Brighter Eyes: Combined Upper Cheek and Tear Trough Augmentation: A Systematic Approach Utilizing Two Complementary Hyaluronic Acid Fillers

September 2012 | Volume 11 | Issue 9 | Original Article | 1094 | Copyright © September 2012

Non-surgical rejuvenation of the periorbital-cheek complex can be effectively and safely accomplished using a combination of two hyaluronic acid (HA) fillers with distinct viscosities. We present a series of 21 patients with mild to moderate tear trough deformities who were treated with concomitant injection of two dermal fillers (Restylane® and Perlane®). Procedural technique entailed micro-depot injections of the finer viscosity HA into the sub-muscular plane along the orbital rim followed by manual massage. Secondly, injections of the thicker, more firm HA were placed in the sub-muscular and/or deep dermal spaces in the upper malar and lateral zygomatic areas and in the medial aspect of the temporal fossa. On average 0.5 mL Restylane and 0.5 mL Perlane were used per side. Statistically significant improvement in modified Wrinkle Severity Rating Scale scores was seen at 20 weeks. Overall improvement in modified Global Aesthetic Improvement Scale scores occurred in 20 out of 21 patients. Mean patient satisfaction scores increased by 2 grades relative to baseline. Patients' self-reported overall mean improvement was 2.23, indicating moderate (26% to 50%) to good (51% to 75%) improvement. Side effects were limited to transient bruising and swelling. No patients required dissolution of injectant with hyaluronidase. Overall, this combination filler procedure was found to produce both statistically significant and clinically apparent improvement and was associated with an extremely high degree of patient satisfaction.

J Drugs Dermatol. 2012;11(9):1094-1097.


In genetically predisposed individuals, cheek, periorbital, and suborbicular fat pads become atrophic over time. Simultaneously, the orbital retaining ligament also relaxes with increasing age, thus allowing further descent of the orbital fat and a resulting indentation (tear trough) between the lower eyelid and cheek. Concurrent muscle changes include elongation of the preseptal orbicularis muscle and its fascia; this causes downward displacement of the lid-cheek junction.1,2,3 All of these changes may create a hollow, tired appearance that patients often find aesthetically unappealing.
Restoration of the periorbital area entails smoothing the lower eyelid, providing medial and lateral cheek definition, and in some cases, supplementing the temporal fossae. When the lower eyelid skin is extremely atrophic and has a crepe-paper appearance, augmentation of the tear trough alone may be insufficient, resulting in surface irregularities and paradoxical exaggeration of the cosmetic imperfection. In these patients, deep cheek and temporal injections can provide anterior-posterior projection and consequential lifting of previously sagging skin that lies below the point of injection, in a manner analogous to an internal sling. Lateral and upward lift of the flaccid lower eyelid skin in turn creates shortening of the lower eyelid, and return of the lid-cheek interface to a more elevated position. Past studies and series have described use of a single hyaluronic acid filler for treatment of the tear trough.4-10 In our practice, we have found that combined injection of a less viscous (Restylane) with a more viscous (Perlane) filler into the periorbital-cheek complex provides safe and effective rejuvenation. We review a series of 21 consecutive patients who had mild to severe tear trough deformities and were treated with combination (Restylane and Perlane) soft tissue augmentation.


Two-Filler Combination Injection Technique for Lower Eyelid-Upper Cheek Augmentation

In many patients, lower eyelid and cheek augmentation can be performed together to maximize aesthetic improvement. Our technique utilizes non-animal stabilized hyaluronic acid products to recontour the periorbital and cheek regions by placing deep (pre-periosteal and sub-muscular) injections gently through the skin after dermal infiltration with local anesthetic (1% lidocaine with epinephrine 1:100,000). The filler is underneath multiple layers, including suborbicularis oculi fat, orbicularis oculi muscle, and skin.