Permanent Filler for Tear Troughs?

Question

Is it effective to use a permanent filler like Radiesse or Artefill for my tear troughs / under-eye hollows?  What are the risks?

Brent Moelleken, MD · Answer

Rejuvenation of the under eye area is different for different ages and degrees of problem.  As surgeons, we must be concerned not only giving a nice durable result to the patient, but also to preventing problems which can be long-lasting and in some cases untreatable. 
The lower eyelids are particularly dangerous because of the thin skin which shows all bulges clearly.  Remember that when you see the fat that normally bulges out below the lower eyes, this fat is covered by the skin, by the orbicularis muscle and by the orbital septum, yet it appears at the surface.  This guides our philosophy that things we do should not be unnecessarily irreversible.
For younger patients, Juvederm, Perlane or  Restylane work very well and are generally smooth.  Obviously your doctor should be familiar with the anatomy and know where larger vessels are typically located, especially as they supply the central midface, to avoid unnecessary bruising.
Permanent and semipermanent fillers in the tear trough area are risky because they can develop granulomas (permanent lumps) which may require excision.  Sculptra around the eyes is particularly bad in this respect.  Silicone is also a disaster, with chronic permanent, untreatable swelling.  I have never seen granulomas from Juvederm.  Occasionally, patients have prolonged swelling from hyaluronic acid fillers, but I have never seen permanent swelling.  Although it is almost never necessary, hyaluronic acid fillers can be reversed with hyaluronidase, not true for the other semi-permanent fillers.
For more severe problems of aging, lower eyelid surgery becomes an option.  This could be transconjunctival surgery, fat repositioning surgery, and possibly canthal surgery , depending on the appearance of the eye and any necessary adjustments.
For patients who have had previous eyelid surgery and have noticed a rounding of their eyes with pulling down of portions of the lower eyelid, a cheeklift may be necessary.  Cheeklifts (i.e. LUSIC) can elevate the thicker tissue of the midface, concealing hollowness.
We have been quite satisfied with LiveFill (nontraumatized fascial fat grafts) and have presented and published our results.  We have found by cellular studies that LiveFill is alive when the grafts are sculpted from the patient's own tissues, unlike fat injection, where most of the injected cells are dead.  While the fat injection technique, under competent hands, can yield excellent results, even in the very best of hands there are often irregularities below the eyelids that can be difficult or impossible to fix. 
So there is the strategy for lower eyelid hollowness through the years.
Patients who focus on the filling material rather than the person administering the material or performing the procedure will be disappointed;  all painters use paint, but their art is not equal.

Nima Shemirani, MD · Answer

I would not recommend Radiesse to be injected into the tear trough area since it is not reversible. Typically, HA based fillers like Juvederm or Restylane are injected into the tear trough area and are reversible with Hylenex if need be.

J. Jason Wendel, MD, FACS · Answer

Thank you for your question in regards to tear troughs. Fillers can be a wonderful product for treating the tear trough area. We use both Vollure and Voluma for tear trough correction. For very deep grooves you might need the lifting capacity of Voluma, but for less severe volume loss Vollure is wonderful. These two products tend to have the least amount of swelling compared to the other hyaluronic acid fillers available in the US, which is very desirable in this specific treatment area. We do not recommend using permanent fillers in the tear trough area. To find out what is best for you, see two or more board-certified providers in your area for a complete evaluation to make sure you are a good candidate and that it is safe for you to have treatment. I hope this helps.

Richard J. Bruneteau, MD · Answer

Patients are often interested in long term solutions for
their aesthetic concerns. When patients have tear trough deformities they often
request long acting fillers for this reason. Unfortunately, long acting fillers
aren’t always the best choice when treating this type of problem. Radiesse,
Scultptra and artefill are all associated with the development of granulomas,
nodules and skin discoloration. This is especially true when injections are
performed in the lower eyelids where the skin is very thin. In addition, these
fillers aren’t easily reversed and therefore effectively permanent.For
this reason, we prefer hyaluronic acid fillers for tear trough deformities.
These fillers which include Juvederm, Restylane and Perlane are soft and smooth
and can be easily reversed with the enzyme hyaluronidase when patients are
dissatisfied. In patients who are satisfied with this approach, but still
desire a long term solution, autologous fat injection may be appropriate. It’s
important to understand that lower eyelid filler injections can be very
effective for treating tear trough deformities. Unfortunately long acting
fillers may be associated with complications and aren’t easily reversed. For
this reason it’s important that patients with tear trough deformities be
evaluated by a board certified plastic surgeon. This surgeon should be able to
formulate an appropriate treatment plan for this problem.

