effect has persisted for 18 months, and during this time no additional injections were needed. Only few patients needed additional injections, and all were treated 1 month after the first injection. Goldberg and Fiaschetti described that substantial residual effect was noted even at 12 months [9]. Cossío and Oreja noted that HA filler gel (Restylane®) remained basically unchanged 8 months after implantation [12]. Lambros observed that HA gel filler had very long-lasting (1 year or more) effect in the tear trough [16].

Although the goal of HA gel filler products is to enhance one’s appearance, there have been some adverse reactions that can occur. The most common reactions described are local edema, erythema, tenderness, bruising, fullness, and contour irregularity [9, 11–14, 17, 18]. The author observed that several patients have had irregularities that were massaged away either at the time of injection or several days later. When irregularities occur, they are usually treatable with massage. The closer one inspects the area, the more effects of the injection that can be seen. Social and casual inspection reveals a smooth contour. If one looks very closely, one can see the sites injected by virtue of very subtle changes in the reflectivity of the skin and its contours. Typically, patients do not notice this degree of imperfection.

Few patients may also present with bluish discoloration in treated areas caused by injections that are placed too superficially. This discoloration can present as a bluish, grayish, or yellowish tint underneath the skin, and it has been known as the Tyndall effect [9–11, 19]. Some surgeons advocate the use of hyaluronidase to solve this problem [9, 19–21]. Others prefer the 1,064 nm Nd:YAG laser to resolve it [22], while Dean & Jacob prefer to extract the superficially placed HA with #11 blade [19].

Much feared is the possibility of an intra-arterial injection, with skin injury or even blindness. The incidence is unknown and at this time there are no reported cases of blindness with HA, although there are a few cases of intra-arterial injection with skin injury [9, 16, 17]. However, the risk of retrograde embolization and consequently visual loss exists with all fillers. Occlusion of the ophthalmic artery with permanent visual loss has been reported with the use of bovine collagen, micronized dermal matrix, injection of autologous fat, silicone oil, and corticosteroids injected into eyelid lesions and nasally [9, 17].

53.7 Conclusions

Periorbital aging often involves soft tissue deflation. Although there is a role for conservatively removing tissue in some patients, almost all patients can benefit from some filling. Even though HA gel filler does not address the root causes of the tear trough, it certainly can improve it without surgery.

The author’s opinion is that the use of HA in the tear trough has the following benefits: injection is relatively easy to perform; there is a high degree of patient satisfaction; the material is very long-lasting in the tear trough; most complications are self-limiting and can be easily treated; in the event of an unsatisfactory effect, the material can be dissolved away. Of course there are some disadvantages as follows: it is not permanent and there are no associated improvements in the lower eyelid.

The author was pleased to note an improvement in tear trough deformity in all cases, and all patients were very satisfied with their results. The main indication for leveling the tear trough is the presence of enough deformity to make a visual difference by its improvement.

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