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
Hyaluronic acid (HA) can be used to correct volume loss associated with periorbital aging.
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.
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.
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
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.
MATERIALS AND METHODS
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.