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  • Oculoplastics/Orbit

    Review of: Nonsurgical tear trough volumization: A systematic review of patient satisfaction

    Gorbea E, Kidwai S, Rosenberg J, et al. Aesthetic Surgery Journal, August 2021

    A systematic review of articles containing more than 5 patients who were injected with tear trough fillers looked at common fillers used, patient satisfaction rate, and complication rate.

    Study design

    This study is a systematic review of PubMed, Cochrane, and Scopus articles that contained more than 5 patients who reported on satisfaction and/or complications from tear trough fillers. Primary outcomes included patient-reported satisfaction rates or complication rates. Secondary outcomes were qualitative, including details on injection technique, type of injected material, as well as injection instrument, location, plane, and volume. Studies were excluded if they included patients who underwent simultaneous blepharoplasty, injection material that was fat, or were not available in English.


    A total of 1,956 patients were reviewed, aged 18 to 89 years, mean 44.9 years, 74.4% female. The most common fillers injected were hyaluronic acid (HA-based) fillers at 78.5%, followed by calcium hydroxyapatite (CaHa) at 19.2%, autologous fibroblast and keratin gel (AFKG) at 1.8%, and collagen-based filler compounds at 0.5%. Among HA fillers, Restylane was the most common (54.7%), followed by Teosyal Pure (9.8%) and Juvederm Ultra XC (9.8%). Overall patient satisfaction rate was 84.4%, with overall long-term patient satisfaction (6+ months later) of 76.7%. The overall complication rate across the entire patient cohort was 44.3% with corresponding rates for the different subgroups as: HA, 50.75%; CaHa, 19.95%; AFKG, 11.43%; and collagen-based filler, 90%. The most common complications included ecchymosis (12.9%), edema (9.2%), and lumpiness (6.5%). Patients on whom cannulas were used were less likely to develop ecchymosis (7.2%) compared with needle (17.2%).


    This review poorly describes the incidence of late complications such as long-term edema or pseudo-festoons and is subject to publication bias and underreporting of certain complications. Particularly since this study excluded articles reporting on fewer than 5 patients, it is likely that rare complications such as necrosis, blindness, and embolic events are underreported. While this study shows that tear trough filler has high satisfaction, it is important to similarly report short- and long-term complications.

    Clinical significance

    Tear trough filling is a challenging procedure that should be performed by an experienced clinician familiar with the periocular anatomy. This review demonstrates evidence that tear trough rejuvenation has high patient satisfaction with few reports of serious complications. Aesthetic surgeons and injectors should be aware of the most common complications such as edema, ecchymosis, pigmentary changes, and lumps, and should discuss these potential complications with patients. Additionally, cannula injection should be considered to decrease ecchymosis and the risk of long-term edema when using HA fillers.