Over the years, our technique changes for every area we inject. One year, we may love Restylane in the tear trough with a cannula, the next we hate it and move on to the next filler du jour! It’s the cycle and rhythm we have come to love in this industry. The hot question at conferences around the wine bottle is often, “how do you treat tear troughs now?” Or, you will hear, “what are you using now for the neck?” It’s these conversations with colleagues at meetings that I love the most. Honestly, it’s where I find the value in meetings and it can often be most valued pearl I bring back to my practice.
So, let’s have a glass of wine together and talk about tear troughs. I will share with you my favorite technique and you share with me yours.
About two years ago, I got on the Restylane tear trough band wagon. If you mention Restylane, you think tear troughs, right? It is still a favorite of mine but very occasionally, I see a localized inflammatory reaction that has no rhyme or reason. One out of a hundred patients may call within 24 hours noting edema,redness and tenderness. Occasionally, it’s moderate edema requiring a steroid dose pack. Yes, I hate admitting it but it’s the truth in my practice. I saw this phenomenon about two years ago, however, I don’t see it much any more.
Now, with Voluma being out, I love how it softens the anteriomedial portion of the cheek but we are still missing that pesky lower lid junction area that requires a small amount of something…but what should it be?
For now, given the fillers from which we can choose, I like using micro droplets of Voluma, 0.02-0.03cc, in the lower lid cheek junction for soft volume correction. By transferring 0.15cc to 0.2cc of Voluma from the 1cc FDA approved syringe into a 3/10cc insulin syringe, I can place 0.01-0.05cc micro droplets of Voluma into this delicate area. Yes, I still pull back on my syringe to check for vascular placement and I avoid the infraorbital foramen when injecting product. I also place the filler on the periosteum, as the needle length is 6mm, typically enough to find the depth of the periosteum in this thin tissue area.
How do I transfer? I remove the plunger of the 3/10cc insulin syringe and place the sterile 27g 1/2 in needle with Voluma into the insulin syringe. Slowly, fill up the insulin syringe until the filler meets the top of the syringe. Reinsert the plunger into the insulin syringe and press the plunger down; air is compressed out of the filler and you have a smooth, air free HA product. Amazingly, the Voluma will flow effortlessly out of the 31g insulin syringe. It’s so awesome!
Here’s a little tip: have the patient open their eyes and gaze towards the ceiling, without moving their chin. This helps isolate the lower lid junction so you can visualize the deficit much more easily!
What I love about this technique is that sterile transfer allows me to only charge patients a portion of what is used for their treatment, rather than a whole syringe. I can use the remaining syringe on another patient b/c of the sterile transfer process. Patients love this, especially if they merely want a small touch up. Yes, this is off label and you won’t be able to learn this technique for any industry trainers, so asking may give you the answer you don’t want.
Another favored technique is blended Voluma or Lyft with microcannula. I will add 1cc of bacteriostatic saline to 1cc of product. It’s a nice blend of HA product that can be used to softly volumize the entire anteriomedial malar region. I reserve this technique for someone who has a good degree of volume loss and requires more volume. Cannulas ease my anxiety when working near the angular artery.
Here is a picture of a before and after for tear troughs. This is 2cc’s of Voluma total, used in the lateral malar region with sharp technique and in the anteriomedial region using the microdroplet technique. She also has 44u Botox in the glabella and crow’s feet region, which I do believe helps with the overall periocular improvement.
When we get our hands on Vobella, I hope it will be the next tear tough wonder! I can’t wait to talk about it around the wine bottle at our next convention.
What is your favorite tear trough technique?