William Groff, DO · Answer

First, Artefil is the only permanent filler FDA approved in the USA.  That being said, none of the fillers are FDA approved in this area.  The tear trough area can be one of the trickiest and unforgiving areas to use fillers.
With that in mind, I do not recommend Artefil for this area.  Radiesse is a good option, but not necessarily the best.  Radiesse, if injected improperly, cannot be removed (except surgically, same with Artefil).
If a hyaluronic acid based filler, like Restylane or Juvederm, is used, and you don't like the results, it can be removed easily by injecting a medication (Vitrase) that dissolves the product completely.
Results with these 2 fillers in the tear trough area can last 9 months to well over 1 year.  Make sure you do your research and seek out a very experienced injector.
Best Wishes,
Dr.Groff

Michael Law, MD · Answer

In patients who have developed deep 'tear troughs' at the junction of the lower lid and cheek, adjacent to the side of the nose, the meticulous grafting of fat harvested from the patient's abdomen, hips or thighs can build this area back up and nicely restore a more youthful contour. In some blepharoplasty patients this depression or 'hollow' extends horizontally across the entire junction of the lower lid and cheek, and this must be corrected to obtain the ideal postoperative result.

	In select patients, lower lid rejuvenation may consist of conservative reduction (not removal) of the lower lid fat pads or 'bags', in combination with structural fat grafting of the 'tear trough' hollow immediately below. As with all aesthetic surgical procedures, it is absolutely essential to customize the surgical plan to the specific needs of every patient. Fat grafting has been performed by plastic surgeons for decades. There is no question that fat is the ideal material for soft tissue augmentation, and that the results obtained with fat grafting are the most natural-appearing. However, one problem with this procedure in years past has been resorption (breakdown) of the grafted fat, so that the resulting improvement is not permanent. The grafted fat must gain its own blood supply in its new location in order to persist long-term, and this generally is not possible when large amounts are injected at once and when specialized instrumentation and techniques are not employed.

	A relatively new technique has been developed called structural fat grafting, in which small amounts (less than 0.1 cc at a time) of fat are carefully microinjected in a series of discrete layers to gradually 'build' new soft tissue structure. As there is space between each microinjection, new blood vessels are able to grow into the grafted fat, allowing it to persist. If this process of blood vessel ingrowth (neovascularization) does not occur, then the injected tissue cannot truly be considered a 'graft' and is instead just another 'soft tissue filler' of limited duration.

Stella Desyatnikova, MD · Answer

This website is a great resource enabling prospective patients to get unbiased information about all the possibilities, as well as the risks and dangers, of the today's world of aesthetic surgery. I would really like to caution prospective patients about the use of permanent fillers.
In fact, I would go further. If your physician or "injector" wants to use a permanent filler around your eyes, I would turn around and run.  By the nature of my practice I end up seeing patients who have a problem or a complication from a procedure performed elsewhere.
I have seen a  number of patients who had Artefill, Sculptra, or Radiesse injected around the eyes only to develop granulomas, nodules, lumps, and other unsightly results, and we had to surgically excise them, usually via a rather extensive procedure.
Sometimes these problems do not develop for a while, so I anticipate we will continue seeing patients who had the procedure up to several years ago and gradually develop a complication.
Hyaluronic acid fillers are great in this area. They are reversible which is important in short term, and they do eventually go away which is important in the long term, as our face changes with age.

Stephen A. Goldstein, MD · Answer

Treatment of facial contour irregularities are both technically and aesthetically demanding.especaily in the tear trough area.  Artefil is a permanent filler that is approved FDA; however, I would not advise injection this particular soft tissue filler because it is permanent without an easy way to correct or remove it outside of surgery.  A much better permanent soft tissue filler is fat injection (auto-grafting) and I am in agreement  with the comments made by the Dr. Freund. 
Radiesse is a chemical found in bone and teeth (calcium hydroxylapatite) and is an efffective soft tissue filler thatit is not permanent.  It tends to last around year or more.  I use this to treat the tear troughs, especially, when a patient reqiures volume correction in the cheeks.  
If a patient is seeking only to improve the contour irregulaities in the transjugual groove-tear trough area, my first choice is to use Juvederm (hyaluronic acid). This product will last around a year. It injects smoothly and evenly.  As mentioned by Dr.Groff, the product can be easily reversedby injectinging hyalurondase.
The choice of a  board certified physician experienced in soft tissue fillers is adivised.
I hope this helpful!
Stephen A. Goldstein, MD

Robert M. Freund, MD · Answer

The tear trough or nasojugal groove is the depression under the eye that can be present genetically from an early age or more often occurs as we age.
The depression is the result of several different things happening at once.

The fat that bathes the eyeball starts to puff out. The bottom edge of the puffiness appears to be a groove. This is best treated by correcting the bulge.
The muscles that surround the eye and the muscle that attach to the nose to make it scrunch up are separated in this area making it look hollow. This can be genetic or progressive with age. Either way the only way to treat it is with a filler.
The cheek tissues are sagging as we get older and the loss of volume enhances the depression. Cheek lifts or mid face lifts will correct most of the depression but not the most medial component next to the nose. I have performed many vertical cheek lifts and had satisfactory improvement of some of the tear trough.

As for the fillers, I am a proponent of using fat injections for several reasons.
1.  It is natural and your own.
2.  It is filling an area that had fat with fat.
3.  The tear troughs usually require 3-4 cc per side for an adequate fill and that makes synthetic fillers prohibitively expensive. fat is more than available.
4.  No concern about unnatural color under the skin. Some fillers create a bluish color under the skin.
In the near future a company is coming out with a fat injection system called Viafill that will increase the number of live fat cells injected by 500% over comparable injection systems.
Best of luck.
Robert M. Freund, MD, FACS

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