title: Evolving Minimally Invasive Techniques for Tear Trough Enhancement.
abstract: OBJECTIVE
  The aim of this study is to investigate whether volumetric enhancement of the infraorbital rim area or, alternatively, of the deep medial cheek, results in greater improvement of tear trough deformity.
  
  
  METHODS
  This prospective, single-blind study recruited 12 patients seeking correction of tear trough deformity. Pretreatment standardized photographs were obtained after which patients were randomized to receive hyaluronic acid gel filler augmentation of the tear trough on one side and hyaluronic acid gel augmentation of the cheek on the contralateral side. The patients were then re-examined at 3 weeks postinjection when standardized photographs were taken again. Following the photographs, filler was added to the side and location where they were not used at the original treatment, resulting in added volume in both the cheek and the tear trough. The patients returned 3 weeks later when final photographs were taken. The pre- and post-treatment images were randomized and evaluated by 3 masked observers asked to evaluate the depth of tear trough.
  
  
  RESULTS
  There was a significant improvement in the depth of the tear trough rating after initial treatment on the side treated in the tear trough (p = 0.0001). There was not a significant change in depth of tear trough rating, however, on the side receiving cheek only treatment (p = 0.0963). There was a statistically significant change in tear trough rating after both tear trough and cheek had been treated on each side (p = 0.001). There was no statistically significant difference between sides after lid and cheek treatment had been completed on each side (p = 0.5986). Intraclass correlation between reviewers for all subjects was excellent at 0.94. Tear trough injections were more technique sensitive than cheek volume augmentation to achieve satisfactory results. There were no complications from cheek volume enhancement. Varying degrees of ecchymosis were encountered with tear trough injections.
  
  
  CONCLUSIONS
  When the patient's primary concern is the appearance of the tear trough, and the physician is limited to treating either the tear trough or the cheek alone, it appears that treatment in the tear trough offers greater improvement in the appearance of the tear trough deformity when compared with treatment in the cheek alone.
authors.affiliation: *Plastic Surgery Ohio, The Eye Center of Columbus; †Department of Ophthalmology, The Ohio State University; ‡Section of Oculofacial Plastic and Reconstructive Surgery, Ohio Health Doctors Hospital, Ohio University, Columbus Ohio; §Department of Ophthalmology, Drexel University; and ‖Scheie Eye Institute, University of Pennsylvania, Philadelphia, Pennysylvania, U.S.A.
authors.forename: Robert H
authors.initials: RH
authors.lastname: Hill
authors.forename: Craig N
authors.initials: CN
authors.lastname: Czyz
authors.forename: Srinivas
authors.initials: S
authors.lastname: Kandapalli
authors.forename: Sandy X
authors.initials: SX
authors.lastname: Zhang-Nunes
authors.forename: Kenneth V
authors.initials: KV
authors.lastname: Cahill
authors.forename: Allan E
authors.initials: AE
authors.lastname: Wulc
authors.forename: Jill A
authors.initials: JA
authors.lastname: Foster
mesh_terms: D003357:Cosmetic Techniques; D000067548:Dermal Fillers; D005260:Female; D006801:Humans; D006820:Hyaluronic Acid / Q000008:administration & dosage / Q000031:analogs & derivatives*; D007765:Lacrimal Apparatus / Q000187:drug effects*; D008297:Male; D019060:Minimally Invasive Surgical Procedures; D011446:Prospective Studies; D016037:Single-Blind Method; D015595:Skin Aging; D055675:Viscosupplements / Q000008:administration & dosage*
chemical_list: D000067548:Dermal Fillers; D055675:Viscosupplements; D006820:Hyaluronic Acid; C445361:Restylane