TEAR THROUGH FILLER TECHNIQUE

UTILIZING HYALURONIC ACID: A

SYSTEMATIC REVIEW
Babar K. Rao, M.D. Lauren E. Berger, B.A.
Catherine Reilly, B.A. Mahin Alamgir, M.D. Hassan Galadari, M.D.
Somerset, N.J.; New York, N.Y.; and Al Ai ,
United Arab Emirates

From the Rutgers Robert Wood Johnson Department of

Dermatology; Department of Dermatology, Weill Cornell Medicine; and the College of Medicine and Health Sciences, United
Arab Emirates University.
Received for publication August 25, 2020; accepted August 12, 2021.
Copyright @ 2022 by the American Society of Plastic Surgeons

Boris Kachman Meir Hospital, Israel 02/08/2022

 Background
Hyaluronic acid soft-tissue augmentation fillers are commonly injected into multiple areas of the face,
including the tear trough.

the evidence supporting use of cannulas over needles to inject hyaluronic acid into the tear trough
derives primarily from weak, indirect comparisons and anecdotal recommendations.

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.
 Soft-tissue fillers are commonly injected into multiple areas of the face, including the cheeks, lips, chin, nasolabial folds, forehead, and under
the eye.

Age-related tear trough “deformity”

results from multiple anatomical changes, mainly with the loss or herniation of
subcutaneous fat in the trough and an enhancement of the gap between the
levator labii superioris alaeque nasi muscle and the orbicularis oculi muscle.
Therefore causes a fatigue facial appearance.
Anatomy
John Humphrey Woodbury
Portrait of Gladys Marie Spencer Churchill, Duchess of Marlborough; the most notable victim of paraffinoma syndrome
 Methods
Searches were conducted across The Cochrane Library, PubMed, Scopus, Web of Science,
and Embase to yield relevant articles published before February of 2020.

Combination search terms included “needle and cannula,” “injection and cannula,” “needle and cannula and filler,”
“injection and cannula and filler,” “needle and cannula and tear trough,” “injection and cannula and tear trough,” and
more.
 Data Extraction
The angle and depth of injection is important for minimizing adverse effects.
Multiple reported techniques utilized to release the filler, including fanning, linear threading, feathering,
singular bolus, and retrograde techniques, were analyzed.

guided by the following predetermined checklist: study type, sample size, year published,
approximate years of experience of the first author, filler type, injection entry site, method of filler
release, needle/cannula gauge, outcome measured, photograph bias (defined as clinical photographs
lacking standardized lighting, angles, proximity, and patient makeup across before and after
photographs), statistically significant results, adverse effects, and levels of evidence grading.
 Inclusion criteria
- filler type: hyaluronic acid
- injection device: needle or cannula
- Tear through

Hypodermic needles- 20 articles.

Blunt-tip canulas- 12 articles.
Levels of evidence were based on the Journal of the American Academy of Dermatology guidelines
55 percent of needle-based articles and 20 percent of cannula-based articles applied at least one of the
following scales: Likert-type Scale, Infraorbital Hollowness Score, visual analogue scale,Global
Aesthetic Improvement Scale, Hirmand Classification System, Allegran Infraorbital Scale, and Barton Grading System.

subjective nature of photonumeric scales led to highly variable results and made it difficult to assess for grading
consistency.
The most frequently reported injection site was the tear trough across needle-based articles, and the
lateral orbital rim hollow across cannula-based articles. Other injection sites included the medial
infraorbital area, nasojugal groove, palpebromalar groove, upper malar area, and frontal-temporal
point of entry.

Needle size ranged from 27 gauge to 32 gauge, with the 30-gauge needle being the most frequent
(65 percent).

Size range was larger among the cannula-based articles (18 to 30 gauge).
Results
Results
Conclusion
a preference of needle or cannula method cannot be made because of inconsistencies across
present data. Future impartial, blinded, and prospective studies directly comparing the two
methods in vivo may help to more clearly establish one.
Limitations
- Study type
- Results by means of photographs
- Method of release
- Needle and cannula size
- Inconsistent terminology of anatomical areas for entry points
- Insufficient Data about cannula based procedures
- Physician skills
- Hyaluronic acid volume/brand
Thank you !