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Indications
Indications
For the lower eyelids, the tear trough is a predominant aesthetically displeasing feature
that can often be corrected with HA tissue augmentation. Tear troughs are often caused by tissue thinning constrained by the orbitomalar ligament.56 The tear troughs are frequently defined as the nasojugal fold;57โ61 however, some prefer the term deepened nasojugal groove.62 Other lower-eyelid deformities that may benefit from soft-tissue augmentation include the palpebromalar groove, ectropion, and lid retraction.63,64 Tissue augmentation in either the lower eyelid or adjacent regions such as the medial cheek can improve not only the contour, but also โcrepeyโ skin, dermatochalasis, and static and dynamic rhytides.65 A prospective study of 12 patients with tear troughs showed that treating the tear trough directly offers greater improvement when compared with treatment in the cheek alone.66 BTX-A may improve dynamic and static rhytides in the lower-eyelid region, especially when combined with crowโs feet treatment.67 BTX- A has been successfully used to treat lower-eyelid senile entropion, blepharospasm,69,70
epiblepharon, dry eyes and to widen the eye aperture, especially in Asian patients.73
Fillers HA products with lower viscosity and hydrating capacity are desirable in this region in order to minimize the risk of the Tyndall effect, edema, and product lumping. Juvederm Volbella, Restylane Refyne, Restylane Fynesse, and Belotero Balance are a few examples. Supraperiosteal placement was recommended for the nasojugal groove. In addition, lower-eyelid supraperiosteal and subcutaneous contouring can be performed, especially for tear troughs related to aging.27,48 Subcutaneous placement may also be used to address rhytides and skin-quality-related changes.48 The risk of edema and Tyndall effect is thought to be higher with superficial product placement.
Serial microaliquots or linear threading with blunt 27 or 25 1ยฝ-in gauge cannulas or sharp 30 or smaller needle injections can be used for supraperiosteal placements to restore volume loss in the tear troughs/nasojugal folds, or the palpebromalar groove. The entry point for microcannulas can be located approximately 1 in below either the medial or lateral canthal commissures.29 Supraperiosteal filler placement should be done inferior to the orbital rim below the level of the orbicularis oculi muscle.
Sharp needle injections with retrograde threading, microaliquots, or cross-hatching might be more appropriate for subcutaneous placements to treat lower-eyelid static rhytides. Sandwiching the orbicularis oculi as described in the lateral canthus region can be performed to achieve better aesthetic outcomes for both dynamic/static rhytides and skin texture.48