Case Study: Rejuvenating the Periorbita

When I assessed her full face, I could see she has a good lateral cheek projection. was needed to achieve the long-lasting periorbital and facial rejuvenation, along with Accordingly, my strategy in treating this patient was to replace the facial volume, as well as to improve dermal thickness and elasticity in this area. By replacing the volume in the mid-cheek deep fat compartments, it’s possible to create adequate support to the tear trough area with an indirect approach and, based on my experience filling this area, improves infraorbital hollows indirectly.

Treatment options Different approaches, along with their advantages and disadvantages were discussed in detail with the patient. A twoweek cooling-off period was implemented before agreeing to go ahead. It was important that she could think carefully about each of her options, weighing the benefits of each against the possible risks and side effects. Options presented included collagenstimulating filler, hyaluronic acid-based fillers, botulinum toxin injections, skin Case Study: boosters and mesotherapy, skin resurfacing procedures such as IPL treatment and laser skin resurfacing. All of them are excellent Rejuvenating the treatments; however, when I asked the patient about her eye area, she mentioned that she gets swelling of the region in the Periorbita morning. Added to the poor elastic recoil, this made me reluctant to treat her tear trough area directly with HA filler, as per my original plan. While the patient knew very little about Nurse prescriber Anna Kremerov describes collagen depletion, she was keen to learn successful treatment of the under-eye area more about how a collagen-stimulating filler could help. using a non-direct approach Unlike HA, PCL particles cannot be dissolved Assessment natural-looking results. special attention to the product specification. A 52-year-old female patient presented to It’s imperative to understand that the cause She was then happy to proceed with the my clinic with concerns of dark under-eye of tear trough deformity is multifactorial, and recommended course of treatment. She was circles and acute skin laxity in the infraorbital isolated treatment may not be sufficient to informed of the possible risks prior to the area, following years of yo-yo dieting, lack of achieve a good aesthetic outcome. 1 The procedure, and an individual treatment plan sleep and stress. She asked for a tear trough main components of the tear trough are the was defined prior to the procedure. correction to achieve the desired outcome. periorbital hollow itself, superior fat bulge, My product of choice was Ellansé M. This She was otherwise healthy, with a history of a distinct change of skin colour and skin is because it works not only by volumising light smoking. thickness in the eyelid-cheek junction. 2 and correcting superficial rhytids but also However, she was quite clearly hollow in the anterior cheek, and this had exacerbated It’s imperative to understand that her under-eye appearance. In addition, her overall tired look was enhanced by facial the cause of tear trough deformity is laxity and formation of superficial rhytids in the infraorbital region. Following assessment, multifactorial and isolated treatment I concluded that a single treatment with a direct approach to treating her tear trough may not be sufficient to achieve a area could fail to meet the patient’s desired aesthetic outcome, and a different approach good aesthetic outcome so I explained this thoroughly to her, paying

Before After the same cannula entry point, treatment was extended to the zygomatic malar region on the periosteal plane to provide a soft contour to the lateral cheek area, with 0.5ml administered on each side. The submalar region was treated from the same entry point in the subcutaneous plane using a retrograde Patient before and immediately after treatment to the infraorbital area linear threading and with indirect approach using Ellansé M. fanning technique, with 0.05-0.1ml per by stimulating the body’s own collagen thread. A total of 0.4ml was used on each for a long-lasting, natural result. 3,4 Ellansé side. More superficial placement of the is a collagen biostimulator composed of a product in the subdermal plane with the totally bioresorbable polycaprolactone (PCL) same size cannula was used to achieve microspheres in a carboxymethylcellulose biostimulation, in order to increase collagen carrier gel. 4 It offers immediately visible production within the dermis and address results, and it’s complete bioresorbability subdermal volume loss. 3 This technique make this product suitable for patients was utilised over the mid-face region, with seeking long-lasting and stable results. 4 0.6ml used on each side. In this case, I used a single entry injection Treatment point to achieve desirable volume The patient was treated in a sitting replacement, with a total on 4ml injected; position. Makeup was removed prior 2ml on each side. to the procedure, and the area was My preferred technique is a single-point carefully disinfected with Clinisept+ Prep entry using a cannula, which allows me to & Procedure. The orbital rim was palpated achieve a whole mid-face revolumisation. and marked. The infraorbital foramen was I believe using a cannula is a safer and identified and marked prior to injection, as more comfortable technique for the patient, this is a no-go area to avoid severe nerve which could also decrease the risk of and artery compression and embolism. potential side effects such as bruising, On examination, there was a noticeable vascular compromise, bleeding and volume deficit in the anterior part of her ecchymosis. 6,7 With any technique, I always cheek, so I made the decision to target this use my non-injecting hand to palpate the area to volumise and improve the patient’s skin and avoid overcorrection. It is also infraorbital hollows indirectly. We agreed important to inject the product slowly with to treat the anterior part of her cheek and small boluses and to watch the tissue as check what degree of improvement we can you inject to see how much filling has been get in the infraorbital region with an indirect created. 8 approach. The procedure was performed The possible side effects observed with the with protective gloves. To facilitate a more PCL-based filler are identical to the comfortable procedure, I mixed 0.2ml of HA-based fillers and can be associated with lidocaine 2% with each 1ml syringe of the a risk of short and long-term complications product, as it can be safely performed such as oedema, bruising, vascular without altering the physical properties of compromise, nodules and granuloma the product. 5 The depth of injection always formation. 8 It’s imperative to discuss depends on the facial area treated and the post-procedural care with the patient and result I am trying to achieve. In the malar to highlight the importance of the aftercare area, a combination of retrograde injections in the prevention of some adverse events. and small boluses performed in the deep Following treatment, patients are advised to supraperiosteal plane, with 0.05-0.1ml per avoid makeup, exposure to heat or extreme line/bolus using a 25 gauge cannula. In cold, keep their face clean, avoid alcohol this case, I used 0.5ml on each side. From and physical activity for the next 24 hours. 8,9

Results At the three-month review, the patient remained extremely happy with the results. By replacing the volume in the mid-cheek deep fat compartments, I have managed to create an adequate support to the tear trough area with an indirect approach and improve infraorbital hollows indirectly. Thanks to the unique product properties, further collagen biostimulation will help to improve facial laxity by stimulating the body’s own collagen for a long-lasting, natural result.

Anna Kremerov is an advanced nurse practitioner and a registered prescriber. She has a Master of Science in Advanced Clinical Practice as well as Level 7 in Injectables for Aesthetic Medicine. Kremerov is a founder and clinical director of Anna Medical Aesthetics based in Swindon, Wiltshire. Qual: ANP, NIP, MSc in Advanced Clinical Practice

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