Volumizing Hyaluronic Acid Filler for Treatment of Infraorbital Hollows

To the Editor I commend Dr Hall and colleagues for their intrepid and innovative contribution to the cosmetic literature. Although anecdotal experience indicates that aesthetic clinicians have been using injectable fillers of various cohesivities and hydrophilicities throughout the face, the prevailing wisdom and literature from core physicians have dictated that physicians avoid products with a high viscous modulus (G′) when treating the tear trough. It is thus refreshing that Hall et al have used their comfort with and knowledge of the tear trough to demonstrate that a long-lasting filler can be both safe and cosmetically pleasing when placed in the infraorbital hollows. Given that hyaluronic acid is commonly placed on periosteum to rejuvenate the tear trough, it would logically follow that Juvéderm Voluma, a product with low hydrophilicity and long duration, designed to be placed supraperiosteally, might yield excellent and sustained outcomes. However, a variety of reasons, ranging from simple risk aversion to insufficient comfort with orbital anatomy to uncertainty about the behavior of a highly cross-linked product in a notoriously delicate and unforgiving space, have dictated that most aesthetic physicians use products of lower cohesivity and G′. In addition, although Hall et al should be commended for their use of the FACE-Q, it is worth noting the potential limitations of this metric. Although overall patient Satisfaction With Eyes and Decision to Treat were 71.1% and 65.6%, respectively, these numbers might be interpreted as artificially low because of the nature of the questions asked. For example, a patient could have an excellent response to tear trough filler resulting in high satisfaction with attractiveness and youthfulness of the eyes but still report being "very dissatisfied" with the shape, openness, and bright-eyed appearance of the eyes; these elements might not be expected to be modulated by infraorbital filler. Overall, this is an interesting and important study demonstrating excellent cosmetic and patient-reported outcomes with the potential to change injection practices.