Sociedade Brasileira de Dermatolodia Surgical & Cosmetic Dermatology


ISSN-e 1984-8773

Volume 3 Number 4

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Case reports

Deep-fill of the tear trough with hyaluronic acid

Preenchimento profundo do sulco lacrimal com ácido hialurônico

Flávia Naranjo Ravelli1, Juliana Sandin1, Fernanda Dias Pacheco Sakai 1, Ana Carolina Lisboa de Macedo1, Viviane Chehin Curi1, Thais Adura Pepe1

Received on: 4 December 2010
Approved on: 15 November 2011

This study was carried out at the authors’ private practice – São Paulo (SP), Brazil.

Conflicts of interest: None
Financial support: None



The protrusion of the orbital fat, aggravated by local dyschromia, causes an unpleasant aesthetic appearance, which worsens with age. This study describes 15 cases of treating the tear trough with hyaluronic acid filling. The substance was deeply injected through retro injection. Eleven patients (73%) were satisfied with the procedure. Two cases (13%) presented edema in the treated area, one case (6%) developed hyperchromia of the lower eyelids, and another (6%) developed an irregularity on the cutaneous surface in the area that was filled, and was treated with hyaluronidase. This technique demonstrated good results, with no serious complications.



Under-eye circles are an important aesthetic problem, cau- sing an appearance of fatigue or sadness, which have a conside- rable negative impact on the quality of life. 1,3 Several factors are implied in its etiology, and recognizing each of them is key for correctly treating this condition. 2-5

Its main cause is local hyperpigmentation, which can be due to post-inflammatory hyperchromia, as is the case in atopic or allergic dermatitis. In addition, a genetic predisposition and excessive exposure to the sun can lead to an increase in the pro- duction of melanin that results in local darkening. 2,4,5

Although under-eye circles can occur in young patients with malar hypoplasia, they become more noticeable as patients age. This is partly due to the pseudo-herniation of the orbital fat that simulates the formation of a pad that causes a shadow and emphasizes the tear trough, worsening the appearance of under- eye circles. 2-6

The excessive transparency of the periorbital skin, combi- ned with its hypervascularization, also causes a darkening of the area, for the subcutaneous vessels become more visible. 2-5 With that in mind, the most suitable treatment would be to fill the infraorbital region to reduce the skin''''''''s transparency. 3-5

Hyaluronic acid (HA) is currently the safest and most com- monly used agent in cosmetic fillings, since it is well tolerated and leads to good aesthetic results. 1,7-9 It rarely presents serious adver- se effects, and most complications disappear once the product is degraded. 8 Nonetheless, the periorbital region presents anatomi- cal features that are challenging for cutaneous filling procedures 10. Although rare, retinal artery occlusion and optic nerve lesions are the most undesirable complications – which can be avoided with a sound understanding of the local anatomy. 1,6,10


To describe the treatment of the tear troughs of 15 patients, through deep-fill injections of HA.


This study was carried out at a dermatologic private prac- tice. The 15 patients were photographed before and 15 days after the procedure. A topicall anesthesia of 5% lidocaine combined with 5% prilocaine was used. A 30G needle supplied with the filler was used to apply HA beneath the orbital muscle and ante- riorly to the infraorbital border of the periosteum, in the tear trough region. The product was injected deeply, parallel to the orbital border. No injections were carried out in the medial part; the product was manually massaged to direct and mold it into that space. In order to reduce possible complications, the needle penetrated the skin bilaterally in approximately three points. Approximately 0.4 ml of Juvederm® Ultra XC (Allergan, Irvine, CA, USA) (containing lidocaine) was injected in each crease. Only ice was applied locally, and no additional care was administered after the procedure. No additional treatments, such as laser, peeling or botulinum toxin, were carried out at this moment. The patients were evaluated 15 days and six months after the procedure, and adverse effects were described.


Of the 15 patients treated, 14 (93%) were female. The ave- rage age was 42. No patient needed more than one session to have the tear trough filled (Figures 1, 2, 3 and 4).

Eleven patients (73%) were satisfied with the procedure. Four patients complained about transient and mild adverse effects. Two cases (13%) presented edema in the lower palpebral region in subsequent days, but this spontaneously resolved in roughly one month. In one case (6%) the hyperchromia of the lower eyelids was intensified after the procedure, and another (6%) presented irregularity in the filled cutaneous surface (hypercorrection), which required local treatment with 2000 UTR (0.01 ml in two points) hyaluronidase. No patient com- plained about ecchymoses or hematomas in the follow-up.


