Treatment of the infraorbital area is one of the most requested areas from those seeking aesthetic facial improvement. The use of hyaluronic acid (HA) fillers to restore volume loss in the infraorbital hollows (IOH) has become a popular nonsurgical treatment. In fact, Juvéderm® Volbella® from Allergan Aesthetics, an AbbVie Company, recently gained FDA approval for this indication.
However, the under-eye area poses a challenge to most physicians due to its high risk for swelling. While post-procedure swelling is normal and occurs with fillers in all locations, small, tightly bound spaces such as the lips and the IOH – which is bound by the malar septum, the orbital retaining ligament (ORL) and the zygomatic cutaneous ligament (ZCL) – are especially susceptible.
In 2013, I started injecting the IOH,
and for those patients that could not afford any social downtime, I combined 1 mg of triamcinolone (TAC) to the filler to decrease the incidence of swelling after injection. From 2013 to 2020, I injected the IOH of over 700 patients, with over 250 of them receiving TAC. There were no cases of skin atrophy, problems with vision, skin ulceration, changes in blood glucose, or hypopigmentation, and the addition of TAC decreased patient reports of swelling by more than half.
The mechanism of action of steroids is multifactorial. Corticosteroids decrease the permeability of vessels and reduce the inflammatory reaction. And while oral steroids are effective and inexpensive, at high doses for prolonged periods, their side effects are considerable (diabetes, osteoporosis, hypertension, gastritis, depression, insomnia, weight gain and skin thinning).
Conversely, short-term local steroids are commonly used without side effects in both dermatology and ophthalmology for acne cysts, chalazion, psoriasis, keloids and hemangiomas.
It is important to be aware of, and educated about, several rare case reports in which injection of triamcinolone alone, directly into the eyelid with a needle, at high doses caused serious side effects such as iris depigmentation and retinal occlusion.
While these side effects need to be taken seriously, our technique recommends 1 mg of TAC mixed with the filler and injected over a large area with a cannula in an area distant and inferior to the eyelid. The recommended 1 mg dose is diluted in 1 cc of filler and is 1/40th or less than the doses causing the aforementioned side effects. In addition, since the particle size of HA filler is larger than the average particle size of triamcinolone, the addition of triamcinolone to HA filler should pose no additional risk for occlusion.
There are other considerations when injecting the IOH to decrease swelling such as selecting the correct filler, as the hydrophilicity of some fillers can lead to significant fluid attraction. I use only Restylane-L® from Galderma Laboratories, Juvéderm Volbella XC, Belotero® (Merz Aesthetics) or RHA®2 from Revance Aesthetics. In addition, limiting the trauma to the
area and reducing the volume of filler will assist in reducing swelling post-procedure. However, even if low doses of the correct filler are used, about half of patients will still experience swelling which is why TAC is offered.
For those receiving TAC, 1 mg of triamcinolone ace- tonide (0.1 mL of kenolog 50 mg / 5 mL) is pulled into a 1 cc syringe and then pushed into a connector to fill the center entirely, then the filler is attached to the other end and the filler is mixed back and forth approximately ten times until it appears to have a uniform color throughout the syringe. The filler/TAC mixture is then entirely drawn back into the original syringe and a cannula is placed for injection.
About the Author
Robyn Siperstein, MD
Dr. Siperstein graduated from Yale University and then went on to Yale University School of Medicine. She became board certified in 2008. In 2010, she founded a practice that mirrored her values of offering the highest level of patient care and has since grown her practice to include other board-certified physicians and staff members that share her passion. Dr. Siperstein enjoys sharing and expanding her knowledge through teaching and research.
