"There is a place for Restylane in the treatment of the tear trough, but only through the correct approach and in good candidates," said Haideh Hirmand, M.D., at the American Society for Aesthetic Plastic Surgery's (ASAPS) Aesthetic 2005 meeting here. "This approach is being put on the forefront because younger and younger patients are looking for correction, and the beauty of (using Restylane in the tear trough) is that those who are seeking it are probably the best candidates. Additionally, the non-permanence is a distinct plus in the dynamic region."
Overcoming concerns The proximity of the eye and the fact that many surgeons are leery of using needles to treat the tear trough is causing a slow acceptance of Restylane use in this area, according to Dr. Hirmand. But with the correct technique, the tear trough can be treated effectively, with amazing results."Understandably there are concerns about reported cases of blindness that have occurred due to the injection of fillers with needles around the eyes and in the face. This risk can be eliminated," says Dr. Hirmand of The New York Presbyterian Hospital and Manhattan Eye, Ear and Throat Hospital in New York and clinical assistant professor of surgery at Cornell Weill Medical College. "I don't use needles, rather I use a custom-made blunt delivery device, which is a stainless steel, 27-gauge, one-half-inch cannula. The blunt cannula allows me to deliver the filler in a deep plane."
"Going deep" is critical to Dr. Hirmand's success in the tear trough area, with the blunt cannula placed immediately supraperiosteal just below the rim under the area of the deformity. While there may be a misconception that the injection needs to be in the globe, it should be clarified that the tear trough deformity is below the infraorbital rim 100 percent of the time except in the most medial part where it is on the rim, Dr. Hirmand says.
Recent review In a recent review of 30 tear troughs in 15 consecutive patients, the medial tear trough was treated with an average of 0.2 cc, and the lateral area was injected with 0.05 cc to 0.1 cc.
"If I look at all of the patients I treat with this technique now, I probably use a little more than I used in the study," Dr. Hirmand says. "But, even with the average amount, we saw impressive results."
The study found the best candidate for treatment of the tear trough with hyaluronic acid is the younger patient with thicker skin and minimal to moderate volume loss in the area. High-risk candidates who are prone to complications are older patients with thin skin, extreme volume loss in the tear trough or periorbital area. Adverse reactions included: ecchymosis to varying degrees lasting on average five to seven days in 50 percent of patients; overall edema in all patients, which resolved in several weeks at most; irregularities (20 percent), which were minor and localized in patients with good skin tone, and most likely represented some persistent edema in patients in whom they resolved expeditiously; and visibility of the implant in patients with extremely thin or adherent skin. Most of the potential morbidities of the procedure can be minimized with good patient selection.
"We see relative stability at six months, with the first touch-up requested at seven months," Dr. Hirmand says. "It is important to note that the loss of correction is gradual and there is some variability — after six months many patients are fine, and some continue to maintain enough correction at one year. They may have initially been 95 percent corrected, but at seven months they're 85 percent corrected. The correction is still better than before."
Patient satisfaction Overall, there was a high degree of patient satisfaction, and all patients perceived their deformity as improved, according to Dr. Hirmand.