- Tear troughs.
They're the grooves or hollows just underneath your eyes
and are a significant cosmetic concern for many people.
- I was born with extremely dark hereditary dark circles.
The thing now is really the under eyes.
- And it really bothered me
because the makeup wasn't hiding it.
The fact that I wouldn't feel confident without makeup on
in this area.
- It's no surprise that they are one of
the most popular areas on the face to fill
with dermal fillers.
The idea of a simple nonsurgical procedure to fix
what is often a lifelong concern can be alluring
for both patients and practitioners.
In fact, it took me 14 years of filling tear troughs
from 2005 to 2019 before I came to the conclusion
that I shouldn't be doing this treatment anymore.
In this video, I wanted to share with you my journey
and experience and provide you with expert opinions
from Dr. Mobin Master, radiologist,
Mr. Bryan Mendelson, plastic surgeon
and Dr. Ben Burt, oculoplastic surgeon
to provide evidence and shed further light on the topic.
I started filling tear troughs back in 2005.
To be honest, the results over 14 years
were varied and inconsistent.
When I started, I probably didn't know
what I was getting myself into.
I used to put in large amounts of filler
to show a difference and make patients happy
at the end of the treatment.
For tear troughs, one syringe possibly per side
in most cases now and I find especially with deeper ones,
you need the full syringe.
Only to find that my patients would come back later
with puffiness and overfilling as the filler hydrated.
The nature of hyaluronic acid fillers
is that they are hydrophilic.
That is, they love water
and attract many times their weight in water with time.
- Then when he did it, I saw an immediate difference
and it was crazy.
- You can see instantly how it fills in.
- What you see immediately after the injection
is not a true result.
This makes it hard to judge how much to put in at a time.
The combination of the hydrophilic nature of
hyaluronic acid fillers, the fine skin around the eyes
that showed any filler imperfection
and patients that wanted perfection,
was, in hindsight, a recipe for disaster.
- It never really got to a point where I really was like
satisfied with it.
I had to go back a few times to get it like
sort of evened out and this side was never like,
never looked the way that I wanted it.
- The past like year, I started noticing
these really harsh dimples forming underneath my eyes
and I spent the past three months going in again and again
and again and again and again.
- I persisted over the years chasing that elusive,
just right tear trough result.
I tried filling tear troughs with smaller amounts,
using less hydrophilic fillers
and modifying my techniques
and using the use of cannulas rather than needles.
Complications, such as swelling
or puffiness of the lower eyelid were still quite common
despite these changes.
I was always reassured by what we have been told about
the longevity of hyaluronic acid fillers,
which is that they only last for six to 18 months.
So, any complication should be resolved
in that timeframe, right?
After several years of doing tear trough filler,
I started to question this as we had several cases
where swelling or puffiness persisted for many years,
well beyond the six to 18 months
we were told that fillers last.
Sometimes the puffiness occurred years after having
what appeared to be a good result.
Some patients had puffiness from filler for years
without even realizing it was the filler,
thinking it was just aging kicking in.
To see if it was filler or maybe just fat pockets
under the eye and aging causing puffiness,
we started doing MRI scans on those
with persistent swelling.
Due to the hydrophilic nature of filler,
fillers signal on MRI as white,
similar to the signal for water and its presence
is clearly delineated on MRI.
What we found was a real eye-opener.
We had many cases where we saw filler lasting
from two to 12 years on MRI.
In this interview, I spoke to Dr. Mobin Master,
who performed these MRI scans about his findings.
Good to see you.
Thanks for coming in to share some of
your invaluable insights with us.
- Yes, good to see you again, Gavin.
Always a pleasure.
- Thank you, thank you.
So, this is the man a radiologist and a cosmetic physician.
He is a guy I send to when I need to see stuff
beneath the skin.
So, he's like the answer book.
He gives us the answers
and I think there's been some huge insights recently,
in the past year or two,
where we've done some MRI scans of patients
and you've found a lot of interesting things.
- Very interesting stuff.
As you mentioned on the previous longevity interview
that we did together and that actually kind of changed
the face of injectables pretty much.
It has really changed the way I inject.
- It's changed my practice too, yeah.
- The way you practice as well, and many other injectors.
So, the paper in
Plastic and Reconstructive Surgery of America was accepted
and it's currently released
and it's on paperback in January 2021
and it describes 14 patients
and we showed that many patients had filler still there
after two years.
One of them was 12 years
and there was still hyaluronic acid filler
in the tear trough for, in the orbital area.
- And I believe out of that study,
out of 10 patients who had fillers more than two years ago,
all 10 showed?
- All the ones that had.
- Fillers?
- The question of do they have filler over two years,
all of them had filler, yes.
- 100%?
- Yeah.
- Isn't that, that just blows me away.
One might argue that even if fillers do hang around
for many years, they are fully reversible
with injections of the enzyme, hyaluronidase.
I used that as my justification for continuing
with performing tear trough filler
until I had a case of lower eyelid swelling
that I just couldn't dissolve.
Again, Dr. Mobin Master reveals how this happened.
