Management of Tear Trough with Hyaluronic Acid Fillers: A Clinical-Practice Dual Approach

Figures & data

Table 1 Tear Trough Deformity Classification Systems.

Barton et al^Citation4	Hirmand^Citation5	Belhaouari et al^Citation7
Grade 0: Absence of medial or lateral lines demarcating the arcus marginalis or the orbital rim and a smooth, youthful contour without a transition zone at the orbit-cheek junction. Grade I: Mild, subtle presence of a medial line or shadow; smooth lateral transition of lid-cheek junction. Grade II: Moderate prominence of a visible demarcation of the lid-cheek junction, extending from medial to lateral. Grade III: Severe demarcation of the orbit-cheek junction, with an obvious step between the orbit and the cheek.	● Class I patients have volume loss limited medially to the tear trough. These patients can also have mild flattening extending to the central cheek. ● Class II patients exhibit volume loss in the lateral orbital area in addition to the medial orbit, and they may have moderate volume deficiency in the medial cheek and flattening of the central upper cheek. ● Class III patients present with a full depression circumferentially along the orbital rim, medial to lateral.	● Stage 1A: insufficient volume without ptosis ● Stage 1B: insufficient volume with ptosis ● Stage 2A: normal volume without ptosis ● Stage 2B: normal volume with ptosis ● Stage 3A: Increased volume without ptosis ● Stage 3B: Increased volume with ptosis.

Note: Data from these studies.^4,5,7

Figure 1 Hirmand classification of tear trough deformity. Data from Hirmand.⁵

Figure 2 Overview of the hyaluronic acid (HA) injectable filler on the muscle activity. Data from de Maio.¹¹ Image courtesy from and reprinted with permission from Allergan plc, Dublin, Ireland.

Abbreviation: N, nasalis; LAN, levator labii superioris alaeque nasi; LLS, levator labii superioris; LAO, levator anguli oris; ZMj, zygomaticus major; ZMi, zygomaticus minor; DSN, depressor septi nasi; DAO, depressor anguli oris; DLI, depressor labi inferiores; B, buccinator; R, risorius; PL, plastisma; OO, orbicularis oris; M, mentalis.

Table 2 Belhaouari et al⁹ Tear Trough Classification System According to the Volume and the Ptosis with the Treatment Strategy with Hyaluronic Acid Filler

Tear Trough Classification System and Treatment Strategy

Stage 1A: Characteristic: Insufficient volume without ptosis. Treatment: Indirect approach (VYC-17.5L/VYC-20L) Stage 1B: Characteristics: Insufficient volume with ptosis. Treatment: Indirect approach (VYC-17.5L+VYC-20L ± VYC-15L) Stage 2A: Characteristics: Normal volume without ptosis. Treatment: Direct approach (VYC-15L) Stage 2B: Characteristics: Normal volume with ptosis. Treatment: Indirect approach (VYC-17.5L+VYC-20L ± VYC-15L) Stage 3A: Characteristics: Increased volume without ptosis. Treatment: Direct approach (VYC-15L) Stage 3B: Characteristics: Increased volume with ptosis. Treatment: Indirect approach (±VYC-17.5L+VYC-20L+ VYC-15L)

Abbrevaition: VYC, Vycross technology.

Table 3 Mechanic Myomodulation Effect with Hyaluronic Acid (HA) Filler on the Different Treatment Points.

