Filling the nasolacrimal sulcus with hyaluronic acid through one point

The appearance of the nasolacrimal sulcus is associated with aging processes and congenital anatomical features of the infraorbital zone.

An aesthetically satisfactory result of the depression correction is a smooth transition from the preseptal to the orbital part of the orbicular muscle of the eye and the absence of a visible demarcation with the upper malar zone.

Filling the nasolacrimal trough with hyaluronic acid allows you to get exactly this result, even when the drug is injected through one point.

This is the opinion of Dr. Abdul Nassimizadeh, Mohammad Nassimizadeh, Shahzada K. Ahmed, whose approach to solving the problem is described in the article estet-portal.com.

• Lacrimal trough: anatomy and aging of the target zone
• Nasolacrimal trough filling with hyaluronic acid: patient choice
• Technique for filling the nasolacrimal trough with HA through one point
• Potential complications to be warned about ta

Lacrimal trough: anatomy and aging of the target zone

When classifying anatomical features and aging of the nasolacrimal trough, three main factors are taken into account:

• volume loss;
• herniated orbital fat;
• excess skin of the lower eyelid.

In the region of the lower eyelid and the middle third of the face, two main tissue planes are distinguished – superficial and deep.

Together they form the junction of the lower eyelid and buccal area, as well as the nasolacrimal sulcus.

The superficial plane includes the pretarsal and orbital parts of the orbicularis muscle of the eye, as well as the fat layer below them.

In the deep plane the junction of the eyelid and cheek is separated from the nasolacrimal sulcus.

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Medially, the orbital part of the orbicularis oculi muscle inserts on the maxilla; laterally, the muscle is also fixed by ligaments.

Fibrous structures extend from the periosteum along the inferior edge of the orbit and eventually delaminate.

Through the orbicular muscle of the eye, they penetrate the skin in the form of a ligament holding the orbicular muscle of the eye, which is attached to the zygomatic bone and caudally – to the bony edge of the orbit.

The formation of the nasolacrimal trough is due to several factors.

Anatomical features may include:

• volume loss;
• flabbiness of the skin;
• in some patients, the nasolacrimal sulcus is located within the border of the orbicular muscle of the eye.

With age, the elasticity and thickness of the skin of the lower eyelid decreases, and a tendency to hyperpigmentation appears.

Loss of volume in the middle third of the face leads to a weakening of the support of the nasopharyngeal cavity, as a result of which the nasolacrimal trough becomes more pronounced.

There is a weakening of the supporting ligaments due to gravity on the middle third of the face.

An important role is also played by features of other structures of the middle third of the face, for example, retrognathia of the upper jawty.

Filling the nasolacrimal trough with hyaluronic acid: patients' choice

The correct choice of the patient largely determines the result of filling the nasolacrimal trough with hyaluronic acid.

During the consultation, it is necessary to evaluate skin quality and furrow depth.

Ideal candidates have:

• good skin tone;
• minimal degree of skin laxity;
• nasolacrimal sulcus small – moderate depth.

Care must be taken if the patient has large fat pads or false hernias in the infraorbital region.

In such cases, the improvement is minimal and often accompanied by complaints of "puffiness"; after correction.

Patients presenting with fatty tissue herniation, excessive laxity or excess skin may be better advised to undergo surgical correction.

Discoloration of the lower eyelid may increase the severity of the nasolacrimal sulcus – and correction with fillersand HA does not always provide a satisfactory result.

Technique for filling the nasolacrimal trough with HA through one point

Direct injection of hyaluronic acid into the lower eyelid area is not recommended due to the thinness of the skin.

In order to reduce swelling and the risk of bruising, ice packs are applied to the target area for several minutes before the administration of the drug.

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Marking is done when the patient is in an upright position and looks up.

The zygomatic area is treated with an anesthetic cream, and then 0.3 ml of lidocaine is injected.

In order to avoid distorting the anatomy, the authors do not use infraorbital anesthesia.

A small channel is created with a 23–25 gauge needle (depending on skin thickness) through which a cannula (25 gauge, 50mm) is inserted.

This reduces the risk and severity of bruising, as the procedure is less traumatic.

Read also: Case report: nasolacrimal trough correction with HA fillers

The cannula is inserted medially to the deepest point, hyaluronic acid is injected deeply at several levels in a retrograde technique as the cannula is withdrawn.

Dashed filler lines are created for the most natural result.

To avoid hypercorrection when filling the nasolacrimal sulcus, the authors inject a small amount of hyaluronic acid, creating a kind of gradient from the medial to the lateral part of the sulcus.

The right choice of patient and well-conducted consultation – key to successful correction of the nasolacrimal trough.

To evenly distribute the product, after completion of the correction, lightly massage the treated area, after which ice packs are applied for 10 minutes.

Potential complications to be warned about

Before the procedure, the patient should be warned about the possibility of:

• ecchymosis (their risk is reduced by cannula technique and the use of ice packs);
• pain and redness (often self-limiting);
• skin surface irregularities (may be corrected by massage immediately after injection or corrected during a follow-up visit; if necessary, 10 units of hyaluronidase can be used to dissolve HA);
• slight swelling (due to the hydrophobicity of the filler and disappears after 2–3 weeks).

The duration of the effect depends on the brand of hyaluronic acid used to fill the tear trough.

However, the result of correction in the infraorbital region often lasts longer than in other areas of the face, due to limited soft tissue mobility.

Read also: Lacrimal trough filling: a case report

Adapted from The PMFA Journal.

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