Estimation of Bony Orbit Depth for Optimal Selection of the Injection Technique to Correct the Tear Trough and Palpebromalar Groove Yehia Farouk El-Garem, MD
BACKGROUND Different techniques have been used for filler injection of the tear trough and palpebromalar groove. Most patients report good results; however, some patients here experienced variable degrees of side effects. OBJECTIVE To assess if previous estimation of the bony orbit depth could affect the choice between bolus and serial puncture technique, and thereby the procedure outcome. MATERIALS AND METHODS In 32 patients, the periosteum depth was measured by using a 28 G needle at 2 points: Point A at the midpupillary line and Point B at the outer canthus. The bolus technique was performed in the right side, and serial puncture technique was done on the left side. RESULTS There was a significant difference in the degree of improvement between both sides in 71% of patients: 40% had better improvement on the right side, whereas 31% had better improvement on the left side. Cases with skin-to-periosteum depth less than 0.5 cm showed better results with serial puncture technique, whereas those with more than 0.5 cm depth showed better results with bolus technique. CONCLUSION technique.
Assessment of bony orbit depth could offer new tool for selecting infraorbital groove injection
The author has indicated no significant interest with commercial supporters.
T
he tear trough, also called the nasojugal groove, is a natural depression that extends inferolaterally from the medial canthus to the approximate location of the midpupillary line.1 The palpebromalar groove, also called the lid–cheek junction, extends laterally from the tear trough.2 Although many factors might contribute to periorbital aging, the presence of atrophy of the skin and subcutaneous fat and bone resorption make the most substantial contributions, leading to accentuation of both nasojugal groove and inferior orbital rim.3,4 Accordingly, current management of the deformity in the tear trough caused by aging has increasingly involved volume restoration and the use of hyaluronic acid (HA).5
Various techniques have been used to correct the tear trough deformity and palpebromalar groove, some of which involve either serial puncture injected along the inferior orbital rim into the suborbicularis oculi,6 or the bolus technique.7 The bolus technique requires subsequent digital massage for effective dispersal of the injected material. Regardless the technique used, most patients report good results; however, some patients experienced variable degrees of bruising, erythema, discomfort, and/or swelling. Occasionally, nodule formation requiring treatment with hyaluronidase has been reported.8–14 The aim in this work was to assess if previous estimation of the skin-to-periosteum depth
Department of Dermatology and Andrology, Alexandria University, Alexandria, Egypt
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© 2014 by the American Society for Dermatologic Surgery, Inc. Published by Lippincott Williams & Wilkins ISSN: 1076-0512 Dermatol Surg 2015;41:94–101 DOI: 10.1097/DSS.0000000000000206
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·
·
94
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
EL-GAREM
in the medial part (tear trough) or lateral part (palpebromalar groove) could affect the choice between bolus and serial puncture technique and thereby the procedure outcome.
Patients and Methods This prospective, randomized comparative clinical study was approved by the Research Ethical Committee of Faculty of Medicine, Alexandria University, and written informed consent was obtained from each patient before participation. The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki. The study design was formulated to assess 75 female patients with defects in the infraorbital groove for selected inclusion criteria. Suitability for the protocol required that the patients not be pregnant, lactating, or have received any dermal fillers, injection lipolysis, or laser treatment in the vicinity of the infraorbital groove during the preceding 12 months. Moreover, inclusion in the study was contingent on the patient having almost the same degree of the infraorbital groove. Other criteria used to exclude patients were evidence of active inflammation, infection, cancerous or precancerous lesions, or changes in the regulation of blood clotting (e.g., as a consequence of anticoagulant treatment). Patients with medical or psychiatric problems that could interfere with their compliance, cooperation, or expectations were also disqualified. In accordance with their inclusion and exclusion criteria, 45 of the original series of 75 female patients were included in the analysis. For each of these patients, 2 vertical lines were drawn: one downward from the midpupillary line and the other one from the outer canthus. The points where these 2 lines intersected with a horizontal crescent line drawn 2 mm below the inferior orbital margin were defined as Points A and B, respectively. A 2-cm-long 28 G needle was inserted at each of these 2 points, and the depth of its penetration until it touched the periosteum was determined and documented. Only 32 patients of the initially selected 45 patients met the criteria of having nearly identical depths of needle penetration at Points A and B in both eyes; the
13 patients in whom this criterion was not met were excluded. For each eligible patient, the treated area was traced on a sketch and kept in their file. This sketch was used to report the skin-to-periosteum depth on both sides, the technique used on each side, and the volume of the injected material. For all included patients, the sites of treatment were photographed before injection and immediately after injection. Injection Technique The filler used was a nonanimal stabilized hyaluronic acid filler (Restylane; Q-Med, Uppsala, Sweden). The right side was injected using the bolus technique, whereas the left side was injected using the serial puncture technique. The same physician treated all patients. For all patients, topical anesthetic cream was applied along the inferior orbital margin for about 45 minutes. Each patient was advised to apply ice packs to the area several minutes before injection to induce an anesthetic effect. The skin was cleaned with alcohol swabs. Injections were performed while each patient was in a vertical sitting position, with their heads rested against a solid headrest. Patients were asked to close their eyes. After marking the lines, the sites of Points A and B were indicated using a ruler. A 2-cm 28 G needle (Figure 1) was introduced perpendicularly in each point. Once skin retraction from the site of needle insertion had disappeared, the author then measured the length of the needle that had not penetrated the skin. The length left outside without penetration was subtracted from the total of 2-cm length of the needle to determine the depth of penetration of the needle (Figures 2 and 3). Bolus Technique (Right Side) The 2-cm 28 G needle was introduced twice to fill the depression and smoothen the lid–cheek margin. The first insertion was at Point A (located at the midpupillary vertical line), whereas the second was at point B (located at the lateral canthus). The author placed the 2-cm 28 G needle through the skin at Point A until they gently touched the periosteum because excess pressure on the periosteum will
41:1:JANUARY 2015
95
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
BONE DEPTH IN TEAR TROUGH
Figure 1. A 2-cm 28 G needle.
