to inject HA gel filler in the preperiosteal tissues. With experience, there appear to be some anatomic situations that benefit from a more superficial placement of filler.

One of the concerns of the patient is the durability of the product, usually I explain that the manufacturer states that will be approximately 6–9 months, but what the author has seen in the initial experience is that the