Dr Paraskevov explains why using APRILINE® hyaluronic acid fillers is an effective solution for the treatment of under-eye dark circles.

The hectic pace of life, fatigue, and sleep disorders put an additional strain on modern society, irrespective of age, gender or ethnicity. These factors contribute to skin ageing as well as creating unappealing dark rings under the eye. There are various methods to combat these issues, with varying degrees of success. These include various types of peeling, laser resurfacing, lipofilling, and other therapeutic and surgical procedures.  One modern, and highly effective alternative is hyaluronic acid (HA) based filler injections, such as the new generation of fillers brought out by Suisselle laboratories. APRILINE® combines new technologies to create a more pure, stable product with optimal visco-elastic properties to create perfectly natural, even enhancements with the additional benefit of being very easily injectable with predictable, reliable outcomes every single treatment.

Wrinkling of the infraorbital region is one of the most widely spread reasons for visiting a medical aesthetics specialist. Problems in this area are typically accompanied by the loss of bone density, decrease in the vertical and increase in the horizontal size of the cranium and increase in the size of the bony orbit. The maxilla is resorbed and the buccal fat pad is shifted inferiorly, causing nasolabial folds. We observe subcutaneous fat redistribution, with loss of tissue fullness in the periorbital and the maxillofacial area. Persistence or hypertrophy of the infraorbital fat is accompanied by the formation of fat sacs. Changes in the soft tissues lead to weakening of the orbital septum and subsequent protrusion of the adipose tissue in the infraorbital region. The volume loss in the infraorbital area also reveals formerly hidden fat bodies in the infraorbital area or ‘palpebral sacs’. The tear trough ligament gets depressed even further, passing obliquely from the lateral part of the nose at the level of the medial angle of the eye downwards to the anterior part of the cheek below the middle of the eyelid. The descending shift of the adipose tissue in the infraorbital area to the weak orbital septum forms a more profound and wide orbit and biconvex deformity of the lower palpebra. Lost tissue fullness between the orbicular muscle of the eye and superjacent skin of the lower palpebra causes approximation of the tissues and makes the thin skin of the infraorbital area look darker leading to eye fatigue.

Anatomic substantiation

Anatomists define a tear trough ligament differently. In their study, having dissected 48 halves of cadaveric faces, Dr. Wong and co-authors described the ligament of the tear trough ligament as a true osteocutaneous ligament1.

As demonstrated in Figure 1, it begins medially, at the level of the insertion of the medial central tendon, just inferior to the anterior lachrymal crest, to approximately the medial-pupil line. The histological evaluation confirmed the ligamentous nature of the tear trough ligament, with features identical to those of the zygomatic ligament.

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Intensity of the tear trough ligament can be estimated using the classification offered by Barton and Hirman. Usage of HA fillers provides for an effective and non-surgical correction of dark circles in the periocular area and tear trough deformity. In a study2, 14 patients were injected with an HA dermal stabilised filler called APRILINE® Normal. This is a non-permanent, absorbable, injectable material for the correction of soft tissue defects. APRILINE® Normal is produced by bacterial fermentation and stabilised using a highly concentrated water solution without addition of other acids or alkaloids (A.P.R.I. Modification). This technology creates the specific spatial structure of HA molecules through effective linkages by BDDE. The concentration of hyaluronic acid per APRILINE® Normal filler is 23 mg/ml. The quantity of filler used for patients is between 0.6 and 0.8 ml.

Procedural technique

The 14 patients who did not demonstrate contraindication to hyaluronic acid filler injections were selected. Standard manipulations were carried out: all the patients were photographed in sufficient lighting on the procedure day, at 30 and 90 days. Written informed consent was obtained from all the patients.

The procedure of filler injection was conducted as follows:

  • Patients are reclined at 45° as the tear trough deformity is better visible in this position
  • Ice is used for the anaesthesia by firmly applying it on the skin between the eyelid and the cheek for a few seconds
  • The treated zone is cleaned and disinfected using Biseptine spray and a sterile compress
  • Injection procedure is performed in a procedure room using disposable equipment
  • APRILINE® NORMAL hyaluronic acid filler is injected using needle 27 G with 0.6-0.8 ml per one patient. The needle is injected at 90 degrees to the skin surface, deep to the orbicularis oculi and periosteal tissue. The first injection is performed from the medial side, usually 0.5 cm from the medial cantus. 3–4 injections below the orbital rim were made in total. To prevent the damage of the neurovascular bundle we recommend to inject the filler avoiding projection of the infraorbital nerve. 0.3–0.5 ml of the filler was injected at once. The injected area is massaged gently for optimal filler distribution.

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Development of the tear trough ligament during ageing can be the reason for dark under-eye circles. Treatment with APRILINE® NORMAL hyaluronic acid filler (0.6-0.8 ml) is a minimally invasive and effective solution for under-eye dark circles. Patients are typically highly satisfied with the aesthetic outcome from the use of this versatile product.