cause pain. Between 0.25 and 0.35 mL of HA per bolus was then placed over the periosteum, and the needle was withdrawn slightly during the period of injection until the tip of the needle was at the innermost surface of the muscle layer. After gentle massage of the affected area, Point B was then injected in a similar way. The rate of injection should be slow with very light pressure and with aspiration (Figure 4). Serial Puncture Technique (Left Side) The 2-cm 28 G needle was introduced at 3 points: the first 2 were similar to Points A and B used for the bolus technique, Point C was midway between the medial canthus and the midpupillary line. The syringe was introduced at Point A until it touched the periosteum, after which a small aliquot (0.1–0.2 mL) of HA was deposited. The needle was then retracted 1 to 2 mm, redirected medially, and then advanced to touch the periosteum again before depositing another similarly
Figure 2. Diagrammatic illustration for Points A and B used to measure the depth of the inferior orbital rim.
96
Figure 3. Placing the needle perpendicularly to measure the depth of the inferior orbital margin by subtracting the reading from the original needle length (2 cm).
sized small aliquot. The needle was never completely withdrawn during the course of medial or lateral movements. These steps were then repeated for Points B and C (Figure 4). All patients were instructed to not massage the injected areas to avoid the possibility of inappropriate dispersal of the product. The material could be easily manipulated and reshaped for at least several weeks. Patients were encouraged to return if they perceived any irregularities. In instances when this was necessary, a few minutes of in-office manipulation usually addressed minor irregularities.
Figure 4. Diagrammatic illustration to show intended points of injection in both techniques (bolus injection on the right side and serial puncture injection on the left side).
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
EL-GAREM
Follow-up Follow-up was performed by an investigator who was masked to the techniques used and was asked to assess each side regarding (1) the improvement (contour of the injected area) using the global aesthetic improvement scale (GAIS)15 and patient satisfaction level (Table 1), and (2) any adverse events (pain, edema, erythema, bruising, infection, nodule formation, and/or need to use hyaluronidase) immediately after injection and throughout the subsequent 2 weeks. Results In this study, the author enrolled 32 female patients with nearly symmetrical tear trough deformities. Their ages ranged from 28 to 55 years (mean 6 SD = 38 6 5.67). The skin-to-periosteum distance in all patients ranged from 0.3 to 1.4 cm. It ranged from 0.3 to 0.49 cm at Point A, and from 0.52 to 1.4 cm at Point B. The skin-to-periosteum depth was considered deep when it exceeded 0.5 cm, whereas a skin-to-periosteum depth of less than 0.5 cm was considered to be shallow. The choice of 0.5 cm as a threshold distance was based on analysis of more than 50 patients, some of whom were included in the study and others were excluded owing to asymmetry. Physician Assessments Various degrees of improvement were documented by the masked investigator in all of the patients included
in the study (n = 32), with GAIS values ranging between 1 and 3 (mean = 1.5). The results after assessment of both sides are summarized in Table 2 and Figures 5–8. The author’s results revealed no significant differences in the degree of improvement between both sides in 9 of the 32 patients (28%), but a significant difference in the degree of improvement between both sides in 23 of the 32 patients (71%). Thirteen (40%) of the patients showed better improvement on the right side than on the left side, whereas 10 (31%) showed better improvement on the left side than on the right side. By correlating these results with the previously documented depths at Points A and B, the author’s results revealed that 11 of 13 patients (84.6%) showed better results on the right side (injected using the bolus technique) with deep (>0.5 cm) injection at Points A and B, whereas 9 of 10 patients (90%) showed better results on the left side (injected using the serial puncture technique) with superficial (
BACKGROUND Different techniques have been used for filler injection of the tear trough and palpebromalar groove. Most patients report good results; however, some patients here experienced variable degrees of side effects. OBJECTIVE To assess if previous estimation of the bony orbit depth could affect the choice between bolus and serial puncture technique, and thereby the procedure outcome. MATERIALS AND METHODS In 32 patients, the periosteum depth was measured by using a 28 G needle at 2 points: Point A at the midpupillary line and Point B at the outer canthus. The bolus technique was performed in the right side, and serial puncture technique was done on the left side. RESULTS There was a significant difference in the degree of improvement between both sides in 71% of patients: 40% had better improvement on the right side, whereas 31% had better improvement on the left side. Cases with skin-to-periosteum depth less than 0.5 cm showed better results with serial puncture technique, whereas those with more than 0.5 cm depth showed better results with bolus technique. CONCLUSION technique.
