Cosmetic Medicine

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Aesthetic Surgery Journal
2021, Vol 41(8) NP1053–NP1060
Nonsurgical Tear Trough Volumization: © The Author(s) 2021. Published
by Oxford University Press on behalf
A Systematic Review of Patient Satisfaction of The Aesthetic Society. All rights
reserved. For permissions, please
e-mail: journals.permissions@oup.com
DOI: 10.1093/asj/sjab116
www.aestheticsurgeryjournal.com

Enrique Gorbea, MD ; Sarah Kidwai, MD; and Joshua Rosenberg, MD

Abstract
Background: Nonsurgical rejuvenation of the tear trough area via the use of injectable filler material has become a
popular procedure in facial rejuvenation. This procedure offers immediate, albeit temporary, results with minimal recovery
time.
Objectives: The aim of this systematic review was to report on patient satisfaction and complication rates to further guide
practitioners.
Methods: PubMed, Cochrane, and Scopus libraries were queried for articles containing relevant terms. Articles with more
than 5 patients who reported on satisfaction and/or complications from the procedure were included for review. In add-
ition to these variables, we noted other aspects of injection, including filler material, technique, and needle or cannula
delivery. Studies that did not otherwise fulfill inclusion criteria for statistical analysis but reported on intravascular injec-
tion–related complications were cited.
Results: Initial query resulted in 1655 studies which were assessed for duplicates and inclusion/exclusion criteria. After
screening, 28 articles were included for analysis. In total, 1956 patients were captured who had been injected with 1 of 4
materials: hyaluronic acid (1535), calcium hydroxyapatite (376), autologous fibroblast/keratin gel (35), and collagen-based
filler (10). Short- and long-term satisfaction rates were 84.4% and 76.7%, respectively. Minor complications were common
(44%). Secondarily, we found the use of cannula for filler injection of this region to be associated with a lower rate of ec-
chymosis (7% vs 17%, P < 0.05).
Conclusions: Filler injection volumization of tear trough deformity is an effective technique for facial rejuvenation associ-
ated with high patient satisfaction. Multiple filler materials offer acceptable satisfaction and complication profiles.

Level of Evidence: 4

Editorial Decision date: February 2, 2021; online publish-ahead-of-print March 5, 2021.

