Periorbital aging has been identified as one of the most important aesthetic concerns of the face, so that lower eyelid rejuvenation has become a topic of major interest. Not every patient requires surgical blepharoplasty and selected lower eyelid problems and defects due to the aging process have been treated with hyaluronic acid (HA) gel injections since 2004. With this as the premise, the current work serves to review the published medical literature on the use of HA for lower eyelid and tear trough rejuvenation. A PubMed search was carried out in May 2020 using the search terms: “Tear trough [and] HA [and] filler”; “Tear trough [and] HA”; “HA [and] lower eyelid [and] filler”; “HA [and] lower eyelid”. A large number of relevant studies were identified. Surgical management remains the gold standard for lower eyelid rejuvenation but increasingly, non-surgical correction of selected deformities with HA injection may provide a reliable option based on the available evidence. Further, prospective randomized controlled studies and systematic reviews of the literature are nevertheless desirable and a standardized, widely accepted grading system of the deformity and its treatment outcomes will allow us to codify this procedure better.
The eyes are located in the centre of the face and are crucial to its aesthetic appeal. It is therefore of major concern to patients. Because minor changes to the eyes can yield dramatic results, many aesthetic procedures have been described, such as brow lifting, autologous fat transfer, surgical excision, chemical peels and lasers.
The nasojugal fold was first described by Loeb[
However, Flowers[
The treatment options to correct a hollow, lower lid area have since been further developed: Hamra
The aforementioned techniques represent different degrees of invasiveness while non-surgical options allow treatment of dark pigmentation but do not successfully treat sunken lower eyelids[
Proper understanding of the role of the orbitomalar ligament in tear trough deformities, as well as of progressively worsening midface ptosis[
Hyaluronic acid (HA) gel injections were first used for this purpose in 2005[
As long as the non-surgical procedure does not violate the key anatomical structures and relationships of the lower eyelid, it can be adopted in properly selected patients as a simple method to accomplish its rejuvenation. Not every patient requires a surgical blepharoplasty to meet their needs and selected lower eyelid deformities and defects due to aging can still be treated easily, safely, and quickly with HA injections.
This study has thus been carried out to review the published medical literature on the use of HA for lower eyelid and tear trough rejuvenation.
A PubMed search was performed in May 2020 using the strings: “Tear trough [and] HA [and] filler”; “Tear trough [and] HA”; “HA [and] lower eyelid [and] filler”; “HA [and] lower eyelid”, which yielded a total of 242 indexed articles.
Results were limited to human subjects, in clinical trials, randomized controlled trials, case reports, comparative studies, controlled clinical trials and multi-center studies.
No limits based on the year or language of publication was applied.
Manual review of abstracts was also performed to omit unrelated articles.
The final result included 66 articles from 2005 to 2020.
There were eighteen prospective studies[
Among the published papers, there has only been one randomized controlled study[
A systematic review presented with a meta-analysis[
Eight review articles have been written, the first in 2007[
Twenty-nine papers are case-series[
Retrieved articles: study type. RCT: Randomized Controlled Trial; CT: Controlled Trial; System. Review: Systematic Review; Comparative: Comparative Study; CS: Case Serie; CR: Case Report
The mean recorded follow-up was 18.2 months[
The study of Airan and Born[
Among the investigated articles which directly mentioned the study population[
Since 2012, three papers have been published with regard to anatomical topics: interestingly, those published in 2012[
Two articles provided a classification system for tear trough deformities, along with a review of the available treatments[
Complication-related papers have been published since 2012[
Research focused on personal techniques purposed by the authors have been published since 2005. Airan and Born[
Anaesthesia has been used both by local infiltration[
Injections performed by needle have been described since 2005 up to 2019[
The injection depth is reported to be carried out directly at the orbital bony border[
Of the 66 studies included for analysis, the majority[
In 2010, two papers on objective and validated measurements of the achievable results of non-surgical tear trough rejuvenation as assessed by digital 3D photographs and cutometer were published[
This review of the medical literature on HA use for lower eyelid and tear trough rejuvenation identified a large number of related studies.
The average study population was 71.37, ranging from 3[
It is remarkable that the first two papers ever published on the topic already had 6.5 months of retrospective follow-up of 400 treated patients[
Even though the lower eyelid and tear trough are considered difficult sites to be injected, only two papers focused on related anatomy were published in 2012[
Anatomy and technical note focused articles: publication trend
The first papers focused on complications arising from lower eyelid and tear trough HA treatment were published in 2012 by Dayan
Articles focused on complications have since been constantly published[
Complication focused articles: publication trend
However, adverse events are occasionally reported in articles that are not directly related[
The most commonly reported complications include the Tyndall effect[
Minor or rarely reported complications secondary to lower eyelid and tear trough HA injections are orbital cellulitis and migraine[
Reported complications
The injection of an adequate dose of hyaluronidase has always been reported to be the best treatment[
Indeed, publications on injection techniques constitute the majority[
Local anaesthesia has been widely used, either topically[
Nevertheless, some authors did not report the use of any form of anaesthesia for this treatment[
In order to avoid the complications above, it is mandatory to inject only a small quantity of HA, as the reported average amount has been 0.56 mL, whilst ranging from 0.2 mL[
Based on personal experience, the authors suggest injecting a lesser quantity of 0.2 mL to 0.45 mL per session[
The authors’ preferred techniques are direct injection on the periosteum (GS) and retrograde injection technique deeper than the orbicularis muscle (AD).