Assessment of bony orbit depth could offer new tool for selecting infraorbital groove injection
The author has indicated no significant interest with commercial supporters.
T
he tear trough, also called the nasojugal groove, is a natural depression that extends inferolaterally from the medial canthus to the approximate location of the midpupillary line.1 The palpebromalar groove, also called the lid–cheek junction, extends laterally from the tear trough.2 Although many factors might contribute to periorbital aging, the presence of atrophy of the skin and subcutaneous fat and bone resorption make the most substantial contributions, leading to accentuation of both nasojugal groove and inferior orbital rim.3,4 Accordingly, current management of the deformity in the tear trough caused by aging has increasingly involved volume restoration and the use of hyaluronic acid (HA).5
Various techniques have been used to correct the tear trough deformity and palpebromalar groove, some of which involve either serial puncture injected along the inferior orbital rim into the suborbicularis oculi,6 or the bolus technique.7 The bolus technique requires subsequent digital massage for effective dispersal of the injected material. Regardless the technique used, most patients report good results; however, some patients experienced variable degrees of bruising, erythema, discomfort, and/or swelling. Occasionally, nodule formation requiring treatment with hyaluronidase has been reported.8–14 The aim in this work was to assess if previous estimation of the skin-to-periosteum depth
Department of Dermatology and Andrology, Alexandria University, Alexandria, Egypt
·
© 2014 by the American Society for Dermatologic Surgery, Inc. Published by Lippincott Williams & Wilkins ISSN: 1076-0512 Dermatol Surg 2015;41:94–101 DOI: 10.1097/DSS.0000000000000206
·
·
·
94
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
EL-GAREM
in the medial part (tear trough) or lateral part (palpebromalar groove) could affect the choice between bolus and serial puncture technique and thereby the procedure outcome.
Patients and Methods This prospective, randomized comparative clinical study was approved by the Research Ethical Committee of Faculty of Medicine, Alexandria University, and written informed consent was obtained from each patient before participation. The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki. The study design was formulated to assess 75 female patients with defects in the infraorbital groove for selected inclusion criteria. Suitability for the protocol required that the patients not be pregnant, lactating, or have received any dermal fillers, injection lipolysis, or laser treatment in the vicinity of the infraorbital groove during the preceding 12 months. Moreover, inclusion in the study was contingent on the patient having almost the same degree of the infraorbital groove. Other criteria used to exclude patients were evidence of active inflammation, infection, cancerous or precancerous lesions, or changes in the regulation of blood clotting (e.g., as a consequence of anticoagulant treatment). Patients with medical or psychiatric problems that could interfere with their compliance, cooperation, or expectations were also disqualified. In accordance with their inclusion and exclusion criteria, 45 of the original series of 75 female patients were included in the analysis. For each of these patients, 2 vertical lines were drawn: one downward from the midpupillary line and the other one from the outer canthus. The points where these 2 lines intersected with a horizontal crescent line drawn 2 mm below the inferior orbital margin were defined as Points A and B, respectively. A 2-cm-long 28 G needle was inserted at each of these 2 points, and the depth of its penetration until it touched the periosteum was determined and documented. Only 32 patients of the initially selected 45 patients met the criteria of having nearly identical depths of needle penetration at Points A and B in both eyes; the
13 patients in whom this criterion was not met were excluded. For each eligible patient, the treated area was traced on a sketch and kept in their file. This sketch was used to report the skin-to-periosteum depth on both sides, the technique used on each side, and the volume of the injected material. For all included patients, the sites of treatment were photographed before injection and immediately after injection. Injection Technique The filler used was a nonanimal stabilized hyaluronic acid filler (Restylane; Q-Med, Uppsala, Sweden). The right side was injected using the bolus technique, whereas the left side was injected using the serial puncture technique. The same physician treated all patients. For all patients, topical anesthetic cream was applied along the inferior orbital margin for about 45 minutes. Each patient was advised to apply ice packs to the area several minutes before injection to induce an anesthetic effect. The skin was cleaned with alcohol swabs. Injections were performed while each patient was in a vertical sitting position, with their heads rested against a solid headrest. Patients were asked to close their eyes. After marking the lines, the sites of Points A and B were indicated using a ruler. A 2-cm 28 G needle (Figure 1) was introduced perpendicularly in each point. Once skin retraction from the site of needle insertion had disappeared, the author then measured the length of the needle that had not penetrated the skin. The length left outside without penetration was subtracted from the total of 2-cm length of the needle to determine the depth of penetration of the needle (Figures 2 and 3). Bolus Technique (Right Side) The 2-cm 28 G needle was introduced twice to fill the depression and smoothen the lid–cheek margin. The first insertion was at Point A (located at the midpupillary vertical line), whereas the second was at point B (located at the lateral canthus). The author placed the 2-cm 28 G needle through the skin at Point A until they gently touched the periosteum because excess pressure on the periosteum will
41:1:JANUARY 2015
95
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
BONE DEPTH IN TEAR TROUGH
Figure 1. A 2-cm 28 G needle.