In recent years, there has been increasing popularity and
interest in nonsurgical procedures for facial rejuvena-
tion.1 After botulinum toxin, injectable fillers are the most
common medical rejuvenation procedure performed in the
United States.1 There has been a nearly 300% increase in
their use since 2000.2 This is largely due to shorter proce-
dure times, rapid recovery times, lack of need for general
anesthesia, and near immediate visualization of results.
Injectable fillers provide a reasonable alternative for cer-
tain patients with specific rejuvenation goals.
Dr Gorbea is an otolaryngology resident and Dr Rosenberg is an
assistant professor, Department of Otolaryngology, Head and Neck
Surgery, Division of Facial Plastic and Reconstructive Surgery, Icahn
School of Medicine at Mount Sinai, New York, NY, USA. Dr Kiwai
is a facial plastic and reconstructive surgery fellow, Department of
Otolaryngology-Head and Neck Surgery, Division of Facial Plastic
and Reconstructive Surgery, University of Washington School of
Medicine, Seattle, WA, USA.
Corresponding Author:
Dr Enrique Gorbea, 310 E 14th Street, New York, NY 10009, USA.
E-mail: egorbea@nyee.edu; Instagram: @egorbea
NP1054
The lower eyelid and cheek undergo many anatomic
changes as the face ages. Laxity of the skin, underlying or-
bital septum, orbicularis oculi muscle, suborbicularis fat, and
canthi, along with descent of the soft tissue structures of the
cheek, such as the malar fat pads, can create infraorbital hol-
lowing.3 The medial one-third of this periorbital hollow is re-
ferred to as the tear trough (TT) deformity. The indentation is
formed at the junction of thin eyelid skin superiorly and the
thicker nasal and cheek skin and subcutaneous tissue in-
feriorly.4 Medially, the trough follows the inferior orbital rim
where the orbicularis oculi is adherent, while laterally it ex-
tends below the rim. The nasojugal groove, which has often
been described as synonymous with the TT, actually refers to
the area at the inferior border of the orbicularis oculi muscle.5
Although the cause of TT deformity and nasojugal groove is
multifactorial, volume loss is the result.
Injectable fillers are especially useful for correcting
areas of soft tissue laxity and volume loss in many areas
of the face. Despite the growing popularity of TT augmen-
tation, there is limited published literature on the most
common filler materials used, injection technique, com-
plication rates, and patient satisfaction. We conducted a
systematic review of published studies to determine the
common filler types used for TT injections, injection tech-
niques utilized, as well as associated patient satisfaction
and complication rates to better understand existing prac-
tices for TT augmentation and further guide practitioners.
METHODS
This study was a retrospective systematic review of pub-
lished literature. As such, IRB approval was not required.
This review was conducted in accordance with the
Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) guidelines (see Appendix A) in
April 2020.6 Keywords and Medical Subject Headings
search terms were used to query 3 databases (Scopus
[Elsevier, Amsterdam, the Netherlands], PubMed [United
States National Library of Medicine, Bethesda, MD], and
Cochrane [Wiley, Hoboken, NJ]) for studies relating to the
use of injectable materials in the TT area. A complete list
of keywords and Medical Subject Headings is reported
in Supplemental Table 1. Resultant records were then im-
