Multimodal Pilot Evaluation of a Hyaluronic Acid Infraorbital Filler Using Precise, Multipositional, 3-Dimensional Imaging Quantification, Patient-Reported Outcomes, and Anatomic Cadaveric Assessments

Abstract

Background: Despite the high demand of filler in the infraorbital area, there remains debate on injection practices, precise anatomical placement, and hyaluronic acid (HA) filler behavior.

Objectives: We aimed to contribute to the clinical and anatomic understanding of infraorbital HA injection through a prospective patient injection study in combination with a cadaveric analysis.

Methods: Patients were injected with Volbella XC (JUVÉDERM, Allergan Aesthetics, an AbbVie Company, Irvine, CA) into the tear trough region by a single experienced aesthetic plastic surgeon. Over a 90-day period, precise undereye volumetric measurements using 3-dimensional photogrammetry (VECTRA-M3, Canfield Scientific, Inc., Fairfield, NJ) and patient-reported outcomes (PROs; FACE-Q) were collected and analyzed relative to 2 pretreatment severity scales. Juvéderm Vycross (Allergan Aesthetics, an AbbVie Company, Irvine, CA) and Restylane NASHA (Galderma, Lausanne, Switzerland) products were injected into the infraorbital and malar region in 6 cephalus specimens and evaluated with regards to the anatomic injection location with and without common clinical physical manipulations.

Results: Eleven patients participated with a 100% retention rate. Infraorbital HA volume maintenance was 70% to 81% at 30 days and 50% to 70% at 90 days. Significant improvement was noted in the eyes, overall facial appearance, and cheekbones (P < .05) with FACE-Q outcomes, irrespective of pretreatment severity. In the cadaver examination, we observed differences in the anatomic locations occupied by Juvéderm and Restylane products as well as in behavior after physical manipulation between gel types.

Conclusions: Volbella XC effectively augments undereye volume to diminish infraorbital hollowing as measured over a 90-day period with significantly improved PROs. Enhanced knowledge of the behavior of Volbella XC and other HA fillers in this sensitive anatomic region will lead to improved patient outcomes.

Figure 1.

Area of interest for VECTRA 3D imaging. Width of the area was defined by the distance between the medial and lateral canthi. Height of the area was 5 mm above and below the tear trough and lid–cheek junction. The peak curvature of the area occurred mid pupil.

Figure 2.

Filler injection by product and location.

Figure 3.

3D photogrammetry with color gradient including areas of interest was defined at 4 different time points (postinjection, 2 weeks, 4 weeks, and 12 weeks). All photographs were registered to preinjection photographs.

Figure 4.

FACE-Q domain scores at post, 14 days, 30 days, and 90 days in comparison with preinjection scores. * means significant difference in scores when compared to pre-injection scores.

Figure 5.

Cadaveric cephalus specimen dissected to reveal the (A) superficial fat pads and (B) deep fat pads.

Figure 6.

Cadaver injected with Restylane-L in the tear trough and restylane-LYFT in the malars on the right, Juvéderm volbella XC and Juvéderm voluma XC on the left after (A) subcutaneous dissection, (B) SMAS dissection, and (C) deep fat compartment dissection. (D) Cadaver injected with Juvéderm Volbella XC in the lower lid and Juvéderm Voluma XC in the malars; Filler product was nonblended on cadaveric right (R) and blended (0.2) on cadaveric left (L). (E) Cadaver injected with Restylane-L in the lower lid and Restylane-LYFT in the malars. (F) Filler product was nonblended on cadaveric right (R) and blended (0.2) on cadaveric left (L).