Comparison of Two Techniques Using Hyaluronic Acid to Correct the Tear Trough Deformity

December 2012 | Volume 11 | Issue 12 | Original Article | 80 | Copyright © December 2012

M. Shane Hamman MD,a Sabrina G. Fabi MD,b and Mitchel P. Goldman MDb

aDepartment of Dermatology, University of California San Diego, San Diego, CAbGoldman Butterwick Fitzpatrick Groff & Fabi, Cosmetic Laser Dermatology, San Diego, CA

Background: Hyaluronic acid (HA) can be used to correct volume loss associated with periorbital aging.
Objective: To report and compare the efficacy and safety of HA used to treat tear trough deformities with two different injection techniques.
Materials and Methods: This is a retrospective, single-center study of 81 patients comparing the two injection techniques used for the treatment of tear trough deformities from 2003 to 2011. Hyaluronic acid was administered either in a single depot in the nasojugal groove and massaged into position or in multiple small aliquots along the inferior orbital rim and massaged into position. Patient satisfaction and the incidence of adverse reactions were evaluated.
Results: Of the 194 patients treated during the study period, 81 (42%) were successfully contacted. The overall patient satisfaction with the correction was similar for both techniques. Two patients treated with a single depot of HA were later given hyaluronidase, but otherwise, there was no statistically significant difference in the incidence and severity of side effects.
Conclusions: We describe and compare an alternative technique for the correction of tear trough deformity using a single deposition of HA in the nasojugal groove with favorable outcomes.

J Drugs Dermatol. 2012;11(12):e80-e84.


One of the major components of periorbital aging is volume loss leading to accentuation of the nasojugal groove and inferior orbital rim.1 The tear trough and lid/cheek junction correlate to the junction of the palpebral and orbital portions of the orbicularis muscle inferior to the orbital rim in the subcutaneous plane, where there is little to no fat between the skin and the muscle. Atrophy of the skin and subcutaneous fat in this area is the most likely explanation for tear trough deformity, because structures in the submuscular plane are firmly fixed to bone and do not move inferiorly with aging.2 With a greater understanding of the role that soft tissue atrophy and bone resorption play in facial aging, current management of the aging lower eyelid has moved toward volume restoration as opposed to the removal of excess skin.
In recent years, the use of hyaluronic acid (HA) to treat tear trough deformities has been described.3-7 Although techniques vary, most involve some form of serial puncture along the inferior orbital rim into the subobicularis oculi, and either layered feathering of the gel using multiple passes of the needle to create a "haystack" or the injection-withdrawal technique followed by digital molding of the filler. Most patients report good results, and the most common complications include some degree of bruising, erythema, and/or local swelling. Occasionally, nodule formation or blue discoloration from the Tyndall effect, requiring treatment with hyaluronidase, has been reported. Other rare complications described with use of fillers in the face include infection, acneiform lesions, cyst and granuloma formation, hypersensitivity reactions, necrosis, and associated vasculitis.8-15
We have been using HA to correct tear trough deformities in our practice for more than 10 years. Two physicians (Dr. A and Dr. B) used two different injection techniques, one of which has not been previously described. We compare and report our experience with both these techniques.



Written informed consent was obtained from patients participating in retrospective data collection. The study protocol conformed to current ethical guidelines according to the 1975 Declaration of Helsinki.


All patients who had been treated with Restylane® (Medicis, Scottsdale, AZ), a nonanimal stabilized hyaluronic acid (NASHA) filler, by two physicians at our clinic between January 2003 and March 2011 were contacted and their charts reviewed with regard to efficacy and adverse reactions after their treatment. Of the 194 patients treated during that period, 81 (42%) were successfully contacted and answered a series of questions from a standardized questionnaire. Ten patients declined to answer, 99 did not answer mailings or return phone calls, and 4 had an incorrect address or phone number. The information collected included age, sex, amount of filler used, treating physician, edema, bruising, erythema, infection, discomfort, pruritus, nodule formation, use of hyaluronidase, degree of improvement, and likelihood of repeating the procedure.