IN TREATING tear trough deformity & dark circles
Pr Noura Lebbar
The correction of tear trough deformity is a highly requested treatment in my daily practice, but at the same time it is very challenging. The complete correction can be reached immediately using cross-linked hyaluronic acid (HA).
As the peri orbital area is very delicate regarding the lymphatic circulation and also the peri ocular dermis and epidermis are the thinner in the whole body, we need to treat this area with a lot of precautions. Filling the tear trough area with cross-linked HA fillers can lead to not only short-term side effects as Tyndall effect (superficial implant above the Orbicularis muscle), but also to long term effects such as delayed secondary oedema and inflammation many years after the injection. The fact that the vascular microcirculation in the peri ocular area is very slow explains the fillers‘ long lasting effect up to 10 years. The patients demanding for aesthetic procedure are younger every year starting from 20 years old, as consequence our approach to our patients should be very conservative.
The future of aesthetic medicine is regenerative medicine using a conservative autologous approach to restore the tear trough area.
The properties of non-cross linked hyaluronic acid are well known since almost 20 years on the modulation of the inflammation, the stimulation of the microcirculation by stimulation the VEGF (vascular endothelial growth factor), behaving as scavenger for the extracellular matrix allowing the detoxification of ROS (reactive oxygen species, the main cause for skin ageing), finally stimulating the fibroblasts to produce more collagen, elastic fibres and endogenous hyaluronic acid and maintaining a very high level of dermal hydration by its high capacity to retain water molecules.
It is also well known that the main factor of melanogenesis is the inflammation trough IL1 -2 TNFa leading to the synthesis of the melanin. Also, the dark circles in the periorbital area are due to the venous stasis and decreased oxygenation of the skin due to a slowed blood circulation. Hyaluronic acid, especially with a molecular weight of 1500 kdalton, is able to stimulate the VEGF contemporarily modulating the inflammation; both actions of HA allow it to be the perfect ingredient to treat the dark circles, skin elastosis and dyschromia. I have chosen Cellular Matrix medical device (RegenBCT-HA) as the elective procedure to treat both dark circles and tear trough deformity for all my patients aged from 18 until 80 years old.
Cellular Matrix is a device that allows the preparation of a high-quality platelet rich plasma with a standardized composition: RegenPRP™, combined with HA. The resulting biological product RegenPRP™-HA combines the properties of non-cross-linked HA with the biological properties of RegenPRP™. The separator gel in Cellular Matrix ensures the purity of the PRP which is fundamental while treating the peri orbital area avoiding any risk of major hyperpigmentation or swelling.
The separator gel isolates a PRP with no red blood cells, which would increase the hyperpigmentation due to the presence of hemosiderin in these cells and no white blood cells, which would increase the inflammation the lower eyelids. Once injected, the platelets in contact with the extracellular matrix release growth factors as VEGF, FGF that allow the stimulation of collagen production and the stimulation of blood circulation in this area. The result is a brighter, denser and more elastic skin with a reduction of the bluish colour of dark circles of the lower eyelid.
In this device, the concentration of non-cross-linked HA is very high 20 mg/ml in 2 ml for a total of 40 mg of very pure HA. The molecular weight of HA is between 1300-1500 KDa the perfect molecular weight to modulate the collagen and elastin synthesis by fibroblasts and to retain a high volume of water allowing a long-lasting skin hydration.
The indications for the treatment of the peri orbital area with Cellular Matrix are many: dark circles, grade 1 to 3 wrinkles, loss of skin tone, tear trough deformity, hyperpigmentation, dark spots, chronic lower eyelids oedema. No patients are excluded from this treatment even if they were treated in the past in this area with cross linked HA fillers or other type of fillers such as PLLA, calcium hydroxyapatite or others. The hole procedure is very fast, I draw approximatively 4ml of blood in a closed system I spin for 5 minutes in a RegenLab centrifuge (45° inclination centrifuge) at 3500 RPM (corresponding to a relative centrifugal force of 1500 x g). We obtain around 2ml of RegenPRP™ mixed with 2ml (40 mg) of non-cross-linked HA.
The studies have shown that the combination of HA with PRP allows a longer action of the growth factors contained in the PRP and more localised effect of the PRP in the area treated.
After the patient’s disinfection I draw my entry point, which is in the prolongation of the tear trough ligament, I enter with my 22G cannula 5cm along the ligament and I fill in 2 layers with a sandwich technique: first under the orbicularis muscle then I change layer and fill in the subdermal area above the orbicularis muscle. Using Cellular Matrix, we can inject superficially in this area as there is no risk of Tyndall effect contrary to the cross-linked HA filler. I inject around 0.8-1ml with the cannula then I use a 31G, 4mm needle and inject superficially in the dermis with papule technique all the peri ocular inferior superior and lateral area including the crow feet with 0.5 ml for each eye. In total in the preorbital area I use 3 ml for both sides. The rest of the PRP-HA combination is used to rejuvenate the whole face: malar zygomatic area peri oral area reinforcing the retaining ligaments and improving the glow effect in the whole face. The rejuvenation of malar zygomatic and mandibular area can be realised with a 22G cannula with the same entry point I have used for the tear trough area or with the classic papule technique with a 31G needle.
No side effects have been observed in hundreds of patients treated.
The procedure can be combined to many energy-based devices used for the peri ocular area as the MFRF (microneedling fractional radio frequency) plasma energy C02 fractional laser, during the same session, accelerating the healing process and improving the results or can be used after few weeks after the energy-based devices to maintain and improve ulteriorly the results. The result after using Cellular Matrix is immediate in term of correction the tear trough deformity the glowing effect and wrinkles correction. The final result should be appreciated at the end of the three treatment sessions, undergone with an interval of 3-4 weeks. Usually, I recommend a 4th session after 6 months to maintain the result.
As a conclusion I would recommend to opt for a regenerative and conservative approach for the peri orbital area as the demanding patients are always younger and the long-term side effects in this area are frequent when using semi-permanent fillers. The RegenPRP™-HA combination is highly efficient in term of skin brightening, collagen and micro vascularisation stimulation in the peri orbital area without causing any short- or long-term side effects. My 17 years of experience allow me to declare that Cellular Matrix is one of the safest and more efficient treatment we can propose to our patients for the peri ocular area.
The future of aesthetic medicine is conservative and regenerative medicine allowing to use autologous growth factors to stimulate the fibroblasts to produce more collagen and elastin fibres as well as endogenous hyaluronic acid. As the social media influence is impacting the young generations demanding always more aesthetic procedures, our role as aesthetic doctors is to direct the patients towards safe autologous regenerative and conservative approaches. That ensure the safety and the absence of any side effects in short and long term.
Pr Noura Lebbar
Cosmetic Surgeon, Milan Italy. Professor at the University of Genova, Italy.