ported into Covidence systematic review software (Veritas
Health Innovation, Melbourne, Australia) for removal of du-
plicates. One independent reviewer (S.K.) screened each
study for relevance based on title and abstract. Conflicting
studies were reviewed by a second reviewer (E.G.). The full
text of each study was then reviewed by all reviewers to
identify inclusion or exclusion. Any conflicts were resolved
by discussion and consensus between the 2 reviewers.
Studies were included if they involved the use of inject-
able material primarily to augment the TT and reported on
patient satisfaction or complications. Studies were excluded
Aesthetic Surgery Journal 41(8)
if they included patients who underwent simultaneous
blepharoplasty, the injection material was fat, or were not
available in English. After initial abstract screening, any case
reports or small case series with fewer than 5 patients were
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screened for reports of rare complications, but otherwise
were not included for further review. Although small case
series and case reports often shed light on rare complica-
tions, these studies do not draw from a representative pop-
ulation same and carry inherent limitations such that their
findings are not generalizable.7 Thus we have not included
these for statistical analysis in our systematic review.
Primary outcomes included patient-reported satisfac-
tion rates or complication rates. Due to the lack of a stand-
ardized satisfaction scale across the included studies, only
overall patient satisfaction or dissatisfaction was analyzed.
Secondary outcomes were qualitative, including details
on injection technique, type of injected material as well as
injection instrument, location, plane, and volume. When
applicable, proportions were compared with the “N – 1”
chi-squared test. Statistical analysis was performed with
SPSS version 22.0.0 statistical software (IBM, Armonk, NY).
Although we did not include case reports in our anal-
ysis, we took note of those case reports and case series
that reported severe complications, particularly vascular
complications.
RESULTS
Our searches of PubMed, Scopus, and Cochrane yielded
a total of 1655 articles, but only 28 fulfilled our inclusion
criteria (Figure 1).8-35 All articles were published between
2006 and 2020. Fourteen articles included were pro-
spective, whereas 12 were retrospective. Two articles did
not state outright if data collection was done retrospect-
ively or prospectively. In total, 1956 patients were captured.
Twenty-two of the studies reported male/female distribu-
tion demonstrating a large female majority (1456/1956,
74.4%). Patient ages ranged from 18 to 89 years with a
mean of 44.9 years. Very few studies reported data on past
history of TT injections or other cosmetic procedures, but
at least 70 patients from our cohort had undergone prior
filler injections, 25 had undergone prior blepharoplasty,
and 3 patients had undergone other prior, otherwise un-
specified, surgical rejuvenation procedures.
Injection Material and Technique
Filler
Thirty-one different protocols for filler injection to the TT
region were described throughout the 28 articles. All but 5
protocols utilized hyaluronic acid (HA)-based fillers for re-
juvenation at this site (1535 patients). Other materials used
across the different protocols included calcium hydroxy-
apatite (CaHa) (3 protocols, 376 patients),9,13,19 autologous
Gorbea et alNP1055