Treated Point	Location	Action
T1	Under	To increase tightening in temporal-orbicular and temporal-cutaneous true retaining ligaments, which cause elevation of the tail of the eyebrow.
Ck1	Under	Myomodulation on the zygomaticus major muscle and tension of the zygomatic-cutaneous-orbicular and orbicular true retaining ligaments, with canthopexy effect.
Ck2	Under	Myomodulation on the zygomaticus minor, orbicular, and levator upper lip muscles and tightening of the zygomatic-cutaneous-orbicular and orbital-malar true retaining ligaments, causing a canthopexy effect
Ck3	Under^a	Myomodulation on the zygomaticus minor and levator upper lip muscles, and tightening of the zygomatic-cutaneous-orbicular and orbital-malar true retaining ligaments, which cause anterior/superior projection of the cheekbone.
Ck4	Above	Myomodulation on zygomaticus major muscle and tightening of true orbicularis retaining ligament.
O1	Under	Myomodulation on orbicular muscle and tightening of true orbicularis retaining ligament.
O2	Under	Myomodulation on orbicular muscle and tightening of true orbicularis retaining ligament.
O3	Under	Myomodulation on orbicular muscle and tightening of true orbicularis retaining ligament.
Tt1^b	Under^c	Myomodulation on orbicular muscle.
Tt2^b	Under^c	Myomodulation on orbicular muscle.
Tt3^b	Under^c	Myomodulation on orbicular muscle.

Notes: ^aInto the deep and supraperiosteal fat compartment at the medial level of the malar. ^bThe direct approach to this area is indicated when patients present negative snap-tests and have a normal or excessive suborbicularis oculi fat pad (SOOF) volume. ^cBolus of hyaluronic acid filler in front of the orbital septum, at supraperiosteal level, between the orbicularis retaining ligament and the zygomatic cutaneous ligament. Data from these studies.^10–12

Abbreviations: T1, anterior temple; T2, posterior temple; Ck1, zygomatic arch; Ck2, zygomatic eminence; Ck3, anteromedial cheek; Ck4, lateral lower cheek/parotid area; O1, central lateral orbital; O2, lower lateral orbital; O3, upper lateral orbital; Tt1, central infraorbital; Tt2, lateral infraorbital; Tt3, medial infraorbital.

Figure 3 Overview of the different codes involved in the tear trough deformity direct approach treatment. Image courtesy from and reprinted with permission from Allergan plc, Dublin, Ireland. Codes have been adapted from de Maio.^10,11

Abbreviations: Tt1, central infraorbital; Tt2, lateral infraorbital; Tt3, medial infraorbital.

Table 4 Overview of the Different Hyaluronic Acid (HA) Fillers Used in Tear Trough Deformity Treatment and Their Main Characteristics

	VYC-25L*	VYC-20L*	VYC-17.5L*	VYC-15L*	VYC-12L*
Indication	Restore and create volume of the face.	Facial volume restoration.	Treatment of deep skin depressions, face contouring and volume restoration to correct facial structural defects, contour deformities volume loss in the lips, cheeks, chin, lower face.	Treatment of fine lines and medium-sized skin depressions, enhancement and pouting of the lips to correct structural defects, contour deformities and volume loss.	Treatment of superficial cutaneous depressions such as fine lines and for improvement of skin quality attributes such as hydration and elasticity.
Concentration of HA	25 mg/mL	20 mg/mL	17.5 mg/mL	15 mg/mL	12 mg/mL
HA molecular weight	Low & high	Low & high	Low & high	Low & high	Low & high
Duration	Up to18 months	Up 2 years	Up to 18 months	Up 1 year	Up to 9 months

Note: *With lidocaine.

Abbreviations: VYC-25L, Volux^® (Allergan plc, Dublin, Ireland); VYC-20L, Voluma^® (Allergan plc, Dublin, Ireland); VYC-17.5L, Volif^® (Allergan plc, Dublin, Ireland); Volbella^® (Allergan plc, Dublin, Ireland); VYC-12L, Volite^® (Allergan plc, Dublin, Ireland); HA, hyaluronic acid.

Table 5 Authors Recommendations for Treating Tear Trough

Recommendations

● Make the injection with the patient seated as the tear trough deformity is better visualized in this position than when the patient is lying down. ● Use low-viscosity instead of high-viscosity hyaluronic acid (HA) or non-biodegradable agents, as it can be safely injected with fewer adverse effects. ● Avoid superficial injections to prevent the Tyndall effect, a bluish discoloration under the skin that may arise when the HA is injected too superficially. ● The HA filler should be gently massaged for even distribution, yet avoiding massaging too strongly. ● Follow the key principle “less is more”, in order to prevent bulges under the eye, it is much better to undercorrect rather than overcorrect the tear trough area. ● It is essential to be cautious while injecting around the infraorbital foramen to avoid injury to the neurovascular bundle. ● Inject very slowly. ● Both a needle or a cannula can be used with good results. Nevertheless, blunt-tipped cannulas may be safer due to the reduced chance of damaging vessels and nerves. ● The patients must be informed that they ought to avoid any strong or extended pressure to the area treated.

