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HA augmentation: natural, persistent rejuvenation


Left: Pre injection. Middle and right: Post injection with 1 cc Restylane.
International report — Injection of a non-animal stabilized hyaluronic acid filler (Restylane or Perlane, Medicis) offers a simple, safe and highly effective technique for reproducibly achieving natural and long-lasting rejuvenation of lower eyelid hollowing, Lisa E. Airan, M.D., and Trevor M. Born, M.D., tell Cosmetic Surgery Times.

Together, Dr. Airan and Dr. Born have accrued a series of approximately 750 patients who have undergone this novel, nonsurgical lower eyelid lift procedure involving injection of the filler material along the inferior orbital rim and malar bone.

They reported on the technique and its outcomes in an article published last year (Plast Reconstr Surg 2005;116:1785-1792), and Dr. Airan has demonstrated it on national TV on The Oprah Winfrey Show.

Lasting outcomes

Their collective experience highlights the procedure's many advantages.

It is performed in an in-office setting in less than an hour, is associated with minimal morbidity and downtime, and improves the contour of the periorbital region to confer a younger-looking appearance with results that can last from eight months to two years.

"Historically, facial cosmetic surgery procedures focused on pulling and tightening, but there has been a recent evolution in principles with a shift in attention toward the importance of volume restoration. This filler procedure is an outgrowth of those newer principles and an extension of our positive outcomes using these hyaluronic acid fillers for augmentation in the lower face as well as with deep microfat grafting to rejuvenate the periocular region," says Dr. Born, clinical lecturer, division of plastic surgery, University of Toronto, Canada.

"In contrast to (fat grafting), injectable hyaluronic acid filler use eliminates the need for a harvesting procedure, and, in our large combined series, it has consistently resulted in favorable cosmetic outcomes that are equivalent to or surpass those seen with more invasive surgical procedures for periocular rejuvenation — but with minimal morbidity. Equipped with thorough knowledge of local anatomy, plus proper training in injection technique, we believe other surgeons as well may offer this procedure and its benefits to their patients."

"Loss of volume around the eye contributes to an aged and tired appearance," notes Dr. Airan, a clinical instructor of dermatology, Mount Sinai School of Medicine, New York. "As one of its key features, the hyaluronic acid injection affords patients a refreshed and much more youthful appearance without any evidence that they have undergone a cosmetic procedure."

Delivery technique paramount

The filler is delivered deep into the infraorbital hollow and nasojugal groove, beneath the periosteum and overlying the bone.

Its placement in that plane fills the space to improve the contour of the lid-cheek junction while minimizing the chance that the injected material will be visible or palpable.

The patient is first carefully marked in an upright position, and then anesthetic is infiltrated into the periosteum. Dr. Born notes articaine with epinephrine is preferred because the anesthetic is very fast-acting, while the vasoconstricting effect of the epinephrine minimizes the risk of post-treatment ecchymosis. A minimal volume of anesthetic is delivered to limit tissue distortion.

After waiting 20 minutes, a 30-gauge needle is inserted bevel down at the most lateral aspect of the orbital rim hollow until the tip reaches bone. Then, the material is injected slowly in a threading technique as the needle is advanced across to the medial side where particular care must be taken to avoid puncturing the infratrochlear vessels. The total volume delivered averages from 1 cc to 1.5 cc per eye with no more than 0.1 cc injected at each site before the needle is advanced.


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