~ 0 z 11:11: ..... t- z ..... z 0 Q z 0 ... .. "'~ 0 0 11:11: t- :::c C) :::::» Ill( z z 0 u Q z Ill( 11:11: C) ..... :::c t- - 0 C"'4 ... "' COSMETIC NEM They say the eyes are the 'window to the soul' so it is no wonder that so many patients visiting aesthetic clinics are concerned about keeping their eyes looking fresh and young.The delicate ski n around the eyes is one of the first areas to show the telltale signs of ageing due to unique biological traits, which make it less resistant to UV radiation and other environmental insults that cause damaging reactive oxygen species (ROS) to bombard skin. Laughter lines or crow's feet can be effectively treated with botulinum toxin however, treating the unflattering tear trough hollows that form between the juncture of the cheek and the orbital rim has always been a challenge for practitioners. Surgery to address the problem is not always appropriate and the growing preference for non-surgical treatments has left physicians wondering how best to advise patients. , strengthening the lower lid and anterior lamella); MODERATE (early fat displacement which needs , deeper volume correction below the orbicularis oculi , plane) and SEVERE (significant anterior herniation of the infraorbital fat into the lower lid and deepening of the tear trough requiring a layered or'sandwich' technique injecting above and below the orbicularis muscle to create 'sheets' of firmer tissue similar to a 'mille feuille'). Most patients with mild tear trough present at an early age because the tethering orbicularis retaining ligament becomes visible due to skin and fat atrophy and these are the easiest cases to correct. I feel that most patients in the severe category can be improved but when the bulging of the lower lid becomes too severe, it is those patients that must consider blepharoplasty to excise the excess infraorbital fat.• Greater understanding of how volume loss contributes , into account when injecting the tear trough these are: to facial ageing has led to consideration of soft tissue augmentation for the treatment of prominent There are a number of causes of dark circles under the , • Patient selection eye, including pigmentation, hollowing and visible tear trough hollows. In the midface, loss of volume Anatomy blood vessels. Dermal fillers can only be used to accentuates the bony orbital rim which leads to Product Choice address the dark circles caused by hollowing from loss exposure of the infraorbital fat pads and accentuation Injector Skill of fat under the eye. This condition can be hereditary, part of the normal ageing process, or following lower of the tear trough hollow. , PATIENT SELECTION • eyelid surgery when too much fat has been removed. Patient selection is paramount when carrying out Dermal fillers can provide a long lasting instant aesthetic solution to this problem however the eye o area is a controversial and tricky area to inject and the • of the eye area will be suitable for fillers and if you tear trough treatments. Not all patients with ageing complex anatomy and risks associated with putting a don't choose your patients carefully you could end filler under the eye mean practitioners should rightly up making the situation worse and having a serious ' Dr Acquilla says, •The tear trough deformity has several ' factors which influence it's appearance but the key structure is the orbicularis retaining ligament which ' tethers the skin down to its bony attachment on the infraorbital rim. Other contributing causes are: tread with caution. In fact treatment of the tear trough ' problem on your hands. 1) Fat displacement in both the infraorbital and malar with fillers is such a contentious issue that few dermal compartments filler manufacturers, if any, promote it as an indication ' Dr Raj Acquilla says,•patient selection and classification for their product, despite the fact increasing numbers is essential to plan a strategic approach to tear trough 1 of practitioners are doing it. correction. Essentially there are three case types: ' translucent and acting as a window through to the MILD (textural change but no volume shift which underlying vasculature causing dark circles. There are a number of key factors that should be taken can be corrected superficially by injecting and 3) Periorbital hyperpigmentation which can be subject II l$melocnewsuk com 2) Dermal atrophy making the skin become more TREATMENT SPOTLIGHT/TEAR TROUGH and in larger volumes. This can be addressed with tiny doses of dilute hyaluronidase but in some cases may be long term. S) Lumps and nodules can occur when products are injected into or above the orbicularis muscle but again are assciated more with large volumes of particulate HAs. 6) Visual acuity compromise. "Visual acuity compromise has never (to my knowledge) been described from injecting HA into the tear trough, however, it has been reported following injection into the glabella and temporal fossa~ says Dr Acquilla. AFTER (COURTESY OF DR LUCY GLANCEY) "Theoretically this could ?