cause pain. Between 0.25 and 0.35 mL of HA per bolus was then placed over the periosteum, and the needle was withdrawn slightly during the period of injection until the tip of the needle was at the innermost surface of the muscle layer. After gentle massage of the affected area, Point B was then injected in a similar way. The rate of injection should be slow with very light pressure and with aspiration (Figure 4). Serial Puncture Technique (Left Side) The 2-cm 28 G needle was introduced at 3 points: the first 2 were similar to Points A and B used for the bolus technique, Point C was midway between the medial canthus and the midpupillary line. The syringe was introduced at Point A until it touched the periosteum, after which a small aliquot (0.1–0.2 mL) of HA was deposited. The needle was then retracted 1 to 2 mm, redirected medially, and then advanced to touch the periosteum again before depositing another similarly
Figure 2. Diagrammatic illustration for Points A and B used to measure the depth of the inferior orbital rim.
96
Figure 3. Placing the needle perpendicularly to measure the depth of the inferior orbital margin by subtracting the reading from the original needle length (2 cm).
sized small aliquot. The needle was never completely withdrawn during the course of medial or lateral movements. These steps were then repeated for Points B and C (Figure 4). All patients were instructed to not massage the injected areas to avoid the possibility of inappropriate dispersal of the product. The material could be easily manipulated and reshaped for at least several weeks. Patients were encouraged to return if they perceived any irregularities. In instances when this was necessary, a few minutes of in-office manipulation usually addressed minor irregularities.
Figure 4. Diagrammatic illustration to show intended points of injection in both techniques (bolus injection on the right side and serial puncture injection on the left side).
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
EL-GAREM
Follow-up Follow-up was performed by an investigator who was masked to the techniques used and was asked to assess each side regarding (1) the improvement (contour of the injected area) using the global aesthetic improvement scale (GAIS)15 and patient satisfaction level (Table 1), and (2) any adverse events (pain, edema, erythema, bruising, infection, nodule formation, and/or need to use hyaluronidase) immediately after injection and throughout the subsequent 2 weeks. Results In this study, the author enrolled 32 female patients with nearly symmetrical tear trough deformities. Their ages ranged from 28 to 55 years (mean 6 SD = 38 6 5.67). The skin-to-periosteum distance in all patients ranged from 0.3 to 1.4 cm. It ranged from 0.3 to 0.49 cm at Point A, and from 0.52 to 1.4 cm at Point B. The skin-to-periosteum depth was considered deep when it exceeded 0.5 cm, whereas a skin-to-periosteum depth of less than 0.5 cm was considered to be shallow. The choice of 0.5 cm as a threshold distance was based on analysis of more than 50 patients, some of whom were included in the study and others were excluded owing to asymmetry. Physician Assessments Various degrees of improvement were documented by the masked investigator in all of the patients included
in the study (n = 32), with GAIS values ranging between 1 and 3 (mean = 1.5). The results after assessment of both sides are summarized in Table 2 and Figures 5–8. The author’s results revealed no significant differences in the degree of improvement between both sides in 9 of the 32 patients (28%), but a significant difference in the degree of improvement between both sides in 23 of the 32 patients (71%). Thirteen (40%) of the patients showed better improvement on the right side than on the left side, whereas 10 (31%) showed better improvement on the left side than on the right side. By correlating these results with the previously documented depths at Points A and B, the author’s results revealed that 11 of 13 patients (84.6%) showed better results on the right side (injected using the bolus technique) with deep (>0.5 cm) injection at Points A and B, whereas 9 of 10 patients (90%) showed better results on the left side (injected using the serial puncture technique) with superficial (
