include a variety of fillers, autologous fat, or solid implants. This section focuses on HA fillers.

HA products are commonly used to fill the tear trough (Fig. 25.5). The senior author prefers Restylane™ due to its firmer consistency. Juvederm Ultra™ and Ultra Plus™ have a smoother consistency but, in the senior author’s experience, are more hydrophilic than Restylane™. Thus, these products will hold more water and result in more edema. This can confuse the correction and lead to eventual undercorrection and shorter duration than anticipated.

Filling the nasojugal groove is a delicate procedure requiring precision and artistry, and one must possess a clear understanding of the anatomy. Topical anesthetic creams and ice offer the best anesthesia. Anesthetic injections can distort the anatomy and interfere with proper filler injection. The patient is seated upright and a light is placed overhead to highlight the lower eyelid to mid-face contour.

Various injection techniques can be used. The senior author prefers to use the serial puncture and retrograde linear threading technique. Some feel the anterograde linear threading technique is easier to verify the proper depth of needle tip placement [3]. Other advantages include possible softer forward movement through tissues, blunting the impact of the sharp needle tip, pushing vessels out of the way, and reducing the chances for bruising. However, cannulization and intravascular injection are a greater risk with this technique. The retrograde technique is felt to avoid intravascular injection of filler as well as the creation of additional tracks or dissection planes [3]. This technique is often used for very soft, thin, or vascular areas present under the eyes. Regardless of the technique used, it is important to inject slowly (less than 0.3 mL/min) and avoid tissue tears. Most clinicians inject between 0.2 and 0.4 mL per side. Since injecting the

nasojugal groove can be extremely volume sensitive, it is important to treat conservatively at first to avoid overcorrection. Reevaluation in 2–4 weeks and touch-up treatment can be performed if needed. In order to achieve an optimal aesthetic result, massage the filler at the time of injection to distribute it. Tyndall effect and water absorption are possible longand short-term side effects.

25.4Avoiding and Managing Complications

BoNTA injections have a long history of safety and efficacy. Since the dosages used in cosmetic treatments are small, serious adverse events are rare. Most adverse events are mild and temporary and include pain at injection sites, bruising, swelling, and flu-like symptoms [19]. Bruising and other adverse events can be decreased by advising patients to avoid taking medications that inhibit clotting. Vitamin E, aspirin, and nonsteroidal anti-inflammatory drugs should be stopped up to 2 weeks before treatments.

More significant complications can occur but are usually due to poor injection techniques, unfamiliarity with muscle anatomy, and injector inexperience. Most of these result from diffusion of toxin into adjacent musculature, which can lead to unexpected muscle weakening. Periorbital complications include an overtreated frontalis, brow ptosis, eyelid ptosis, asymmetry, cocked eyebrows, diplopia, ectropion, decreased strength of eye closure, and dry eyes. One should also carefully evaluate patients for any pre-existing low brow position or ptosis prior to treatment. Brow ptosis can generally be avoided by injecting no closer than 1 cm above the bony orbital rim in the mid-pupillary line and using lower doses in the frontalis [20].

One of the most common significant complications is eyelid ptosis. Publications have reported an average incidence of 6.5%, though in the senior author’s experience, this is extremely high. Clinical trial data suggests an approximately 3% rate with BotoxCosmetic™ and 2% rate with Dysport™. Even these numbers are higher than those experienced by the senior author.

Upper eyelid ptosis can occur as early as 48 h after injection and as late as 14 days post treatment. The duration rarely lasts more than 3–4 weeks, but the problem can be particularly bothersome to patients. This complication most commonly occurs after BoNTA injections to the glabellar complex. Most authors believe the etiology of eyelid ptosis is diffusion of the toxin through the orbital septum into the levator palpebrae muscle. It is also felt that older patients, or those with loose skin or a weak orbital septum, are more susceptible to this complication. The senior author feels that ptosis is related to hydrostatic pressure from injection or localized edema, with subsequent diffusion of product via the supraorbital or supratrochlear foramina (or notch) or the superior orbital fissure. Eyelid ptosis may be avoided by using a higher concentration (lower volume) of BoNTA and by applying low plunger pressure during injection. In addition, one should avoid placing high levels of direct pressure at sites after injection.

While diplopia and dry eyes are well-described complications of BoNTA treatment for blepharospasm, facial spasm, and essential hyperlacrimation (crocodile tears), these are extremely rare complications from cosmetic applications and only reported in various case reports [21, 22]. Possible explanations for diplopia include incorrect placement of injections, larger volumes that lead to greater toxin diffusion, or a defective orbital septum that allows the toxin to reach extraocular muscles [22]. Dry eyes can result from diffusion of toxin into the lacrimal gland or paralytic lagophthalmos, leading to decreased blink strength. The case report attributed this complication to an injection site 0.5 cm from the superior orbital rim [21].

As mentioned previously, using fillers in the upper face is an advanced technique that should be undertaken by experienced injectors. Though rare, the most serious complication is necrosis, which can occur when any filler is inadvertently injected intravascularly [14–17]. Thus, injectors must have thorough knowledge of upper facial anatomy and blood supply. Additionally, one should inject slowly (<0.3 mL/min) and with low pressure. Blanching and sudden pain are symptoms and signs of possible blood-vessel occlusion. Injectors must be alert to these warning signs and immediately intervene to mitigate serious problems. If signs of occlusion occur, immediately stop and apply a topical vasodilator. Hyaluronidase should be given if an HA filler was used. One can also consider giving low-molecular-weight heparin daily for 1 week [14–17].

Fig. 25.6 Unpleasant bluish tint (Tyndall effect, arrow) seen in the nasolabial folds from injection of Restylane™ placed too superficially

Too superficial injection of hyaluronic acid filler can create visible ridges as well as an undesirable bluish tint known as the Tyndall effect [9] (Fig. 25.6). This complication can be avoided by injecting in the subdermis. Another helpful trick is to inject with the bevel down. Beading, clumping, and overcorrection are other potential complications with fillers. Massaging the area to distribute the filler can help in preventing this complication. Overcorrection can be minimized by using the multiple puncture serial technique. One can also consider using smaller gauge needles to control the amount of filler injected. Finally, hyaluronidase can be used to reverse unwanted effects of hyaluronic acid filler.

25.5Conclusion

Neuromodulators and periorbital fillers offer an excellent means of periorbital rejuvenation and can also serve as an adjunctive treatment to surgery. While BoNTA remains the foundation of injectable treatment, soft-tissue fillers can enhance results, particularly the deep resting lines that persist after BoNTA treatment has been maximized. In addition, fillers alone improve depressions and contour irregularities, such as the nasojugal groove (tear trough).

Over the last decade, the burgeoning interest in minimally invasive aesthetic treatments has created a competitive and lucrative market for injectable cosmetic agents. The past several years has witnessed the introduction of numerous injectable fillers as well as an effective BoNTA competitor to Botox Cosmetic. This expansion of products offers both clinicians and patients more options for rejuvenation.

The goal of any aesthetic facial procedure should be the achievement of a refreshed, balanced, and harmonious aesthetic result. Attaining this requires a detailed knowledge of facial anatomy and facial aging. This is especially true

in the very delicate periorbital region. A comprehensive understanding of the different clinical applications of BoNTA and the various filler agents available can help the clinician attain this goal by creating a customized approach for each patient.

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