Q: Dr. Eppley, I am interested in getting injectable fillers into my tear troughs (tear trough injections) but am very nervous about it. I have read numerous horror stories of significant bruising and clumps and irregularities in this area. What is the best way to inject the tear troughs and not have these problems?
A: Injections for tear trough (nasojugal) effacement is the most technique sensitive of all injectable filler treatments of the face. I used to use a 1/2 inch 30 gauge needle and injected down to the level of the periosteum along the medial orbital rim. But the periosteum over the orbital rim is quite adherent and recent studies have shown that the periosteum and the retaining ligaments in this area are very difficult to elevate and are prone to bleeding and external bruising.
I have subsequently changed my tear trough filler technique to using a microcannula rather than a needle. Coming though the thicker cheek skin rather than the thinner eyelid skin, I enter the submuscular plane above the periosteum to inject. This approach puts the microcannula directly into the tear trough and has no risk of causing bleeding or bruising afterwards. This more superficial submuscular deposition of filler has improved my results dramatically. In addition, the entire tear trough can be filled from a single puncture in the upper cheek. The microcannula can reach the most medial part of the tear trough.
It is important when filling the tear trough to only use hyaluronic acid-based fillers to avoid clumping and to not overfill. Less is more when it comes to filling the tear troughs.
Dr. Barry Eppley
Q: Dr. Eppley, I am a 38 year-old female that has chubby cheeks. They make me look ten years older than I am and I just hate them. I have been to several plastic surgeons and they have uniformly said there is nothing to do about them. I have tried injectable fillers around them but that just makes me look puffy and is not an improvement. What do you recommend? I have attached pictures so you can see what they look like in different lighting.
A: Thank you for sending your pictures. I can clearly see your concerns of the ‘fatty or chubby cheeks’. The first question is always what is the diagnosis. Why do your cheeks look chubby? Is it because they are chubby or is what is around has become indented or atrophic? I am going to assume that they did not look like this originally ten or fifteen years ago. Many people with aging will develop malar festoons. These occur because the cheek pad falls off of the bone (ptosis) and in much later years can even become chronically swollen. While your cheek problem initially may appear as festoons, on close examination of the pictures they are not. Your cheek tissues are up high on the bone as would be commensurate with your still young age. It is easy to see that you have little aging around the eyelid area. In short, I do not feel that your chubby cheeks are from soft tissue laxity or ptosis. You clearly have tear troughs and a descending infraorbital groove which goes below the cheek area. This is what I think makes your cheeks look chubby, it is what is around them either from the early signs of aging or genetic predisposition that makes them look fat.
In theory, the correct treatment would not be cheek reduction but augmentation of the tear troughs and infraorbital groove. Having had this done through injectable fillers with an unsatisfactory result, this appears to not be a good option for you. It may be that the injectable fillers were not placed correctly or overdone, but I will assume for now they were and the look from that approach was not an improvement.
This raises the next question of what can be done with the cheek pad tissue. Simple ‘removal’ is not a realistic treatment as you can not liposuction the cheek pads or perform direct excision. Even if that was technically possible, it would leave the cheek skin deflated, possibly wrinkled, and thus create an alternative problem that would not be viewed as an improvement. Treatment possibilities include some higher malar suspension through a transcutaneous lower eyelid incision, possibly combined with a small cheek implant that would augment the lower cheek groove. Even though you don’t have true malar ptosis, lifting and repositioning this cheek tissue slightly higher would help to efface the lower malar groove. One way you can get a feel if this approach might be effective is to push up on the skin by the corner of the eye and see what happens to the appearance of the chubby cheeks.
Another option to consider before surgery is non-invasive skin tightening and fat shrinking devices. There are numerous device options out there. My current favorite is that of Exilis. It is a radiofrequency device that has the ability to perform some small amounts of fat reduction and skin tightening. It always takes a series of treatments, usually four, to get the final result. But I would be very interested in seeing you have this done before any surgical efforts are made. Whether it would solve your cheek issues is unknown, but it would be more reassuring that you tried every less invasive option before you came to the conclusion that surgery was warranted.
Dr. Barry Eppley