Table 6 Overview of the Authors’ Recommendations for Treating Tear Trough Deformity with Hyaluronic Acid (HA) Filler According to the MD Codes^®.

Code	HA Filler	Amount	Administration	Level
T1+T2	VYC-20L/VYC-25L	0.5 to 0.7 mL	27G needle	Supraperiosteal
Ck1^a	VYC-20L/VYC-25L	0.3 mL	27–30 needle	Supraperiosteal
Ck2	VYC-20L	0.1 to 0.2 mL	27–30G needle	Supraperiosteal
Ck3^b	VYC-20L	0.2 to 0.4 mL	27G and 30G needle	Supraperiosteal
	VYC-20L+VYC-17.5L	0.3 to 0.6 mL	25G-27G blunt cannula	Supraperiosteal
Ck4	VYC-20L	0.5 to 0.7 mL	25–27 G blunt cannula	Deep subcutaneous
Ck5	VYC-20L or VYC-25L^c	0.4 to 0.7 mL	25–27 G blunt cannula	Deep subcutaneous
O1^d	VYC-15L or VYC-20L	0.1–0.15 mL	27–30G needle	Supreperiosteal
O2^d	VYC-15L or VYC-20L	0.1–0.15 mL	27–30G needle	Supreperiosteal
O3^d	VYC-15L or VYC-20L	0.1–0.15 mL	27–30G needle	Supreperiosteal
Tt1	VYC-15L	0.1–0.2 mL	27 G blunt cannula	Supreperiosteal
Tt2	VYC-15L	0.1–0.2 mL	27 G blunt cannula	Supreperiosteal
Tt3	VYC-15L	0.1–0.1 mL	27 G blunt cannula	Supreperiosteal

Notes: ^aIt is possible to inject 3 microboluses of 0.1 mL (one in the suture notch and the other two ones to the sides). ^bTreatment is performed in two phases. Phase 1: To inject 0.2 to 0.4 mL of a HA filler of 20 mg/mL (VYC-20L), at the supraperiosteal, by means 27G and 30G needles. Phase 2: Injecting 0.3 to 0.6 mL (with a fan technique) of VYC-20L, by means25-27G cannulas, and injecting afterwards in the same area a more superficial amount of HA (either VYC-25L or VYC-20L, according to the patient needs) under the orbicularis muscle. ^cThe injection of the bolus of VYC-20L or VYC-25L depends on the skin thickness and bone structure of the patient. ^dIn some patients with excessive contractility of the orbicularis muscle, it is necessary to inject, at the superficial subdermal level, a HA filler (VYC-15L) for correcting the horizontal wrinkles. Data from these studies.^10–12

Abbreviations: T1, anterior temple; T2, posterior temple; Ck1, zygomatic arch; Ck2, zygomatic eminence; Ck3, anteromedial cheek; O1, central lateral orbital; O2, lower lateral orbital; O3, upper lateral orbital; Tt1, central infraorbital; Tt2, lateral infraorbital; Tt3, medial infraorbital; VYC-15L, Volift^® (Allergan plc, Dublin, Ireland); VYC-17.5L, Volbella^® (Allergan plc, Dublin, Ireland); VYC-20L, Voluma^® (Allergan plc, Dublin, Ireland); VYC-25L, Volux^® (Allergan plc, Dublin, Ireland).

Figure 4 Overview of the different Codes involved in the tear trough deformity indirect approach treatment. Data from Peng et al⁶ and de Maio.¹⁰ Image courtesy from and reprinted with permission from Allergan plc, Dublin, Ireland.

