Improvement of Tear Trough by Monophasic Hyaluronic Acid and Calcium Hydroxylapatite

Uwe Wollina, MD
Department of Dermatology and Allergology, Academic Teaching Hospital Dresden-Friedrichstadt, Dresden, Germany

Dr. Wollina has provided lectures and courses for Pharm-Allergan and Merz Pharma.

Tear trough deformities are a sign of facial aging. The anatomical base is well understood. In many patients, minimal invasive surgical procedures are useful to improve appearance. Here, the authors describe the use of monophasic hyaluronic acid dermal filler and calcium hydroxylapatite injection for correction. Forty female patients with a mean age of 50 years have been treated. On average, an improvement of one class of Hidman’s severity score could be achieved by single treatment. Mean duration of the effect was 10.1 months for hyaluronic acid and 12.8 months for calcium hydroxylapatite. Adverse effects were mild and temporary. Patients satisfaction was high (95%). (J Clin Aesthet Dermatol. 2014;7(10):38–43.)

Considering facial aesthetics, the periorbital region is one of the most important regions. Facial aging and loss of volume can be recognized easily due to the delicate structure of periorbital skin and subcutaneous tissue. Tear trough or nasojugal groove describes the concavity at the border of the lower eyelid and medial
cheek. This hollow area elicits a tired or wearied appearance. The shadow created by this groove is commonly perceived as dark circles.[1]

The tear trough represents also a border between loose tissue of the lower lid and more compact structures of the cheek. This line or border is defined by an anchoring fascia (septum orbitale) to the periosteum of the inferomedial arcus marginalis. This leads to a separation of adjacent fat compartments of the face—inferior orbital from medial cheek and nasolabial fat pads. In contrast to other prominent facial folds, there is an additional structure separating superficial and deep fat pads—the orbicularis retaining ligament.[1] This ligament is stronger in the medial portion, but weaker in the central part. With age, a further weakening can lead to herniation of orbital fat.

Recently, Wong et al[2] succeeded in isolation and characterization of the tear trough ligament. This is an osteocutaneous ligament found on the maxilla between the palpebral and the orbital parts of the musculus orbicularis. It commences medially just inferior to the anterior lacrimal crest and continues laterally as orbicularis retaining ligament.[2]

In the infraorbital region, the superficial musculoaponeurotic system (SMAS) consists of a network of small fibrous septae, which traverse perpendicularly between fat lobules to the dermis and deeply into facial muscles or periosteum. Loss of maxillary bone projection negatively affects appearance with increasing age. Severity of tear trough deformity correlates with the anterior angle of the anterior face of maxillary sinus.[3,4] Other factors contributing to an aged appearance are loss of skin elasticity, festoons, and musculus orbicularis prominence. The loss of volume indirectly contributes to the tear trough deformity,[5,6] which can be associated with lower lid eye bags. The major factors contributing to tear trough deformity can be described by the trinity of relaxation, atrophy, and ptosis. This makes the correction of tear trough deformities one of the most challenging topics for minimal invasive facial aesthetic procedures.[7,8]

Although various surgical techniques have been developed to correct tear trough deformity, non-surgical techniques have gained a wider acceptance by both patients and medical doctors.[9,10]

Patients and Methods

This is a retrospective uncontrolled trial in patients treated with dermal fillers for tear trough deformity. Patients with contraindications to filler injection were excluded.[11] To classify the severity of tear trough deformity, the author used the Hirmand scale.[8] The scale differentiated between three classes with I as the less pronounced and III as the most pronounced.

Class I is defined as patients with loss of volume limited medially. Class II is defined as patients with loss of volume also in the lateral orbital area and moderate volume deficiency of medial and upper central cheek. Class III is characterized by a full depression circumferentially to the orbital rim.[8]

All procedures were performed with protective gloves. Patients were treated in a sitting position. Make-up was removed and ice packs were placed on the face for several minutes. The area was carefully disinfected by chlorhexidine solution. The clinicians used hyaluronic acid (HA) fillers (Belotero Basic® and Glytone 3®, Merz Pharma, Frankfurt/Main, Germany) with a 30-gauge needle. The orbital rim was palpated. The infraorbital foramen was identified prior to injection since this is a no-go area. Filler injection into the foramen would cause severe nerve and artery compression. Intra-arterial injection can cause embolism with disastrous damage.

The clinicians started in the medial part below the orbital rim with deep periosteal injection and positioning the filler while moving the needle backwards. Care must be taken to avoid HA filler placement while moving the needle out of skin. Otherwise, pigmentation due to the Tyndall effect would be possible. In accordance with the Hirmand scale, further injections are placed centrally and laterally. The amount of filler was dependent on the tear trough class and individual anatomical situation. Usually, the clinicians applied 0.2 to 0.6mL. Thereafter, the area was gently massaged to smoothen appearance. Ice packs were placed onto the skin for a couple of minutes to reduce bruising.