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Figure 1. Study selection process.

A B

Figure 2. (A) Graph and (B) representations of different filler subtypes used for the rejuvenation of the tear trough in our review
of the literature. AFKG, autologous fibroblast and keratin gel.

fibroblast and keratin gel (AFKG) (1 protocol, 35 patients),35 Preinjection Protocol

and collagen-based filler compound (1 protocol, 10 pa-
tients) (Figure 2).16
Among HA fillers, Restylane (Galderma Laboratories,
Lausanne, Switzerland) was the most common (n = 839,
54.7%), followed by Teosyal Pure (Teoxane Laboratories,
Geneva, Switzerland) (n = 151, 9.8%) and Juvederm Ultra
XC (Allergan, Dublin, Ireland) (n = 150, 9.8%). A total of 10
different HA filler compounds were employed, and 1 study
utilized an otherwise unnamed “crosslinked hyaluronic
acid.” 31 The full breakdown of HA fillers used is illustrated
in Figure 3.
The use of preinjection disinfectant was discussed in 13
of the 31 protocols. Eight of these protocols employed al-
cohol wipes (62.2%), whereas 3 used biseptine (23.1%) and
2 used chlorhexidine (15.4%).
Anesthetic technique was discussed in 19 of the re-
viewed protocols. All but 1 employed topical anesthetics.
There were 6 (31.6%) protocols in which a combination of
topical and local anesthetics were used. Among the dif-
ferent topical anesthetics, the combination of prilocaine
and lidocaine was most commonly described (33.3%).
NP1056
A B
Figure 3. (A) Graph and (B) table representations of the breakdown of the HA filler subtypes used.
Tung et al were the only authors who did not utilize top-
ical anesthetic, and reported instead using 1% lidocaine
with 1:100,000 epinephrine.33 It is also worth noting that
6 protocols combined filler material with local anesthetic
for injection. Use of 0.3% lidocaine, 1% lidocaine (both with
and without epinephrine), and 2% lidocaine were all de-
scribed for this purpose.
Injection Technique
Injection of filler to the TT region was performed with a
needle in 21 of the 30 (70%) protocols that reported this
information. Seven protocols used cannulas (23.33%).
Two studies reported utilizing both cannulas and nee-
dles (6.67%).8,30 Needle size was most commonly 27G
(20%) or 30G (73.33%), but 31G (6.66%) was also reported.
Whenever cannulas were used, 25G (6/7, 85.71%) was the
favored size, with the exception of 1 study in which 27G (1/7,
14.29%) was used.
The volume of filler used to correct TT deformities
varied across and within filler subgroups. The volume of
HA injected per TT ranged from 0.2 to 0.58 mL. The av-
erage volume of HA filler injected per patient was 1.16 mL.
Three protocols reported volumes of CaHa filler used.
Hevia reported injecting less than 0.6 mL per patient,
whereas Corduff describes injecting 0.3 to 0.4 mL per
side.19,13 Finally, Bernardini did not provide a range of filler
amounts injected but instead reported averages by patient
and by TT (2 and 1 mL, respectively).9
Goldberg, in the only study of Evolence (collagen-based
filler) used for TT augmentation, reported dosing 0.3 to
0.6 mL per patient.16 In the single study in which AFKG was
used, no dosage information was provided.35
When discussing depth of filler injection, most protocols
(86.67%) reported injection of filler in the preperiosteal,
Aesthetic Surgery Journal 41(8)
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suborbicularis plane. One of these protocols involved com-
bining injection in this plane with subcutaneous injection.33
Yet another combined preperiosteal injection with deep
dermal injection.22 Additionally, 3 protocols endorse only
subcutaneous injection9,13,35 and another endorses only
deep dermal injection.25
Regarding injection technique, injectors could be cat-
egorized into 4 main categories: those who preferred
microbolus injection, retrograde injection, fanning tech-
nique, or a combination of these. Microbolus techniques
were reported in 37.7% patients. An additional 14.8% of
patients underwent microbolus injections in combination
with retrograde technique and yet another 2.8% of patients
were treated with a combination of microbolus and fanning
technique. Fanning-style injections were the preferred
technique in 4 studies,11,15,27,28 which represented 19.15% of
patients, whereas retrograde technique was preferred in 7
studies (25.6% of patients).9,10,20,24,33,35 Two protocols did
not describe the specifics of their injection technique.
Although many authors did not report their preferred
needle trajectory, 11 studies described approaches in which
the needle travels longitudinally along the length of the TT,
whereas 6 others describe inserting the needle perpendic-
ular to the skin at the site of filler placement. This translates
to 85.7% of patients receiving filler through needles traveling
some distance throughout the TT, whereas 14.3% of patients
received injections placed perpendicular to the skin.
Patient Satisfaction
Short-term patient satisfaction survey results (those
obtained within 1 month of injection) were published in 18
of the reviewed protocols, allowing us to analyze the self-
reported outcomes for 973 patients. Overall, 84.4% of pa-
tients were satisfied with the result of filler injection to the
Gorbea et alNP1057
TT region in the short term. Ninety percent of these 973
patients received HA injections. In this group, we found a
