Volume Replacement Tips Top Periorbital Pearls : Use patient age, overall fat distribution to guide treatment choices, troubleshoot complications.

LAS VEGAS — Periocular fat injections in thin patients are more likely to capsulize and create unsightly "hot dog" rods in the tear trough that require multiple surgeries to remove, Dr. Cynthia Boxrud said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

Injected adipocytes behave differently in thin, muscular patients than in patients with more fat in their bodies, explained Dr. Boxrud of the University of California, Los Angeles. Be cautious with periorbital fillers in thinner patients, and warn them of the added risk.

Dr. Boxrud shared other pearls for successful periorbital volume replacement at the symposium. Tear-trough augmentation is an off-label indication for injectable fillers.

The first step is to obtain photos of the patient at a younger age to get a sense of the desired look. "Our faces age like a balloon deflates," she said.

Harvest fat from another body area using a small 10-cc syringe and let the tube of fat sit upright for 10 minutes before reinjecting. It settles into three layers: a top layer of oil, a middle layer of usable fat, and a bottom layer of blood. Studies have shown that centrifuging harvested fat makes no difference for these purposes, "so you don't have to spin it," Dr. Boxrud said.

Reinject the fat into the periocular area in a vertical direction using a blunt cannula pointing away from the eye. Dr. Boxrud prefers a 1.2-mm cannula instead of a 0.9-mm because she has seen some of the smaller cannulas bend during this procedure.

Inject small amounts of fat at a time, giving 20–25 injections, and be conservative, she advised. Insert the syringe deep below the surface and only release the fat when pulling the syringe back out. "Don't inject directly into muscles. I've seen muscle wasting from this," Dr. Boxrud added.

Document everything with photos and record the volume of fat injected.

Injectable collagen filler (Restylane) is another option for periorbital volume replacement. Results usually are more subtle than with fat injections, especially in younger patients.

"Young people aren't going to see great changes," Dr. Boxrud said.

Inject minimally, placing 0.2–0.3 cc under each eye via many small injections.

Results with Restylane are less successful in patients who have malar hypoplasia or translucent or thin skin. The product can cause temporary color changes in thin skin. "For the thinnest skin, use fat transplantation, not Restylane," she said.

Fat injection in the tear trough of this patient capsulized into a "hot dog" formation that necessitated surgical removal. Courtesy Dr. Cynthia Boxrud