is injected, the needle withdrawn and the filler molded and massaged against the bone to achieve the desired contour and reduce any prominent lumps (Fig. 15.3d). The injections are repeated in successively more lateral locations along the tear trough, by means of serial puncture. Usually 3–5 injections su ce. Care must be taken to avoid placement of more viscous gels, such as Restylane Perlane®, in the pre-septal lower eyelid location, as it is di cult to mold filler here and the very superficial position leads to prominent lumps or blue discoloration and consequent patient dissatisfaction. If additional contouring is required in this area it is best undertaken with a gel of very small particle size, such as Restylane Vittal® or Restylane Touch®, administered via the “haystack” approach. Postoperative recommendations to patients are as for upper eyelid contouring.

In general 1–1.2 ml of filler is su cient for tear trough contouring, but this can range to 3.5 mls when extending out to the malar region [47]. The latter helps to achieve a smoother lower lid/cheek contour and often gives a better esthetic finish. Duration of treatment ranges from 6–18 months although 8–20% of patients will request a touchup prior to this, usually due to insu cient initial fill or patient desire for a fuller look [30, 47].

Bruising and mild swelling is common following teartrough filler treatment and can last up to one week (Fig. 15.3g). However, it is readily camouflaged with concealers or glasses such that less than 20% of patients need to restrict their social engagements or work schedule following treatment [47]. Persistent malar edema has been described with lateral filler placement in a few patients and has proven di cult to treat [30]. Mild lumpiness has been described by up to one third of patients but this usually settles over the next two weeks (Fig. 15.3h). However, it may require additional treatment in up to 15% of cases [30, 47]. This includes further massage by the treating physician, additional filler to smooth out any contor irregularities or dissolution of hyaluronic acid gel. This can be performed in the o ce by injecting 0.2–0.5 ml of a 1500i unit/5 ml solution of hyaluronidase in saline into the lumpy area [47]. The e ects are immediate so the dose of hyaluronidase can be readily titrated against the extent of the lumpiness. Additional filler should not be injected into the treated area for a week to ensure that the e ect of the hyaluronidase has ceased. Blue discoloration has also been reported by 5–10% of patients [30, 47]. It is thought to occur due to a superficial placement of a pool of filler which causes preferential scattering of blue light (Tyndall e ect) or which becomes stained with blood. Treatment for this is also dissolution with hyaluronidase.

Patient satisfaction with lower eyelid/tear trough volume augmentation using hyaluronic acid gel is reported

as being in the region of 85%,with 50% of patients expressing “marked” satisfaction with the treatment [30, 47]. Examples of outcomes from tear trough contouring using hyaluronic acid gel (Perlane®) are given in Figs. 15.5a–d.

15.5.4 Temple and Brow

Non-surgical volume augmentation of the temple region with soft-tissue filler is well established for patients with HIV-treatment-associated facial lipoatrophy. In these patients, poly-L-lactic acid (Sculptra®, Dermik Labs, Bridgewater, New Jersey) has been repeatedly used with high patient satisfaction and e ects lasting over three years [11, 41]. However, the use of fillers to treat other causes of temple hollowing remains less well established. Reports are now emerging of the use of injectable softtissue fillers in temple asymmetry following excision of orbitotemporal neurofibromas, as well as in facial aging [52]. Hyaluronic acid fillers have been preferred for treating these causes of temple hollowing as the volume loss is more subtle and requires more careful titration of the dose of filler. The possibility of reversing the treatment, should the patients not like the esthetic result, is also useful. However, a viscous filler, such as Restylane Perlane®, should be selected as the skin overlying the temple is much thicker than the eyelid and can tolerate a filler with a larger particle size. Temple filler should also always be considered in patients receiving lateral upper eyelid/subbrow filler as otherwise the latter can result in a prominent bulge at the lateral brow which contrasts with the adjacent hollow temple.

Patient preparation is as described previously. Injections are given behind the zygomaticofrontal process so as to soften the bony contour of the lateral orbital rim [52]. Care must be taken to avoid the path of the superficial temporal artery. The filler is administered via a serial puncture technique, with 3–5 injections, each delivering approximately 0.3 ml of filler. Placement of the filler is deep within the superficial temporal fascia (Fig. 15.3e). After each aliquot is injected, the filler is massaged and molded against the temporal bone to achieve a smooth contour (Fig. 15.3f).

Typical treatment volumes are 1 ml per side, although this can range up to 3 ml for prominent hollowing following surgical excision (e.g., of a neurofibroma) [52]. As yet, little has been published on the longevity of hyaluronic acid filler in this area but the use of higher viscosity filler and the relative immobility of the skin in that area suggests that e ects may last one year. As with most facial filler treatments, patient satisfaction has been high, with over 80% of patients very or moderately satisfied [52].

Side-e ects of this procedure include transient mild or moderate discomfort which can be associated with chewing,especially if the filler has been placed deep into the temporalis muscle [52]. Localized bruising is also common, although this generally resolves within one week, and occasionally prominence of a temple vein may persist for 2–3 weeks. There is also some initial lumpiness, in keeping with

hyaluronic acid filler treatment in other sites but this soon settles.Alternatively it can be relieved by further massage or additional filler. No patients in the reported series of temple filling with NASHA required dissolution with hyalase although one requested additional filler to one side due to asymmetry [52]. Examples of temple hollowing corrected with injectable soft-tissue fillers are given in Figs. 15.5e–h.