Just over a year ago I had a patient,
which I sent to you and it was a really difficult patient
and she had fillers done in her tear trough
and she had this persistent swelling,
which just wouldn't go away
and we dissolved it with a bucket load of dissolving
or hyaluronidase and it just wouldn't go away
and I was so puzzled and I sent her to you.
Maybe you can tell us a bit about what you found.
- She was a fascinating case actually
and he sent her to me and I thought, well,
how are we going to work this out?
And he said, well, why don't you do an MRI?
So, we did an MRI and we found that yes,
there was filler in the tear trough area,
which is quite typical
and it shows that bright signal on T2,
which demonstrates the filler
located in the tear trough area,
but it also showed post septal filler,
meaning that it was underneath the globe.
So, it had somehow got under the globe
and since then, we've had another two cases of that
and we can discuss the treatment.
- That is phenomenal.
So, maybe you can explain to the viewers, Mobin,
what the orbital septum is
and what it means to go through that
and go underneath the globe or the eyeball basically,
just explain why was this patient so difficult?
- So, the orbital septum is actually a division
beneath the eyelid that separates the globe
and the intraocular orb in the eye,
the actual eye area underneath your actual eyeball.
So, you've got a septum at the bottom
and you got a septum at the top
and for example, if you've got a really bad infection,
we always talk about, has it gone postictal
because that's dangerous because it means
it's gone underneath the globe.
So, it's a barrier,
it's basically a very fine film barrier
and I think it's finer than we think.
- So, a needle or cannula could penetrate it
pretty, without knowing possibly?
- That's right.
And two, one of the cases was I think the case
that you had sent me was a cannula
and the other, I think one other case from elsewhere
was a cannula and one with a needle.
- Okay, there you go.
But this basically, this MRI that you did
explains why we had such a hard time dissolving it.
So, maybe you can explain why it was so hard
and what was done to actually alleviate that filler?
- So, clinically what you do is you get the needle
and you inject where the puffiness is, right?
- Yep, that's what we do, yep.
- So, generally that's a logical point of call
and you are trying to inject
and go, okay, why is this not going away?
The septum though is underneath the globe
and not in a million years,
I don't think an injector would have thought
it has gone under the eyeball
and you're probably without ultrasound vision,
you probably wouldn't be willing to stick a needle
under the eyeball, would you?
- That's why we had problems
'cause we never stuck the needle under the eyeball so.
- That's right.
- I left that to my friend here, Mobin.
So, tell us what you did.
- What I did is get an ultrasound probe.
- Yep.
- And you're running a needle underneath
the ultrasound probe where you can actually see it.
So, it has to be directly parallel to that probe
and I could see the globe and I knew where the filler was,
but I couldn't, it was kind of semi-blind,
i.e. I couldn't actually see that post septal filler,
but I knew I was directly underneath the globe.
So, I use the MRI like a map.
So, it's like a map in front of me.
So, I was looking at that going, okay,
it's under the eyeball, probably dead center
and then what I did is I used the ultrasound
to make sure that my needle didn't touch the globe.
- Okay.
- So, I'm within a few millimeters of the actual eyeball.
- Wow.
- And then squirted it and then we did an MRI afterwards,
which showed that it had resolved
and it got rid of the filler underneath the eyeball.
- So, I mean, we must have tried about seven times
to dissolve this, just without ultrasound guidance or MRI
and it really took your expertise to do this
and I'd imagine that in the world,
there are not many people who actually have done
this sort of dissolving.
I could imagine you'd be one of the few.
- Yeah, I haven't heard of anyone
doing dissolving underneath the globe.
- And since then, this case, this first case,
where we've had this post septal filler,
you've had a few others presented?
- Yeah, we have had a few others
and while we're talking about that,
there's a picture you can see there of the before and after.
The post septal filler was dissolved
and you can see a little crease under her eye has come back,
meaning that it's less puffy.
- Yep.
- So, we did get majority of the resolution in that case.
Another two cases did come to me
and I MR'd these patients.
I didn't expect it and these two patients had post septal.
One of them had an injection 12 years ago.
- Wow, there you go.
- She said she was puffy immediately after the injection
and often this is the problem.
You're puffy immediately after the injection
and then you wait for it to resolve,
but then it never resolves.
So, I think it was in the post septal
or underneath the eyeball from the start.
So, we MR'd her and I did exactly the same process,
the same pathway.
- Given fillers can last a very long time
and also have the potential to be injected post septally
or under the eyeball,
I needed to make sure that there was an appropriate basis
for treating tear trough fillers.
I started researching this
and I found the answer was right under my nose.
I found in 2012, Mr. Bryan Mendelson published an article
titled, The Tear Trough Ligament:
Anatomical Basis for the Tear Trough Deformity.
Unfortunately the cosmetic world didn't heed the warning
contained in this paper, that is almost now a decade old.
In this paper, through dissection of 24 cadaveric faces,
he found a true osteocutaneous ligament
attaching skin to bone in the tear trough.
That is the skin of the tear trough groove
is tethered to the bone underneath by a ligament,
which means you can't lift it with filler.
It's anchored down.
It's like the buttons of a mattress,
pulling the mattress down.
