New Orleans — Hyaluronic acid is a satisfactory alternative for correction of tear trough deformity in a diverse cross section of people, and an excellent choice for tear trough volume restoration in select candidates. The best candidate is a younger person who has thicker skin and minimal to moderate volume loss, according to New York City cosmetic surgeon Haideh Hirmand, M.D., plastic surgery clinical assistant professor of surgery, Cornell Medical College.
Key to procedure Dr. Hirmand performed a study of 30 tear trough deformities in 15 consecutive patients who had volume restoration with hyaluronic acid.
"In clinical practice the key to this procedure is patient selection, and the patients who lend themselves best to it are the younger ones - in their 30s, early 40s - who just started losing some volume in the tear trough area," Dr. Hirmand tells Dermatology Times. "The beauty of this filler is that the patients who seek it (for tear trough volume restoration) and need it most are the patients who are not as good a candidate for blepharoplasty because they're younger or they're just starting to have some volume loss and they may not want surgery yet."
Study subjects The study subjects ranged in age from 36 to 59; there were 13 women and two men. The average amount of hyaluronic acid used was .2 cc medially and .05 laterally. Fitzpatrick skin types one through four were represented, and five patients, or 30 percent of the group, had previous blepharoplasty.
Preoperatively the subjects were categorized as having morphology that was either limited to the tear trough, extended to the lateral area or "full." Tear trough depth was ranked zero through five and skin quality was ranked one through three.
"The morphology distribution was basically 30 percent, 30 percent and 30 percent, so all three of the morphologies were represented," Dr. Hirmand says.
Most of the patients had depth of tear trough category two and three; and all skin thicknesses were represented.
All of the patients had an infra-orbital nerve block. They were evaluated for pain, ecchymosis, edema, irregularity and visibility of filler after the procedure, and then at one, three, six and nine weeks, and monthly thereafter. Overall appearance, patient perception and complications were also noted.
"At each follow-up visit we looked at the depth of the tear trough and the estimated percent of correction and morphology," Dr. Hirmand says.
The tear trough deformity was down-staged by one or two categories in every patient after the procedure.
How performed Dr. Hirmand performs the procedure with a blunt-tipped cannula rather than a needle.
"I used a 27-gauge, custom-made stainless steel blunt cannula, and inject medially to laterally in a very deep plane beneath the muscle," she explains. "There are misconceptions about the tear trough anatomy. Something to remember is that the tear trough is at or below the rim in 100 percent of cases, so you don't need to inject above the rim or into the globe. If you use a blunt cannula and do that, the safety factor increases significantly."
In every case the depth and appearance of the tear trough was improved, according to Dr. Hirmand.
"All except one patient was satisfied," she says.
The effect remained stable at six months, and after that there was gradual loss of effect.
"There was individual variation; however, the majority still had their full correction at six months and 60 percent to 70 percent of their correction at one year. So, as I see it, there is some persistence of this filler in this location at one year," Dr. Hirmand says.