The first requires the identification and protection of the infraorbital foramen with gentle finger pressure, followed by insertion of a 30-gauge needle into the deepest portion of the tear trough, which is always treated first by injection of the HA gel as a single bolus on the bony surface. The injected area is then gently massaged to create a natural shape and then assessed for further injections, if needed.
When a cannula is preferred, the entry point is located at the intersection between the vertical line passing through the external canthus and the line marked by the tear trough. Once inserted, it should pierce the orbicularis oculi muscle, and advanced until it reaches the bony orbital ridge. The infraorbital foramen will therefore be located deeper than the injection plane.
The cannula should then be moved medially toward the inner canthus and small amounts of HA are injected retrograde. Touch-up has been necessary within 1 month in around 20% of cases treated with cannula, normally requiring further injection of 0.1 mL to 0.3 mL of HA in order to improve the outcome of the previous session, whilst injections with needles did not require further corrections.
The choice between needle or cannula is based on personal experience and preference. While the authors experienced post-injection swelling and redness and pain in 2% to 3% of cases, less bruising and ecchymosis occur with the latter. Bruising may also cause lymphatic vessel compression with a greater risk of oedema, although it minimizes the risks of intravascular injection and embolism.
As a general rule, it is advisable not to inject medially in the inner canthus to avoid lesions or compression of the angular vessels[
In the authors’ experience, the use of cannula leads to overcorrection and the Tyndall effect in 6% to 7% of cases whilst needle injections avoid such complications; nevertheless, it has to be carried out by experienced injectors.
Subcutaneous placement of the HA is seldom reported[
The injection can be performed by both the needle or cannula technique; it is remarkable that the technique with needle has been referred to since the very first papers in 2005, up to 2019[
The purpose of this paper is not to discuss the safety of these two methods of HA injection for tear trough and lower eyelid deformities, but it is the author’s opinion that growing awareness of the relevant anatomy[
Complications focused articles: publication trend with respect to needle and cannula use
Finally, to highlight the reliability of HA injections for the treatment of lower eyelid deformities, 10 studies out of the 66 reviewed in this paper focused on its use in the treatment of functional impairments such as retraction[
With respect to the published literature, it could therefore be claimed that interest in lower eyelid and tear trough rejuvenation peaked in 2012, but has continued on an ascending trend, as summarized in
Techniques and complications focused articles: publication trend
Indeed, this paper has some limitations as the presented review is non-systematic and therefore does not allow a meta-analysis of the collected data.
Furthermore, with respect to the Levels of Evidence classification of the Oxford Centre for Evidence-based Medicine (OCEBM)[
The remaining literature was limited to case series, case reports and observational cohorts and lacks multicentre studies, highlighting the bias due to variances in single operator techniques.
Multiple classifications of the severity of tear trough deformities are presented[
The lack of a grading system or classification directly correlates with the paucity of available articles focused on objective outcome evaluation of tear trough deformity treatment with HA injections. Digital 3D photography has been adopted as a method of choice since 2010[
It is remarkable that only one paper has focused on instrumental follow-up and outcomes evaluation with ultrasound and this was published in 2013[
Whilst surgical management remains the standard for lower eyelid rejuvenation, non-surgical correction of its selected deformities, such as the tear trough by HA injections may provide a reliable and viable option based upon the presented evidence.
In the author’s experience, this treatment can achieve, when properly executed, great satisfaction of both patients and doctors, due to its immediate result and longevity, as it can be assessed for up to 1 year after the injection.
To the best of the authors’ knowledge, this is the first literature review related to HA use in lower eyelid for tear trough deformity correction and rejuvenation.
This review has been performed based on the common assumption that when a method to determine the true outcomes, safety and reliability of treatments is lacking besides the mere judgement of patients and clinicians, evidence has to be incorporated into daily clinical practice by considering case reports, pilot studies and available, high-quality studies, as the authors believe that evidence based medicine is essential to provide better answers for both the patients and us healthcare professionals[
Further prospective, randomized controlled studies and systematic reviews of the literature are thus desirable, along with a standardized and widely-accepted grading system of the deformity and its treatment outcomes will allow us to better codify this procedure.
The authors would like to thank Giulia Tanteri, an independent medical writer, who provided English-language editing and journal styling prior to submission.
Made substantial contributions to conception and design of the study, performed data analysis and interpretation: Diaspro A
Verified the analytical methods, provided critical feedback and helped shape the research, analysis and manuscript: Sito G
Contributed to the final manuscript the final manuscript: Diaspro A, Sito G
Not applicable.
None.
All authors declared that there are no conflicts of interest.
Not applicable.
Not applicable.
© The Author(s) 2020.