<=cur by a fragment of HA entering an arterial vessel and finding its way to the seen almost anything being injected into the under eye This is a caution shared by Mr Inglefield, "I do one lower terminal branch of the central retinal artery. In my area but when it comes to the products that are most bleph every six weeks to remove product from the tear opinion this risk can be minimised by injecting low commonly used it is the hyaluronic acids because there trough~ he says. molecular weight, low viscosity HAs in tiny quantities and in fine streams or droplets. I rarely keep the needle is an exit strategy- if there is a lump or a bump then you are able to use an enzyme to reduce it." INJECTOR SKILL AND TECHNIQUE standing still and never in large quantities. This way Treatment of the tear trough hollows should only be even if a fragment of HA enters a vessel it is likely to be Dr Acquilla says, "I tend to select different products for administered by an experienced medical aesthetic too tiny to embolise and cause ischaemia. Nevertheless specific injection depth according to their viscosity, practitioner who has undergone advanced injection I still always fully consent my patients for every possible tissue integration and osmotic potential. This can technique training. Placing the product in the wrong be broken down into three injection planes: MILD- place cannot only cause a poor aesthetic result and superificial injection into the upper dermis of the lower patient dissatisfaction but can also be dangerous. 1 complication but stress the rareness of such an event~ 1 It can take six to 12 months to become fully competent in treating this indication and you may wish to seek the lid using a 32G ultra thin walled needle (TSK) with a low viscosity HA (eg. Juvederm Hydrate/Restylane and Dr Patel says, "A problem with tear trough treatment is support and help of your local ocular plastic surgeon Emervel Touch I Belotero Soft); MODERATE - deeper that the techniques are often lacking. Even if it is the during this period. The procedure itself is relatively injection below the orbicularis muscle using a 30G 4" right product and the right patient, it can be placed quick however and can be conducted in an out patient needle with a medium viscosity HA (eg. Juvederm Ultra incorrectly. If it is too low you don't see it if is too high setting. The patient is seated upright woth the head 2/Restylane/Emervel Classic/Belotero Basic); SEVERE you can get doscoloration ~ firmly resting against a solid headlt!st and is asked to look upwards in order to accentuate the appearance of - supraperiosteal injection into the superior malar groove/orbito-malar junction using a higher viscosity There are a number of potential side effects of the HA (Juvederm Ultra 3/Perlane/Emervel Deep/Belotero treatment: the tear trough deformity and lower eyelid fat pads. Either the serial puncture or linear threading injection technique can be used placing the gel in the deep Intense)." Dr Elisabeth Dancey uses the HA filler Stylage because 1) Redness, swelling and bruising are common (3Q- sub-orbicularis. The area is then gently massaged 40% of cases) which subsides within a few days. to ensure even distribution along the tear trough of the addition of the anti-oxidant mannitol. She says, hollow to achieve the desired contour. The treatment "When treating the delicate eye area you need to avoid 2) Hydrophyllic rebound is less common and treatments that cause swelling so Stylage is an ideal associated with products which have a large amount choice for this because the natural addition of mannitol offree (non-cross linked) HA, especially when injected reduces inflammation. You also need to choose a filler In larger volumes and superficially. Products which result can be seen immediately with the true result 1 noticeable seven to 10 days later when any post treatment swelling has subsided. that conforms to the shape of the eye area. Also where contain mannitol e.g. Juvederm Hydrate and Stylage The results in this area tend to last longer than other the skin is thin and crepy you risk being able to see can temper this hydrophyllic response and control post dermal fillers because the eye area is less mobile. 1 injection swelling. Wendy says, "The good news with the tear trough is 1 3) Prolonged oedema can be seen in certain patients areas. You can get nine months or even a year and a who already have a degree of periorbital lymphatic half for some people.· 1 compromise and where injection of a HA into the tear trough further reduces interstitial fluid drainage. "It's so IN CONCLUSION 1 important to take a good history from our patients and Tear trough treatment with dermal fillers can be a very the filler so Stylage Hydro Max that cross links HA with it lasts quite well because it is not as mobile as other sorbitol increases hydration and can help plump and rejuvenate hollow eyes or dark circles via 'nappage' techniques• Permanent fillers are definitely a 'no no: Wendy says, -n,e other thing I would issue extreme caution on is permanent fillers. Permanent fillers = permanent ask them whether they notice puffy eyes when they problems. This is a very unforgiving area because you wake and if this improves as the day progresse~ says Dr have a lot going on there anatomically. One of the Acquilla. "If the answer is 'yes' then please do not treat says, "As with any treatment if it is a suitable patient with reasons the companies don't promote it is because if their tear trough as the puffiness and bags are likely to the right indication and a suitably trained practitioner you are going to have a problem with a filler you are worsen.• 1 1 effective and long lasting solution to hollowing and dark circles under the eye for the right patient. Dr Patel using an appropriate product then it is a wonderful treatment and it can give sensational results. However going to have it in the tear trough or in the lips. No filler is approved for the tear trough indication in the US and 4) Tindal (blue/grey) effect is noted more with the amount of patients who do benefit from it isfar less I doubt it will ever be because it is too risky.' particulate HAs, particularly when injected superficially than people realise~ lfJ :»mehcnewsul< com