Treating the tear trough

Day two of injectables demos at Aesthetic Medicine London included a masterclass on periorbital rejuvenation.

“I think the tear trough is a great area to treat,” Dr Johanna Ward told delegates. “I know a lot of practitioners are cautious or scared, but it can have a high impact for patients and can last well. It’s about knowing how to choose the right product and understanding the patient – it’s important to know who not to treat – and understanding clear placement.”

Dr Ward, who recently announced the release of her new book ‘Collagen: not a beauty molecule’, explained how the Canadian company Prollenium has developed a unique range of hyaluronic acid (HA) dermal fillers using a gel that is wet-milled and sieved, resulting in smoother and more spherical particleswhich typically have less surface area. “This is important”, she stressed, “If there is fat pad loss in the midface, addressing that first may be necessary. Your patient might also benefit from cheek augmentation for optimal results. It’s crucial to clearly explain your treatment plan to ensure your patient understands it. Fat loss in the temples can also be addressed concurrently with other areas, but a thorough consultation is essential to set appropriate expectations.“

Plus, its unique seven-day dialysis process removes residual toxins and creates a purer product with a neutralised PH – the cleaner the product, the softer the treatment. This step in the manufacturing process also prevents the gels from absorbing water post-injection for accurate treatment results which can be more specifically tailored to meet each patient’s individual needs.”

Dr Ward added: “I have been using Revanesse exclusively for three years in my Kent clinic.”

Recently, Prollenium launched Revise, an HA dermal filler specifically designed for the under-eye correction. It is a very pure product, as all residual BDDE has been removed, ensuring high biocompatibility for delicate areas. As practitioners, we need to be confident that any facial product will look good today, tomorrow, in six months, and in twelve months. The unique feature of this gel is that it is pre-hydrated during the manufacturing process to minimise swelling once injected into the tear trough.“

 “We’ve all seen bad tear troughs where people present with bulges or bluish tinges from bad filler that needs to be dissolved, that’s a case of wrong product, wrong patient, and wrong placement.

“And that is why it is important that you use a product that works best for your patient, when chosen carefully, your product can yield very satisfying and rewarding results.

“I would say that approximately 60% of people are not suitable for this type of treatment.We need to be honest and inform our patients if it’s not right for them, thereby limiting the risk of disapointment. However, it’s important to guide them towards alternative treatments if they are not good candidates for HA fillers injection.”

ASSESS AND TREAT

Dr Ward explained that patients nomally only need one treatment, although sometimes there is a need for a second follow-up four to six weeks after the first: “You don’t need to keep treating this area over and over again,” she warned.

“Also assess how the cheeks look,” she advised as she began to examine her patient, Dominique. “If there is fat pad loss in the midface, addressing that first may be necessary. Your patient might also benefit from cheek augmentation for optimal results. It’s crucial to clearly explain your treatment plan to ensure your patient understands it. Fat loss in the temples can also be addressed concurrently with other areas, but a thorough consultation is essential to set appropriate expectations.

“The tear trough is a very unforgiving area. Placement needs to be deep on the periosteum, not superficial, you shouldn’t be able to see the cannula in the skin. A 25-gauge cannula gives me good control and nice results with a retrograde fanning technique.”

Dr Ward also warned against using large boluses in this area: “You don’t want your cannula freestyling in orbit,” she continued. “It’s a very precise injection, but not difficult once you know what you are doing. It’s always a small volume, you’re never in a rush.

“Dominique will likely need a second treatment in four weeks. It’s important to be conservative as an injector in this delicate area. In Dominique’s case, she requires cheek support and temple filling which may complete the periorbital rejuvenation nicely.”

Sharing her technique for assessing the suitability of a patient’s skin, she added: “Pinch the skin and let it drop down, if it returns to normal in a couple of seconds the patient has reasonable skin and you can do the treatment. If it takes five or six seconds to return that’s the kind of laxity you shouldn’t be treating. Loose skin is not suitable for this treatment.

“You want to look for a negative vector, not a bulge or positive vector, we do not want to add hyaluronic acid in that area because it is easy for the filler to make a sluggish lymphatic bulge.

“In terms of anatomy and danger zones, the tear trough is moderate in terms of risk. You shouldn’t be going anywhere near the eye, use finger palpating to know where the orbital rim is and mark it out as a no-go area. It’s a bit like driving, you need to be looking at the road and the steering wheel and all the gadgets inside the car at the same time.”

EASY GLIDE CANNULA

As she began to inject Dominique using Contour from the Revanesse range to give lift and projection in the cheek area, Dr Ward explained: “To inject this area, you can use a Softfil micro cannula EasyGuide, enabling precise and gradual injection. Outline requires minimal volume to effectively support the mid-cheek area.

“The patented EasyGuide is a half-needle introducer that smoothly guides cannulas into the dermis in a single action.

Its design includes a half-needle shaped gutter, which ensures accurate insertion of the microcannula to the appropriate injection depth.

“What can be quite helpful is to double-check the entry point by hovering over it, gently pinch the skin, and then glide along, feeling the bone structure. Travel slowly upward, adding tiny micro boluses with the nondominant hand to ensure precision and protection.

“When injecting the tear trough, this cannula will ease the entry, allowing you to ensure depth by using the index finger of your nondominant hand. If you encounter resistance, withdraw slightly and reposition.

“I recommend always gently massaging the product into the area for a smooth finish. Revise is a forgiving product that can be easily massaged after injection due to its soft and malleable nature, ensuring a natural appearance even during facial expressions.

“It’s a smooth product that requires minimal volume; for instance, some individuals only need 0.2ml in each tear trough”

Dr Ward ended her demonstration with some sage advice for practitioners: “Patients are coming to see you as the expert, they need your advice so don’t be afraid to take charge. Frame it in a soft way, you don’t want to traumatise the patient by suggesting too many things are wrong. We universally have changes in elasticity, so you can say, ‘Don’t worry it happens to everyone but I can help you if you would like.’

“If you become a master at the consultation process you will have much less confusion and fewer complaints. Choose who you treat carefully, and you will have happy patients. Never be afraid to say, ‘I can’t treat you and, even with the best treatments I have, your expectations cannot be matched.’

“I make it crystal clear what I can’t help with and what I can help with; it’s very much about dialogue, assessing and talking together. Some patients are against certain treatments, they have to understand what’s driving that, and it changes over the years. They may come to realise we have reached the limit of non-surgical procedures, and they may need to consult a surgeon.

“I’ve learned to value how essential the consultation process is in understanding when to decline treatments for patients who may never be satisfied—because such patients do exist!”