Due to the orbital region''''''''s peculiar anatomy, there is no consensus in the literature on the best HA application method 10. Coimbra described the string of beads technique in the application of low concentration and viscosity (18 mg/ml) HA in superficial planes, demonstrating that 15 days after the proce- dure, seven of the 30 patients needed complementary treatment. 10 However, most studies show the use of higher HA concentra- tions (ranging from 20 to 24 mg/ml). 10 Given that the objecti- ve of filling the under-eye circle area is to restore the local volu- me, we also opted to use HA in a higher concentration (24 mg/ml), obtaining great results with a single session.

Although Coimbra needed more than one session to achieve the abovementioned results, the total amount of product used was similar to that employed in the present study (0.4 ml of HA for each side, on average). Our data diverge from most studies, which in general use larger amounts of product applied in more than one session. 2-4,11

When the product is applied superficially, some studies des- cribe cases of bluish color arising in the filled site (Tyndall effect), mainly in patients with low phototypes. 1,11 This compli- cation was not noticed in our patients, probably due to the fact that the filler was applied in deeper planes – a technique similar to the one described by other authors. 1,3,6,11

Goldberg et al. used HA (Restylane R, ® Q-Med, Uppsala, Sweden) in infra-muscular filling with multiple passes of the needle in several directions, simultaneously treating other areas of the face. 12 In turn, Steinsapir et al. carried out deep micro- punctures with Restylane R. ® Both described a greater number of complications, such as persistent edema. 6,12 The present study used the retro injection technique in the tear trough only, for the number of punctures is smaller and has a lower risk of ecchymoses.

According to the literature, some degree of local ecchymo- ses and mild and transient edema should be expected in most patients. 2,4,11 Although the authors of the present study noticed mild ecchymosis during the application, no alteration was noti- ceable in the evaluation carried out 15 days after the procedure.

When under-eye circles are mainly caused by cutaneous hyperpigmentation, the use of fillers can worsen their appearan- ce, since they elevate the eyelid tissue. 12 In the present study, one patient complained about the worsening of dyschromia, which resulted from administering an inadequate treatment for the cause of her under-eye circles.

Only one patient – a figure much lower than those found in the literature – needed hyaluronidase to correct irregularities after the procedure. 6,12 Other possible complications that were not found in this study are: lymphedema that is unresponsive to hyaluronidase, migraine and local cellulite. 6,12

Vascular interruption caused by compression or obstruction of the blood flow can occur as often from direct vascular lesion as from embolization, and could besides lead to amaurosis. 1,2,4,11 As described, there were no cases of visual complications after the procedure in the present study. Nevertheless, understanding the local anatomy and mastering the appropriate technique is of paramount importance to avoid possible complications.


Despite the periorbital region''''''''s complex anatomy, with appropriate understanding and training, the under-eye circle area can be treated with deep applications of HA. Notwithstanding the adverse effects described, the majority of our patients believed that the filling of their under-eye circle region improved their appearance and self-esteem, reduced the appearance of fatigue and provided local rejuvenation.


1 . Infraorbital hollow treatment by dermal fillers. Dermatol Surg.2007;33(9): 1116-1119.

2 . Deep-fill hyaluronic acid for temporary treatment of the naso-jugal groove: a report of 303 consecutive treatments. Ophthal Plast Reconstr Surg.2006; 22(5):344-348.

3 . The hyaluronic acid push technique for the nasojugal groove. Dermatol Surg. 2008;34(1):127-31.

4 . Infraorbital dark circles: definition, causes, and treatment options. Dermatol Surg. 2009;35(8):1163-71.

5 . Treatment of infraorbital dark circles by autologous fat transplantation: a pilot study. Br J Dermatol.2009;160(5):1022-5.

6 . Deep-fill hyaluronic acid for the temporary treatment of the naso-jugal groove: a report of 303 consecutive treatments. Ophthal Plast Reconstr Surg.2006;22(5):344-8.

7 . Avaliação da permanência do ácido hialurônico injetável no sulco nasogeniano e rítides labiais. Surg Cosmet Dermatol.2011;3(2):112-5.

8 . Preenchimento dos sulcos orbital inferior e naso-jugal com ácido hialurônico de baixa concentração: uma nova técnica de aplicação. Surg Cosmet Dermatol.2010;2(1):67-70.

9 . Anatomy and nonsurgical correction of the tear trough deformity. Plast Reconstr Surg.2009;125(2):699-708.

10 . Filling the periorbital hollows with hyaluronic acid gel: inicial experience with 244 injections. Ophthal Plast Reconstr Surg.2006; 22(5):335-343.

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