Abbreviations: Ck1, zygomatic arch; Ck2, zygomatic eminence; Ck3, anteromedial cheek; Ck4, lateral lower cheek/parotid area; Ck5, submalar/buccal area; O1, central lateral orbital; O2, lower lateral orbital; O3, upper lateral orbital.

Figure 5 Codes involved in the direct approach strategy for treating tear trough deformity. Tear trough and orbital codes should be reserved for specialists specifically trained in this technique and those who have a sound knowledge of the anatomy and physiology for this particular area. Data from Peng et al⁶ and de Maio.¹⁰ Image courtesy from and reprinted with permission from Allergan plc, Dublin, Ireland. (A) Imaging representing the frontal view. (B) Imaging representing the anatomical structures. Red circle under Tt1 and exclamation mark: Be aware of the infraorbital artery branches. Red circle near to Tt3 and exclamation mark: Be aware of the angular artery and vein. Codes have been adapted from de Maio.^10,11

Abbreviations: Tt1, central infraorbital; Tt2, lateral infraorbital; Tt3, medial infraorbital.

Figure 6 Temporal point to be treated. Data from de Maio.¹⁰ Image courtesy from and reprinted with permission from Allergan plc, Dublin, Ireland.

Abbreviation: T1, anterior temple.

Figure 7 Structural treatment of tear trough deformity. Image courtesy from and reprinted with permission from Allergan plc, Dublin, Ireland. ^aDo not inject into the cartilage or into the bone, but rather at the level of the cartilage or the level of the bone.

Abbreviations: Ck, cheek; Ck1, zygomatic arch; Ck2, zygomatic eminence; Ck3, anteromedial cheek.

Figure 8 Different anatomical structures and the codes of the periorbital region. Data from de Maio.¹⁰ Image courtesy from and reprinted with permission from Allergan plc, Dublin, Ireland.

Abbreviations: E1, eyebrow tail; E2, eyebrow center; E3, eyebrow head; T1, anterior temple; T2, posterior temple; Ck1, zygomatic arch; Ck2, zygomatic eminence; Ck3, anteromedial cheek; Ck4, lateral lower cheek/parotid area; Tt1, central infraorbital; Tt2, lateral infraorbital; Tt3, medial infraorbital.

Figure 9 Frontal, right, and left projection of a 40-year-old patient face before (A) and after (B) being treated. The patient provided their consent for the use of their image in this publication. 1. Zygomatic arch (Ck1): 0.3 mL per side of Hyaluronic acid filler (VYC-20L). 2. Anteromedial cheek (Ck3): 0.7 mL per side of Hyaluronic acid filler (VYC-20L). Image courtesy with permission from Dr Farollch. Codes have been adapted from de Maio.¹⁰

Figure 10 Forty-five years old women with a tear trough deformity (according to Belhaouari classification: 1B (see reference 7)) before treatment (A); that shows the treatment plan (B); and after treatment (C). The patient provided their consent for the use of their image in this publication. 1. Temporo-orbicular cutaneous retaining ligament; 2. Anterior temple (T1); 3. Palpebral ligament; 4. Orbicular retaining ligament; 5. Zygomatic-cutaneous-orbicularis retaining ligament; 6. Zygomatic arch (Ck1); 7. Zygomatic eminence (Ck2); 8. Anteromedial cheek (Ck3); 9. Central infraorbital (Tt1); 10. Medial infraorbital (Tt3). T1 (2): 0.5 mL per side of Hyaluronic acid (HA) filler (VYC-25L; Volux^®; Allergan plc, Dublin, Ireland). Ck1 (6): 3 microboluses of 0.1 mL (one in the suture notch and the other two ones to the sides) of HA filler (VYC-20L). Ck2 (7): 0.1 mL of HA filler (VYC-20L). Ck3 (8): 0.2 mL lateral + 0.25 mL medial of HA filler (VYC-20L). Tt1 (9): 0.2 mL of HA filler (VYC-20L). Tt3 (10): 0.2 mL of HA filler (VYC-20L). Image courtesy with permission from courtesy of Dr Urdiales-Gálvez. Codes have been adapted from de Maio.¹⁰