satisfaction rate of 83.6% (n = 732), with 8.2% (n = 72) of pa-
tients reporting no obvious change in their TT deformity
and the same amount expressing dissatisfaction.
Only 3 of the studies in which patient satisfaction was
reported included patients receiving non-HA filler injec-
tions. Bernardini et al reported satisfaction results for 62
patients receiving CaHa fillers: 58 (93.5%) of these pa-
tients were satisfied, 3 noted no change (4.8%), and only
1 expressed dissatisfaction (1.6%).9 Xing et al reported out-
comes for their cohort of 35 patients receiving AFKG. They
found no dissatisfied patients, but 4 patients (11.4%) did not
notice a significant change; the other 31 patients (88.6%)
expressed satisfaction with their outcome.35
We considered long-term patient satisfaction outcomes
as those being collected more than 6 months after having
had the procedure. Only 6 of the reviewed protocols
offered these results, with all but 1 coming from the HA
group. Overall long-term patient satisfaction for patients
receiving TT injection was 76.7%. Within the HA filler sub-
group, this number was 75.7%, whereas an 88.9% long-
term satisfaction rate was noted for the patients receiving
AFKG.35
Complications
The overall complication rate across the entire patient co-
hort was 44.3%. The corresponding rates for the different
subgroups were: HA, 50.75%; CaHa, 19.95%; AFKG, 11.43%;
and collagen-based filler, 90%. These differences in com-
plication rates were found to be statistically significant
(P < 0.0001), although the clinical significance of the differ-
ences in complication rates is unclear.
Whereas use of filler “touch-ups” is considered an ac-
ceptable practice to ensure optimal results with filler re-
juvenation, for the purposes of this study we will describe
them as complications reflecting failed initial treatment.
In our cohort, 220 patients were reported to have had at
least 1 touch-up treatment (11.2%). In the HA group, 12.8% of
patients were reported to have required touch-up proced-
ures compared with 6.1% of patients in the CaHa group. No
patients in the collagen or AFKG groups were reported to
require touch-ups.
All complications reported throughout our review are
displayed in Table 1. Overall, complications were common
(n = 867, 44.3%), but were driven mainly by minor events
such as ecchymosis (n = 254, 13%) and edema (n = 180 pa-
tients, 9.2%). Ecchymosis rates were lower among patients
who were injected with filler via cannula (7.2%) than in
those injected with needle (17.2%) (P < 0.0005). Prolonged
edema was more likely to occur among patients receiving
HA injections than in patients injected with the other
materials (P < 0.00001). Analysis of filler density and rates
of prolonged edema was performed among the 7 studies
in which filler density was reported. No statistically signifi-
cant difference in rates of edema were noted on this basis
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(P > 0.05).
The so-called Tyndall effect, lumpiness, and product mi-
gration were only reported in the HA group. Thirty of 31 pa-
tients who were noted to have product migration were in
the HA group. Yellow discoloration, sometimes called xan-
thoma, was developed by 22 (5.85%) of the patients in the
CaHa group. No xanthomas were described for patients in
any other subgroup.
Infection, pruritus, and prolonged discomfort were ex-
ceedingly rare, occurring in less than 1% of patients.
Throughout our review of the literature we identified 4
reported cases of complications related to intravascular
injection of filler in the periorbital region.36-38 It is unclear
from these reports whether these complications resulted
from TT augmentation specifically. These reports did not
otherwise fulfill our inclusion criteria, but given the severity
of these events, we cite them for the reader’s benefit.
We have summarized a few of the key findings de-
scribed above in Table 2.
DISCUSSION
To our knowledge, this is the first systematic review of out-
comes and patient satisfaction of filler augmentation to
the TT region. The periorbital region, and the TT in par-
ticular, are considered among the most challenging to
address with filler.21 The TT skin is the thinnest in the body,
making the margin of error for overvolumization quite low
because misplaced filler will be easily visible or palpable.
Additionally, hyperpigmentation or discoloration of the skin
in this area can be made more obvious with volumization.
Finally, the multiple regional blood vessels that course
near the TT make intravascular filler injection, and the po-
tentially catastrophic downstream complications from this
event, a significant threat.
As our results show, different filler materials have been
used for TT augmentation with high patient satisfaction.
Consistent with filler usage trends throughout the face,
HA-based fillers are most commonly employed for the TT.
Authors who choose HA-based fillers cite wide availability,
high reported patient satisfaction rate, reversibility with
hyaluronidase, and the relatively benign and self-limited
complication profile as qualities that make this substance
an ideal filler choice. Additionally, a bevy of formulations
with different rheologic characteristics are available for
the injector to select from.
Despite its many benefits, HA fillers also have a few
flaws which are often cited by critics and proponents of
NP1058 Aesthetic Surgery Journal 41(8)

