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Three Part Question

In [a patient seeking cosmetic treatment to the lower eyelid], how [effective] is [hyaluronic acid] and what technique should be used?

Clinical Scenario

Patient seeking a relatively safe, non surgical cosmetic treatment to the lower eyelid.

Search Strategy

PubMed
(lower[All Fields] AND ("eyelids"[MeSH Terms] OR "eyelids"[All Fields] OR "eyelid"[All Fields]) AND ("hyaluronic acid"[MeSH Terms] OR ("hyaluronic"[All Fields] AND "acid"[All Fields]) OR "hyaluronic acid"[All Fields])) AND ("2005/07/31"[PDat] : "2015/07/28"[PDat] AND "humans"[MeSH Terms] AND English[lang])

Search Outcome

27 results in total
Only 3 were relevant
Another 2 articles identified from 'related articles'

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Morley 2009 UK	A total of 198 eyes of 100 patients were treated. Patients were principally female (87%), white (89%), and middle aged (mean age = 47.8 years).	Consecutive, interventional case series involving case note review, masked grading of clinical photographs, and patient satisfaction survey. Injection technique: The gel was placed preperiosteally, deep to orbicularis, anterior to the inferior orbital rim. The injection procedure was tolerable in 95% of patients without local anesthetic.	Volume of filler injected	Mean 0.59 ml per eye	Describing the experience of one surgeon only. Non validated assessment tool.
			Complications	Bruising (75%), swelling (26%), blue discoloration (4%), and lumpiness (33%). (7%) required dissolution with hyaluronidase.
			Downtime	Mean 1 day
			Patient satisfaction	Most patients (85%) described marked or moderate satisfaction with the treatment, 5% were ambivalent, and 10% were dissatisfied.
Airan 2005 Nov USA & Canada	Not stated however the author claim that she used her technique successfully in over 400 patients.	Expert opinion. Injection technique: Mark the patient in a seated position. Anesthetic is infiltrated into the periosteum. After 20 minutes, the HA injection is started at the lateral orbital rim hollow. The needle is placed through the skin down to the bone surface with the bevel down. A small amount of hyaluronic acid is injected while it is palpated with the index, The needle is then marched along the bone and small amounts injected <0.1 ml. The needle is then advanced along the rim until the entire region is filled. The most medial aspect of the nasojugal groove is filled by “pushing” the hyaluronic acid with a finger into the area to avoid puncture of the prominent infratrochlear vessels adjacent to the nasal bone. Post injection cool packs and patients advised to minimize strenuous activity for 48 hours. Patients assessed for contour irregularity at 1 week. If present, the irregularity can be massaged down. Additional filler can also be used.	Complications	Irregularities, temporary bruising and swelling.	No clear outcome measure. Experience of a single practitioner. Level of evidence 5.
			Volume of filler used	Ranges from 0.35 to 1.40 ml.
			Outcome	Excellent contour was achieved in all patients according to the author.
Kane 2005 Sep USA	24 patients have had their tear troughs treated. All the patients were women ranging in age from 35 to 56 years (average, 41 years). Five patients had undergone prior lower lid blepharoplasty. Nine patients had undergone concomitant Botox treatment of the orbicularis oculi muscle for crow’s feet.	Case series by single author. Injection technique: skin is prepped with alcohol; and the morphology of the eyelids is studied. Betacaine topical anesthetic ointment is applied to the lower eyelids and allowed to stand for at least 20 min. The ointment then is removed with alcohol. Patient’s chair reclined 30 degrees. The lower lid skin is spread and held at some tension and inspected carefully for visible vessels.Using 30 and 32 gauge needles the deepest part of the medial tear trough is treated first. A minuscule amount of hyaluronic filler is injected at each pass. Then parallel ‘‘threads’’ of filler are injected cephalad and caudad to the tear trough. When the tear trough is deep or a large area is to be injected (nearly the entire lower lid at times), the direction of the needle is changed throughout the injection so the filler is laid down in a cross-hatched fashion. All patients are instructed to rest after injection, with strict head elevation and cold compresses on the eyelids for 2 days. Follow up after 10 days. Results were improved greatly after the change to a 32-gauge needle according to the author.	Volume of filler injected	Range is 0.1 to 0.45 ml per eyelid	Experience of a single practitioner. Non validated assessment tool.
			Downtime	Most were able to resume their normal activities after 3 to 4 days. Few after 1 day
			Outcome	The tear trough depression was improved in all cases.
			Complications	All the patients had some early surface irregularities for the first 7 to 10 days.
			Patient satisfaction	2 patients were dissatisfied (injected with 30-gauge needle)
Lambros 2007 Nov USA	Approximately 200 patients have been treated.	Expert opinion. Injection Technique: The borders of the tear trough are marked, ice is firmly applied, using a 1-cc syringe and a half-inch, 30- to 32-gauge needle, 0.2 to 0.4 cc of 0.5% lidocaine with epinephrine is injected into the orbicularis oculi muscle and up the tear trough. Finger pressure applied. The patient is kept in vertical position. The needle is inserted through the skin at the most lateral extent of the tear trough, advancing fully and very small amount of product is then placed while the needle is withdrawn. Another parallel injection at the same depth is made below and another above. The process is repeated to the apex of the deformity. the withdrawal injection should not continue to the skin or one will be left with a superficial dermal bump. The preferred plane of injection is the orbicularis oculi muscle rather than periperiosteal. The area is then massaged lightly. According to the author, the best patients for the treatment are those with young, thick skin and a definite hollow.	The volume of filler injected	0.1 to 0.4 cc	Describes the experience and the opinion of one expert. Level of evidence 5. Conflict of interest: The author was paid by Medicis to be part of a Restylane expert users group.
			Longevity of the treatment	At least 1 year and up to 2 years.
			Complications	Minimal: bruising, irregularities, bluish discolouration.
			Outcome	All patients were improved roughly in proportion to their skin quality.
Viana 2011 Feb Brazil	25 patients were treated with HA to correct tear trough deformities.	Case series. The HA was administered into the preperiosteal tissues with a serial puncture technique and approximately 0.1 mL was injected at each pass. Each patient’s before and after photographs were reviewed by three surgeons; to objectively assess the outcomes, a quantitative scale was used to grade the pre- and postinjection results. The significance of subjective aesthetic evaluation of the photographs was evaluated with the Mann-Whitney U-test. Differences were regarded as significant if probabilities were less than 0.05.	Outcome	Most patients (88%) had cosmetic improvement.	Non validated assessment tool. Conflict of interest: The Restylane filler administered in this study was donated by Q-Med Brazil.
			Volume of filler used	The mean (SD) volume was 0.54 (0.27) mL on the right and 0.61 (0.30) mL on the left.
			Complications	Some bruising, erythema, and local swelling.
			Patient satisfaction	All patients were very satisfied.