Table 7 Different Aspects That Need to Be Considered When Injecting Hyaluronic Acid (HA) Fillers for Treating Tear Trough Deformity. Adapted from de Maio

MD Code^®	Special Consideration
T1	Pay attention to the superficial frontal artery and the deep temporal arteries.
Ck1	None
Ck2	Pay attention to the zygomaticofacial artery
Ck3	Pay attention to the infraorbital artery
Tt1	Pay attention to the infraorbital artery branches
Tt2	None
Tt3	Pay attention to the angular artery and vein

Note:Data from these studies.^10,11

Abbreviations: T1, anterior temple; Ck1, zygomatic arch; Ck2, zygomatic eminence; Ck3, anteromedial cheek; Tt1, central infraorbital; Tt2, lateral infraorbital; Tt3, medial infraorbital.

Table 8 Overview of the Adverse Events Associated with the Use of Dermal Fillers. Adapted from Funt and Pavicic

	Early Adverse Events^a	Delayed Adverse Events^b
Injection site reactions^c	Erythema Edema Pain/tenderness Bruising Itching	Erythema Edema Pain/tenderness Nodule/abscess Systemic responses Biofilm
Infection	Erythema Edema Pain/tenderness Acne papule formation Nodule/abscess	Foreign body granuloma^d
Hypersensitivity	Erythema Edema Pain/tenderness Non-fluctuant nodules	Migration of filler material
Technical and placement errors	Lumps Asymmetries Contour irregularities Dysesthesias, paresthesias, and anesthesia	Immune reactions Dysesthesias, paresthesias, and anesthesia
Skin discoloration	Redness Whiteness Hyperpigmentation	Persistent discoloration Persistent scarring
Vascular compromise^e	Blurred vision Loss of vision	Tissue necrosis

Notes: ^aOccurring up to several days post-treatment. ^bOccurring from weeks to years post-treatment. ^cAtypical as delayed adverse events. ^dVarying from subclinical histologic changes to disfiguring nodules. ^eRetinal artery occlusion. Data from these studies.^19-21,23

Table 9 Overview of the Early and Delayed Adverse Events in Patients Who Underwent Tear Trough Deformity Treatment with Hyaluronic Acid (HA) Fillers

Early Adverse Events
Event	Prevention/Treatment
Pain	To use HA fillers with lidocaine
Erythema	N.A.
Swelling/Bruising	To avoid all blood-thinning medications. Fillers that incorporate lidocaine and epinephrine (adrenaline) may reduce the amount of postinjection bruising. To apply firm pressure and ice packs before and after the treatment session.
Asymmetry	N.A.
Migraine	N.A.
Delayed Adverse Events
Event	Prevention/Treatment
Orange-brown staining	Preinjection ice application. Proper depth of injection. Discontinuation of anticoagulants at least seven days before injection.
Postinflammatory hyperpigmentation	It is usually associated with dark skin types due to bruising and hematoma. It can be difficult to treat
Puffiness	Its incidence may be reduced by proper patient and filler selection.
Infections	Filler injections should not be performed if there is an infection in the adjacent site. It can be treated with antibiotics active against frequent skin bacteria including Staphylococcus epidermidis or Propionibacterium acnes.
The Tyndall effect	It occurs when particulate HA fillers are inappropriately implanted into the superficial dermis or epidermis. Hyaluronidase should be the initial approach to treatment.
Nodules	They can be treated with local massage, aspiration or incision and drainage of the product. Hyaluronidase can be used to dissolve a nodule or a focus of overcorrection.
Blindness^a	To limit the amount of filler bolus injected in one site. One way to do this is to use blunt cannulas. To apply minimal pressure on the syringe, which decreases the risk of retrograde flow into the retinal arteries.

Notes: Data from these studies.^15,19-23 aRetinal artery occlusion is a rare event.²⁴

Abbreviations: HA, hyaluronic acid; NA, not applicable.

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