Independent nurse prescriber Anna Kremerov provides a case study of a tear trough complication and how she corrected it using dermal filler
In the realm of aesthetic medicine, rejuvenating the under-eye area is a crucial aspect patients often want addressed.
Tear trough injections, employed strategically, can work wonders in diminishing unsightly dark circles and hollows beneath the eyes, restoring a youthful and refreshed appearance. However, practitioners should treat with caution.
This procedure, whilst transformative, is also notorious for its complications, especially when administered by less experienced/unqualified practitioners. Common signs of complications include, but are not limited to, persistent swelling, lumps, asymmetry and discolouration.1
In this article, I will present a patient case of a tear trough complication after a non-qualified practitioner administered dermal filler in this area.
A 38-year-old female patient underwent a tear trough treatment with dermal filler performed by a non-medical beauty therapist. The patient had concerns surrounding the darkness of her under-eyes and wanted this area to be rejuvenated.
Unhappy with the results, she returned to the practitioner six weeks later to request that the filler was dissolved. The practitioner was unable to perform a hyaluronidase treatment, so sought help from their trainer, who was a beauty therapist at a beauty academy. The dissolving procedure was unsuccessful, and in fact, my patient felt it had made matters worse. Therefore, she presented to my clinic the following week.
The patient was tearful and told me she didn’t recognise herself and did not want other people to look at her. She pointed out blue areas under her eyes and hollows in her cheeks that she believed were more visible than prior to the initial treatment, which is a sign of Tyndall effect (Figure 1). She was also concerned about darkness under her eyes, all of which she had originally sought treatment for but felt had worsened through the dermal filler procedure and dissolving.
During the initial consultation at my clinic, I asked the patient whether she knew what dermal filler product was used. She believed that the brand administered was of good quality, and I confirmed that this was the case. The patient was also unsure which dissolving product the therapist used. It is challenging to ascertain whether the products were sourced through a licensed UK pharmacy/distributor which ensures the authenticity, quality and safety standards of the product. Without concrete verification, it is critical to approach such cases with caution.
Alongside this, the level of training from a non-experienced and non-medical practitioner is considerably variable and may not adhere to the rigorous standards expected in medical aesthetics. In my opinion, both factors combined could account for the unsuccessful outcome the patient experienced following her treatment.
In situations such as this, I would usually refer patients back to their initial practitioner. However, I didn’t feel it was ethically acceptable to refer her back to a non-medical beauty therapist and by this point, the patient had lost faith in her practitioner, so was reluctant to return.
As the initial dissolving procedure was performed a week prior to her appointment with me, it was important to wait at least three weeks to allow the treated tissue to settle down, for swelling to reduce and for all the previously injected filler to be completely dissolved.2 It was also pivotal to wait as sometimes the body dissolves its own hyaluronic acid alongside the filler, which means some patients initially appear to have more hollowness than after three weeks’ healing time.2 I advised that she return to the clinic in two weeks’ time. I was certain that after this time period, we would conduct a further procedure, taking into consideration she had already had the dissolving treatment.
After two weeks, the patient returned to clinic. However, there was still some puffiness around her eyes. Upon examination, I used the Clarius L20 handheld ultrasound device, and noticed that some dermal filler was still present, although it was difficult to be sure as I had no prior records or good quality pre-procedure photographs. I advised her that rather than undergoing a new treatment, we should first dissolve any remaining filler that might be exacerbating her issues.
The emotional toll of her previous experience was evident, as she exhibited distress over the results. The challenge lay in not only addressing the aesthetic concerns, but also rebuilding her confidence in medical interventions after a disappointing experience. It is paramount to provide an informed and compassionate approach to ensure the best outcome for the patient’s needs.
To ensure her safety and to minimise the risk of an allergic reaction to the dissolving agent, I conducted a sensitivity patch test.3 This involved an intradermal injection of four to eight units of the hyaluronidase solution to the forearm. After observing no adverse reactions for more than 30 minutes, indicating she was not allergic or hypersensitive to the agent, we proceeded to dissolve the remaining filler.3
Afterwards, we waited another three weeks before beginning a new treatment plan. Based on the literature, it is common practice to wait two to three weeks before re-injecting fillers after hyaluronidase treatment.2 This waiting period allows for full restoration of swelling, possible inflammation and ensure that all the previously injected filler has been completely dissolved.2
After the three weeks, I would proceed to address her infraorbital hollows – the result of both her anatomical structure and age, which had caused her to lose some volume in the fat pads of the anterior part of the face. We also decided to restructure the whole anterior medial cheek and proceed to her tear troughs if necessary.
Prior to dermal filler treatment, I fully assessed the patient’s periorbital area and identified a negative vector, with a decrease and recession of the frontal mid-malar volume. Infraorbital fat had a visible degree of prolapse, which gave the appearance of eye bags. There was no infraorbital hyperpigmentation contributing to the visible depth of the tear trough. The patient’s snap test (highlighting the patients’ skin elasticity) was negative. She had class two periorbital volume loss using Hirmand’s classification.4
For the treatment, I used MaiLi dermal fillers from Sinclair. I particularly like treating my patients with MaiLi because it is subtle and dynamic – it moves with the skin, muscle and facial expressions, and when correctly placed, you can achieve natural results.
The first step was to restore the patient’s suborbicularis oculi fat (SOOF) using MaiLi Volume, injecting 0.2ml per side with a 27 gauge needle for a supraperiosteal bolus to the Y spot.
This was followed by 0.6ml of MaiLi Precise to the right SOOF and 0.8ml to the left SOOF with a 22 gauge cannula. The cannula entry point was at the intersection of the vertical axis through the lateral canthus and the nasotragal line. This allowed me to access the medial aspect of the tear trough and SOOF. MaiLi Volume was deposited in the retrograde linear threading technique on the supraperiosteal label.
Afterwards, I used 0.4ml of MaiLi Precise to the patient’s right side and 0.6ml to her left side using a 22 gauge cannula supraperiosteally in her medial tear trough area with linear retrograde injections and micro bolus (Figure 1).
I always use a cannula rather than a needle, conducting a retrograde threading technique. Utilising a cannula offers a few advantages when performing this technique. A cannula’s blunt tip reduces the risk of puncturing blood vessels, minimising vascular complications, bruising and swelling post-procedure.5,6 In my experience, when employing the technique, the cannula also facilitates a smoother, more even distribution of product, helping to ensure a natural and harmonious result.
Both fillers were inserted on the bone; MaiLi Extreme was injected at the periosteal level for the reconstruction. I also used a sandwich technique to correct the volume deficiency in the mid-face fat pads.
I gave the patient detailed post-treatment information as well as descriptions of the red flags to look out for so the information will stick with them, including the worst possible scenarios like vascular occlusion. In an emergency, I am accessible 24/7, so they know how to contact the clinic. The patient was also advised about more common side effects, such as bruising and swelling. I also gave the patient written information on exposure to sunlight, the medications which were safe to take and how not to aggravate the bruising or swelling.7
When the patient returned to the clinic two weeks later, she was happy with the results and very thankful.
Complications from aesthetic procedures, especially those conducted by unqualified and non-medical practitioners, can have both physical and emotional ramifications for patients. When patients present with issues such as exacerbated under-eye circles, hollowness or adverse reactions from prior treatments, practitioners must approach with caution and thoroughness.
If practitioners encounter similar complications in their clinics, it is paramount to prioritise the patient’s wellbeing, opting for safer and more effective techniques, and provide holistic care that addresses both the physical and emotional toll of previous unsatisfactory treatments.
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