You can't lift these buttons by stuffing more foam
or padding underneath them.
You can see this when you are squinting.
The orbicularis oculi muscle that surrounds the eye moves,
except for the tear trough where it is tethered down to.
Many attempts to find an anatomical basis
for the tear trough had been made in the past
with no prior studies finding a tear trough ligament.
Mendelson states that the discrepancy was
from the dissection approach used in previous attempts.
Basically, there's been a lot of hypotheses
about why there's this hollow trough there
and multiple surgeons or anatomists or doctors
have tried to find this, a ligament there
and been unsuccessful.
So, maybe you could tell us why,
what made your study successful?
How did you find it when others had failed?
- Well, it's so often with anatomy, it's the way you dissect
and also just know that one day you dissect
a few millimeters to the side
and you see the structures differently
from what you're used to seeing.
So, but fundamentally surgeons dissect by layers
and they lift up the skin, then they lift the orbicularis,
and then they go down to the layer three,
where the ligaments may be and they couldn't see it
and the reason that they couldn't see it
is because the ligament is,
extends between the dermis and the berm
and as soon as you take the top layer off,
the ligament loses all its structure.
- Mendelson's anatomical approach
found the elusive tear trough ligament
that hadn't been found previously
and helped explain the reason why filler simply can't
lift the tear trough groove that is held down
by this ligament.
In his publication, Mendelson's conclusion was that
filler can be placed underneath the tear trough ligament
to support it,
but should not be placed above
or directly into the tear trough
as this can aggravate the deformity.
Given its tough fibrous nature,
I feel that filling directly over
or in the tear trough ligament
commonly leads to extrusion of the filler to either sides
of the ligament, which causes puffiness in the lower eyelid.
The technique suggested by Mendelson of placing filler
underneath the tear trough ligament,
essentially in the cheek, has become my go-to method
for consistently improving the tear trough groove
through support of the ligament.
I never fill over the tear trough groove or ligament now.
To see if a patient will benefit from
this supportive filler,
I perform a simple press test on the cheek.
If there is improvement in the tear trough from the test,
then it is likely that filler in the mid cheek,
under the tear trough ligament will help.
Patient expectations are paramount here
and it's important to explain prior
that it may not completely remove the tear trough groove,
only soften it and that further improvement
may require surgery correction.
Surgery should also be presented as an option
for anyone presenting with concerns about their tear trough
to provide a more balanced view,
even though the prospect of surgery may be scarier
than a few injections.
I spoke to Ben Burt, oculoplastic surgeon
about the surgical options for tear troughs.
I'd like to introduce Dr. Ben Burt,
who is an oculoplastic surgeon
and he is very well-known for his work
with lower eyelids in particular.
Firstly, so what sort of people are you seeing
come in for lower eyelid surgery?
When would you say sir, it's time to have surgery now?
- I think there's two big groups.
So, there's one group that I would almost say are congenital
in terms of their tear trough deformity
and those people always have noticed that feature.
Even when you look at photos of them as a child,
maybe one of their parents has it as well.
Usually one does, and they've never liked that appearance
and they've always waited to have something done about it.
- So, these patients are really quite young?
So, it's not like necessarily like a older sort of patient.
They can come in their 20s say for example?
- Yes, even teens.
- Even teens, yeah.
- Probably once, twice, you see someone who is so sure
they want surgery and their parents know about it,
they're unhappy about it
and they just wait until they're about 18,
maybe leaving school, that group
and then there's the more acquired group
where they're a little bit older and they just age
in a certain way that creates a bag
and a very firm trough underneath the bag.
- Right, so tell us about what you do
with that tear trough ligament in surgery.
I mean, how do you, you literally detach it?
- It's detached.
So, when, so I go via a transconjunctival approach
or the patient's always asleep.
My assistant's retracting the eyelid forward,
going through the conjunctiva through the retractor
down to the periosteum.
So, I'm literally looking at the periosteum
and then I'll either incise it directly
with a sharp edge of a Freer,
a Freer periosteal elevator,
or even with a diathermy just to get on to the bone.
Certainly that's a robust way to lift that area
and to, as we heard earlier about the anatomy,
to elevate the attachment,
one of the attachments of that ligament.
- I mean, when you say, even just saying those words,
it makes me think back on all those patients I've done,
where we're trying to lift this tear trough
hollow with a filler
and they've got literally this tear trough attached to bone,
which is attached then to their skin
and here we are trying to lift it up with
a very sort of soft filler
and that's probably one of the reasons why
we've had so many issues.
In conclusion, given the potential longevity of
hyaluronic acid fillers,
the risk of inadvertent injection of filler
under the eyeball
and the anatomical basis for the presence of
the tear trough,
the use of filler in the tear trough needs to be questioned.
Filler injected into the tear trough commonly results in
complications and regret.
As doctors, we take on board the Hippocratic oath,
which is first, do no harm and given the likelihood for
potential problems that tear trough filler can cause,
we must consider our oath in this situation.
I hope the lesson that took me 14 years to learn
and the production of this video
will have a positive effect in helping to educate people
out there about the potential dangers of
filling the tear trough region.
(soft music)