Tear Trough Filler Techniques Utilizing Hyaluronic Acid: A Systematic Review

Abstract

Background: Hyaluronic acid soft-tissue augmentation fillers are commonly injected into multiple areas of the face, including the tear trough. Despite well-documented risks, there is no standardized, evidence-based approach to inject filler in this area, be it using a hypodermic needle or a microcannula. The authors, therefore, sought to establish a preference between the two methods to facilitate progression toward standardization and prevention of adverse events. Methods: This is a systematic review of articles discussing hyaluronic acid tear trough injection techniques performed in vivo and related outcomes. Searches were conducted across The Cochrane Library, PubMed, Scopus, Web of Science, and Embase to yield relevant articles published before February of 2020. All selected articles incorporated discrete patient cases and were analyzed by a variety of variables assessing evidence strength, outcomes, technique, and patient safety. Results: After appraisal, 42 articles met eligibility criteria: 20 using needles, 12 using cannulas, and 10 focusing on adverse events. Level III was the most commonly awarded evidence grade, corresponding to retrospective, nonexperimental descriptive studies. There were no statistically significant differences in reported aesthetic results, patient satisfaction, or incidence of adverse events across the needle-based and cannula-based articles. Some technique trends, such as targeted anatomical plane and needle position, emerged in subsequent articles. Conclusion: Given that there were no statistically significant differences in patient safety or outcomes, an evidence-based preference for needle or cannula injection into the tear trough cannot be made at this time. Current inconsistencies make tear trough injection procedures difficult to replicate, making standardization based on avoidance of adverse events not feasible.

Tear Trough Filler Using the Three-point Tangent Technique: Lessons from 1452 Tear Trough Applications

“…When comparing needle-based and cannula injection techniques, bruising has been shown to be more common in needle techniques. 9 There were no complications of vascular occlusion or visual loss, but one patient developed a retrobulbar hemorrhage, despite the use of a blunt canula. This was identified immediately by the injecting surgeon and dealt with promptly with canthotomy and cantholysis.…”

“…When comparing needle-based and cannula injection techniques, bruising has been shown to be more common in needle techniques. 9…”

“…A blunt cannula is used to reduce tissue trauma and the risk of complications. 8,9 The benefit of our technique is that the curved nasojugal and palpebromalar groove are deconstructed into linear components. This allows for retrograde linear threading, following the course of a straight cannula, creating minimal collateral tissue damage and enabling filler placement in the correct position.…”

Facial fillers: Relevant anatomy, injection techniques, and complications

“…Injection can be accomplished via needle or cannula injection. The most common technique is retrograde linear threading 20 . The ideal injection depth is deep to the orbicularis oculi muscle and superficial to the periosteum.…”

Prospective comparative clinical study: Efficacy evaluation of collagen combined with hyaluronic acid injections for tear trough deformity

“…7 Surgical interventions may present challenges in this population including overcorrection and prolonged recovery periods, making filler injections an appealing alternative. 8 Hyaluronic acid (HA) is currently the preferred filler for tear troughs, with other options like calcium hydroxyapatite and collagen also available. 9 Due to its low elasticity and enzymatic solubility, HA is recommended as the injectable filler of choice for the periorbital region.…”