Nurse prescriber Anna Kremerov describes successful treatment of the under-eye area using a non-direct approach
A 52-year-old female patient presented to my clinic with concerns of dark under-eye circles and acute skin laxity in the infraorbital area, following years of yo-yo dieting, lack of sleep and stress. She asked for a tear trough correction to achieve the desired outcome. She was otherwise healthy, with a history of light smoking.
When I assessed her full face, I could see she has a good lateral cheek projection. However, she was quite clearly hollow in the anterior cheek, and this had exacerbated her under-eye appearance. In addition, her overall tired look was enhanced by facial laxity and formation of superficial rhytids in the infraoribital region. Following assessment, I concluded that a single treatment with a direct approach to treating her tear trough area could fail to meet the patient’s desired aesthetic outcome, and a different approach was needed to achieve the long-lasting periorbital and facial rejuvenation, along with natural-looking results.
It's imperative to understand that the cause of tear trough deformity is multifactorial, and isolated treatment may not be sufficient to achieve a good aesthetic outcome.1 The main components of the tear trough are the periorbital hollow itself, superior fat bulge, a distinct change of skin colour and skin thickness in the eyelid-cheek junction.2
Accordingly, my strategy in treating this patient was to replace the facial volume as well as to improve dermal thickness and elasticity in this area. By replacing the volume in the mid-cheek fat compartments it's possible to create adequate support to the tear trough area with an indirect appraoch and, based on my experience filling this area, improves infraorbital hollows directly.
Different approaches, along with their advantages and disadvantages were discussed in detail with the patient. A two-week cooling-off period was implemented before agreeing to go ahead. It was important that she could think carefully about each of her options, weighing the benefits of each against the possible risks and side effects.
Options presented included collagen-stimulating filler, hyaluronic acid-based fillers, botulinum toxin injections, skin boosters and mesotherapy, skin resurfacing procedures such as IPL treatment and laser skin resurfacing. All of them are excellent treatments; however, when I asked the patient about her eye area, she mentioned that she gets swelling of the region in the morning. Added to the poor elastic recoil, this made me reluctant to treat her tear trough area directly with HA filler, as per my original plan. While the patient knew very little about collagen depletion, she was keen to learn more about how a collagen-stimulating filler could help.
Unlike HA, PCL particles cannot be dissolved so I explained this thoroughly to her, paying special attention to the product specification. She was then happy to proceed with the recommended course of treatment. She was informed of the possible risks prior to the procedure, and an individual treatment plan was defined prior to the procedure.
My product of choice was Ellansé M. This is because it works not only by volumising and correcting superficial rhytids but also by atimulating the bodys own collagen for a long lasting, natural result.3,4 Ellanse is a collagen biostimulator composed of a totally bioresorbable
polycaprolactone (PCL) microspheres in a carboxymethycellulose carrier
gel.4 It offers immediatley visible results, and it's
complete bioresorbability make this product suitable for patients
seeking long-lasting and stable results.
The patient was treated in a sitting position. Makeup was removed prior to the procedure, and the area was carefully disinfected with Clinisept+ Prep & Procedure. The orbital rim was palpated and marked. The infraorbital foramen was identified and marked prior to injection, as this is a no-go area to avoid severe nerve and artery compression and embolism.
On examination, there was a noticeable volume deficit in the anterior part of her cheek, so I made the decision to target this area to volumise and improve the patient’s infraorbital hollows indirectly. We agreed to treat the anterior part of her cheek and check what degree of improvement we can get in the infraorbital region with an indirect approach.
The procedure was performed with protective gloves. To facilitate a more comfortable procedure, I mixed 0.2ml of lidocaine 2% with each 1ml syringe of the product, and it can be safely performed without altering the physical properties of the product.5 The depth of injection always depends on the facial area treated and the result I am trying to achieve. In the malar area, a combination of retrograde injections and small boluses performed in the deep supraperiosteal plane, with 0.05-0.1ml per line/bolus using a 25 gauge cannula. In this case, I used 0.5ml on each side. From the same cannula entry point, treatment was extended to the zygomatic malar region on the periosteal plane to provide a soft contour to the lateral cheek area, with 0.5ml administered on each side.
The submalar region was treated from the same entry point in the subcutaneous plane using a retrograde linear threading and fanning technique, with 0.05-0.1ml per thread. A total of 0.4ml was used on each side. More superficial placement of the product in the subdermal plane with the same size cannula was used to achieve a biostimulation, in order to increase collagen production within the dermis and address subdermal volume loss.3 This technique was utilised over the mid-face region, with 0.6ml used on each side.
In this case, I used a single entry injection point to achieve desirable volume replacement, with a total on 4ml injected; 2ml on each side.
My preferred technique is a single-point entry using a cannula, which allows me to achieve a whole mid-face revolumisation. I believe using a cannula is a safer and more comfortable technique for the patient, which could also decrease the risk of potential side effects such as bruising, vascular compromise, bleeding and ecchymosis.6,7 With any technique, I always use my non-injecting hand to palpate the skin and avoid overcorrection. It is also important to inject the product slowly with small boluses and to watch the tissue as you inject to see how much filling has been created.8
The possible side effects observed with the PCL-based filler are identical to the HA-based fillers and can be associated with a risk of short and long-term complications such as oedema, bruising, vascular compromise, nodules and granuloma formation.8 It’s imperative to discuss post-procedural care with the patient and to highlight the importance of the aftercare in the prevention of some adverse events. Following treatment, patients are advised to avoid makeup, exposure to heat or extreme cold, keep their face clean, avoid alcohol and physical activity for the next 24 hours.8,9
At the three-month review, the patient remained extremely happy with the results. By replacing the volume in the mid-cheek deep fat compartments, I have managed to create an adequate support to the tear trough area with an indirect approach and improve infraorbital hollows indirectly. Thanks to the unique product properties, further collagen biostimulation will help patient to improve facial laxity by stimulating the body’s own collagen for a long-lasting, natural result.