Comment(s)

There is lack of high quality evidence in this field. Lower eyelid rejuvenation with treatment of the tear trough deformity can be challenging. The duration of efficacy for HA filler in the tear trough has been reported from six months to two years. There may be minimal downtime due to swelling and bruising. The volume injected varies from patient to patient.

Clinical Bottom Line

HA filler injection is relatively safe and effective treatment for tear trough deformity and lower eyelid rejuvenation. Patient selection is essential. Good aesthetic results can be achieved when the right HA filler is injected with good technique.

References

1. Morley Use of Hyaluronic Acid Filler for Tear-Trough Rejuvenation as an Alternative to Lower Eyelid Surgery Ophthal Plast Reconstr Surg. 2011 Mar-Apr;27(2):69-73.
2. Airan Nonsurgical lower eyelid lift. Plast Reconstr Surg. 2005 Nov;116(6):1785-92.
3. Kane Treatment of tear trough deformity and lower lid bowing with injectable hyaluronic acid. Aesth. Plast. Surg 2005 Sep-Oct;29(5):363-7
4. Lambros Hyaluronic acid injections for correction of the tear trough deformity Plast Reconstr Surg. 2007 Nov;120(6 Suppl):74S-80S
5. Viana Treatment of the Tear Trough Deformity With Hyaluronic Acid Aesthet Surg J. 2011 Feb;31(2):225-31