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Approach to Periocular Fillers


From patient position to product choice, one expert offers her approach to successfully filling the tear troughs.

This is part 2 of a 2-part series.

Part 1: Injecting the Tear Troughs

According to Dr. Barbarino, successful tear trough treatment also relies on technique.

“The key to getting it right, is making sure that the patient is upright while injecting and looking straight ahead,” she says. Again, “Make sure you have a nice scaffolding built with your midface to have a smooth transition between the midface, and the lower eyelid area.”

Sitting upright and looking straight ahead isn’t something that patients automatically do, she points out.

“[Looking up or closing their eyes] is naturally what patients want to do when you come at them with a needle [but] you'll never see how deep the tear troughs are, and… that’s when you either underfill them or overfill them,” she says.

To avoid Tyndall effect, place the product deep rather than superficial. And if you’re using HAs, she says, under inject.

“When the weather is hot and patients aren’t hydrated, it tends to swell.”

Not only do HAs work well under the eyes, they also usually last longer here than in other areas of the face, says Dr. Barbarino. In terms of product selection, the only HA she cautions about using is Juvéderm because she’s seen repeat cases of patients with prolonged edema.

“The good news is that it is easily dissolved by hyaluronidase, if this does happen to you. However, you don't ever want that to be the case—that it looked great for several months or even a couple years and all of the sudden you have this prolonged edema.”

Tips for Tear Trough Treatments

Dr. Barbarino says she’s started asking patients if they have extreme chronic sinusitis, persistent allergies, or a history of chronic water retention.

“These are the patients you’re going to really struggle with when you give them tear trough filler,” she says.

If the tear trough area swells significantly, have patients take Benadryl at bedtime. Dr. Barbarino sometimes gives patients a mineral does pack and/or Arnica Montana.

Alastin INhance also can be used to break up chromophore from hemoglobin.

Dr. Barbarino offers these final tips for rejuvenating the tear troughs:

  • Remember your anatomy.
  • Build necessary structure first.
  • Set yourself up for success by being selective with patient and treatment choices.
  • Don’t forget that each patient's face, lifestyle, and personal beliefs are different.

And finally, “Always address the lower eyelids and the midface as a single unit and not two separate units because you're never going to get the desired result if you treat them as two separate areas.”

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