>75% clearance = 4. Clinical grades ranged from 1 to 4, with
an average score of 2.5, corresponding to approximately 50%
improvement 9 weeks after laser resurfacing Posttreatment
melanin readings (mean value = 1.14) were not significantly different
from those obtained preoperatively (mean value = 1.25),
and thus did not correlate with the favorable clinical findings
seen. Four patients experienced transient infraorbital hyperpigmentation
postoperatively lasting 8 weeks.37
Another study used a CO2 laser followed by a Q-switched alexandrite
laser, effectively targeting pigmentation in the dermis
and epidermis.38 Several authors including Tierney, Hanke, and
Moody have commented on the effectiveness of nonablative
fractional photothermolysis (FP) for the treatment of POH.36,38
The fractionated 1550nm erbium doped fiber laser creates
microscopic, pixels of wounding in the dermis results in significant
skin pigmentary and textural improvements without
the adverse effects of prolonged wound healing and risks of
dyspigmentation associated with traditional ablative resurfacing.
39 The nonablative fractionated 1550-nm erbium-doped
fiber laser been proven to treat a variety of pigmented conditions
effectively, including photoaging and melasma. The
proposed mechanism of action is fractionated photothermolysis
with preservation of the stratum corneum while creating
microscopic treatment zones (MTZs) of thermal injury in the
epidermis and dermis.39,40 The laser functions to eliminate
melanin pigment from the epidermis and dermis through a
“melanin shuttle,†which exudes the pigment from the skin
through the MTZs.40,41 Moody et al, reported one case of a Fitzpatrick
II female diagnosed with POH who underwent four non
ablative laser treatments spaced out at 4 week intervals with a
1550nm fractionated erbium-doped fiber laser over a 4 month
period. They used a 15mm spot, energy fluency of 70 J/cm2
treatment level of 10-11, 4 passes for a total surface area coverage
of 29-32%. This was used in conjunction with a Zimmer chilling cryo system that kept the epidermis cool during the
treatment. Two months after the last treatment the physician
and patient noted significant improvement of the POH.40 What
must be stressed in this successful case report is the skin type
of the patient and these settings must be readjusted in skin of
color patients (Case 1 and Case 2). In 2010 a consensus panel
of experts convened to communicate best practices for fractional
photothermolysis42 Ruiz Esparza examined the efficacy
of nonablative radiofrequency (NARF) to tighten noninvasively
the skin laxity of the lower eyelids by treating the periorbital
area.43 Nine patients with skin flaccidity of the lower eyelids had
a single treatment session with NARF in a small area of skin in
the periorbital region, specifically the zygomatic and/or temporal
areas. His results indicated that all of the nine patients in the
study achieved cosmetic improvement of the eyelids ostensibly
through skin contraction. All patients were able to return to
their normal routines immediately. Results were gradual and
patient satisfaction was remarkable. No complications were
seen in this study. He concluded that NARF was successful in
providing a safe, noninvasive, cosmetic improvement in patients
with excessive skin laxity of the lower eyelids. Similar
findings for NARF were also seen in 2008 by Sukai.44
Injectable Filler
While there have been no randomized controlled studies analyzing
the effectiveness of treating POH in isolation, there is
evidence based medicine that dermal fillers have shown efficacy
in repairing the tear trough deformity that may be an
important contributing factor to some cases of POH especially
in the skin of color patient. Carruthers, Sadick, and others have
worked to classify this complex and multidynamic area.45,46 The
European and North and South American aesthetic experts
convened at an academic workshop to develop keys to optimal
outcomes.47 The best practice guidelines recommended from
the consensus group for midface and infraorbital hollow injections
were the vertical supraperiosteal depot technique (VSDT)
or linear threading for infraorbital hollow augmentation.48
Sharad has recently done a comprehensive review of the tear
trough anatomy, treatment techniques, and clinical outcomes. I
recommend the reader to this article.49
Ten Clinical Pearls for Tear Trough Injection
- It is an advanced technique not for novice injectors
- The skin should be sanitized with antiseptic and gloves should be worn throughout the session.
- Caution with injecting too quickly either with needle or cannula.
- Low-viscosity HA can be safely injected to correct tear trough deformity. High-viscosity HA and permanent fillers should be avoided and only done in the hands of an experienced injector.