The technique was different when using hydroxylapatite (Radiesse®, Merz Pharma, Frankfurt/ Main, Germany). The filler was diluted by 0.8mL prilocaine 1% (Xylocaine 1%®, AstraZeneca, Wedel, Germany). Serial injections can be performed with microdroplets of 0.1mL. Using a 27-gauge needle, deep vertical injections were placed every centimeter in a line about 1cm beneath the lower orbital rim. This was followed by one to two additional lines beneath with 0.5cm distance in cases of flat medial cheeks. Alternatively, this filler can also be injected during slow withdrawal of the needle (linear threading). The product needs to be placed deep to avoid nodule formation. The author prefered the microdroplets when patients had thin skin. After injection, the area was gently massaged. Overcorrection needs to be avoided. To avoid bumps and nodules, calcium hydroxylapatite should never be placed above the orbital rim. Photographs were taken before and after the procedure. A work-up was done within two to three weeks after first treatment, when necessary. Postprocedural recommendations included avoidance of unnecessary touching of the area, intense sunlight or tanning beds, and saunas for at least two weeks.

Forty Caucasian women between the ages of 32 and 90 years (median ± standard deviation: 50±11.1 years) were treated—31 with HA filler and nine with calcium hydroxylapatite. The mean age was 51±11.8 years in the HA group and 50±7.7 years for calcium hydroxylapatite patients.

The author utilized Glytone 3 in 10 patients, Belotero Basic in 21 patients, and Radiesse in nine patients. Linear threading was used in all patients with HA filler and three patients with calcium hydroxylapatite. The others were treated by serial punctures and microdroplets. According to Hirmand’s classification, six women had Class I, 20 had Class II, and 13 had Class III tear troughs.[8]

All patients improved after one procedure; two obtained a touch-up two to three weeks later (all in the HA group). The average improvement among study patients was one Hirmand class (Figures 1–6). Twelve patients who were classified as having Class II tear troughs before treatment obtained an improvement of two classes. Patient satisfaction was high. Of the 40 patients treated, 38 were very satisfied (95%).

Skin laxity and pronounced fine wrinkling had a negative effect on overall outcome. Adverse effects were seen in 25 of 31 patients treated with HA filler. The adverse effects included minor bruising (13), edema (6), and redness (6). A single patients could show several adverse effects.

All adverse effects were mild and temporary and were gone within two to three weeks after treatment without any medical intervention needed. No Tyndall effects, bumps, or nodules were seen. No hyaluronidase therapy was necessary.

In the calcium hydroxylapatite group, bruising was seen in four patients and redness and edema were seen in two patients. Adverse effects were noted in four of nine patients, but all were mild and temporary.

Duration of effect was between nine and 12 months with HA filler (10.1±2.4 months). The calcium hydroxylapatite patients achieved a volumizing effect between 11 to 15 months after treatment (12.8±3.9 months).

HA fillers have been used to correct tear trough deformity in several studies (Table 1). Vertical supraperiosteal injection of small deposits or linear threading are both recommended, although some authors found no difference between single bolus and multiple injection techniques.[12] The mean volumes necessary for corrections are low (0.2–0.6mL).[12–14] Overcorrection should be avoided.

Although the technique is safe in the hands of experienced users, adverse effects are quite common. Typical adverse effects of dermal filler injection in the tear trough include some degree of bruising, erythema, and local swelling/edema. The Tyndall effect can be avoided by placing the filler deeply periosteally.[15] A very rare complication is diplopia, which can be corrected by the use of hyaluronidase.[16] The author has seen mild and temporary adverse effects in 72.5 percent of patients. All adverse effects disappeared without any medical intervention.

Usually, the filler augmentation will last for about 10 to 12 months.[13] Using 3D photography, mean duration of volume augmentation lasted as long as 14.4 months in an uncontrolled trial (n=20) with non-animal stabilized HA.[17]

Both Glytone and Belotero are brands made of monophasic fillers, but with different cross-linking technologies. Glytone contains mannitol—an antioxidant. Belotero Basic is a monophasic HA filler with a cohesive polydensified matrix.[18] Histological studies suggest a more even tissue distribution compared to biphasic HA-fillers.[19] The mean duration of effect was 10.1 months in this study.

Calcium hydroxylapatite is a relatively new filler working not only as a volume replacement but biostimulant. It consists of calcium hydroxylapatite microspheres of a diameter between 25 to 45?m in a 70% methylcellulose carrier. The volumizing effects last between 12 to 18 months. Loss of augmentation is gradual.[20] This filler type has been used for rejuvenation of the periocular region including tear trough, but it is most important to use safe injection techniques.[21–23] For safety reasons, this filler needs a deep periosteal placement. It is unsuitable for corrections of the lips and for injections above the lower orbital rim.[24]

Dermal filler changes mechanical stress to fibroblasts and extracellular matrix. This results in upregulation of type II tumor growth factor beta-receptor, increased production of procollagen, collagen type I, and tissue inhibitor I of matrix metalloproteinase, and fibroblast proliferation, even in patients of advanced age.[25,26]

In cases of overcorrection or nodule formation, injection with hyaluronidase can rapidly resolve these problems.[27] For touch-up, the author uses an overlay of calcium hydroxylapatite by HA filler. Correction of fine wrinkles of the lower eyelid is more sophisticated. Low viscosity HA fillers with lidocaine, such as Juvederm Ultrasmile® (Pharm- Allergan; Ettlingen, Germany), are suitable, as long as the pinch test is negative. Monopolar radiofrequency technique is another option. The author prefers a series of six treatments before injection of fillers.[28]

Nonsurgical correction of tear trough deformity is a safe and effective, minimally invasive method for middle-aged and elderly women. Selection of patients is important to obtain best results. Ideal candidates are those with thick skin, those with no pseudoherniation of the lower fat pads, and those who avoid tanning beds.[29]

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