Table 1. Complications From Tear Trough Augmentation by Filler Subtype

Filler type Ecchymosis Erythema Edema Lumpiness Tyndall Product Yellow Hyaluronidase Infection Fluid Itching Migraine Discomfort Total
effect migration disc collection

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HA 215 (14.01) 33 (2.15) 172 (11.21) 127 (8.27) 83 (5.41) 30 (1.95) 0 (0) 77 (5.02) 2 (0.13) 18 (1.17) 5 (0.33) 1 (0.07) 16 (1.04) 779 (50.75)

CaHa 30 (7.98) 13 (3.46) 8 (2.13) 0 (0) 0 (0) 1 (0.27) 22 (5.85) 0 (0) 1 (0.27) 0 (0) 0 (0) 0 (0) 0 (0) 75 (19.95)

AFKG 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 4 (11.43) 4 (11.43)

Collagen 9 (90) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 9 (90)

Total 254 (12.99) 46 (2.35) 180 (9.2) 131 (6.49) 83 (4.24) 31 (1.58) 22 (1.12) 77 (3.94) 3 (0.15) 18 (0.92) 5 (0.26) 1 (0.05) 20 (0.1) 871 (44.3)

Values are n (%). HA, hyaluronic acid; CaHa, calcium hydroxyapatite; AFKG, autologous fibroblast and keratin gel.

alternative soft tissue fillers. One of the well-known is- Table 2. Take-away Points
sues with HA is its hydrophilicity, which leads to variable
HA-based fillers are most 78.5%
amounts of postinjection water absorption.9,31 Patients who common
were satisfied with the amount of volumization achieved
Average volume of HA filler 1.16 mL
immediately postinjection may become disappointed if
injected per patient
water absorption leads to an overvolumized appearance
or persistent soft tissue edema. The extent of water ab- Overall patient satisfaction rate 84.4%
sorption may vary across the different HA formulations.17 Most common complications Ecchymosis (12.9%), edema (9.2%),
The density of hyaluronic acid per volume of material in- lumpiness (6.5%)
jected has also been purported to affect the amount of
Patients on whom cannulas were 7.2% (cannula) vs 17.2% (needle)
postinjection water absorption.8 Among the few studies used were less likely to
in which filler material density was reported, we found develop ecchymosis
that rates of prolonged edema were 8.7%, 7.7%, and 9.3%
among patients receiving 15, 20, and 24 mg/mL of HA, re- HA, hyaluronic acid.

spectively. Although the highest concentration fillers did

have higher rates of edema, this finding was not statisti-
cally significant.
One of the pitfalls of HA fillers used for TT rejuvena-
tion is the potential for development of a blue-gray skin
dyschromia, termed the Tyndall effect. The matter is further
complicated by the fact that some people naturally have dis-
colored skin in the TT prior to filler application. These dark
areas may be made more obvious by volumization and lead
to patient dissatisfaction. In order to minimize the occurrence
of blue-gray dyschromia, Mustak et al suggest maintaining a
deep injection plane and minimizing the injected volume of
filler at the thin-skinned TT.27 This suggestion seems to have
resonated with the filler-injecting community because 86.7%
of the protocols reviewed endorsed injecting at this layer.
Despite this percentage being even higher among proto-
cols involving HA injection (91.7%), the Tyndall effect was a
significant complication, occurring in 5.4% of patients. This
dyschromia is a frequently cited cause of patient dissatisfac-
tion after TT filler injection,15 and some authors have sought
alternatives to HA in order to avoid it.
Corduff, for example, investigated the use of CaHa for
filler volumization of the TT in patients who have had un-
satisfactory results with HA or have dark discoloration of
their TT.13 Her technique involved combining deep filler
injection volumization with subcutaneous placement
of diluted CaHa for the purpose of reducing under-eye
pigmentation. In addition to the potential for avoiding
and even improving dark spots in the TT region, CaHa
has been purported to have other benefits over HA.
Bernardini et al cite CaHa’s comparatively lower tendency
for postinjection water absorption, increased moldability,
and collagen-stimulating capacity as additional benefits
over HA-based fillers.9 Both CaHa and HA have been
noted to have biostimulatory capabilities, but a split-face
histopathologic study by Yutskovskaya et al in 2014 sug-
gests that CaHa injection results in more collagenesis
and elastin production, and less inflammation, than HA
filler injection.39
Additionally, CaHa is also known to be longer lasting
than HA products, with longevity of up to 2 years.40 This in-
creased duration comes with increased risk because there
is no antidote to CaHa. Other potential deterring factors
when injecting CaHa for TT augmentation is that, although
no incidents of blue-gray dyschromia were reported, yellow
dyschromia was reported by 5.8% of patients in this group.
Although the studies which assessed TT augmentation
with the collagen-based filler Evolence and the autologous
keratin/fibroblast-based filler described by Xing et al both
reported satisfactory results, these products are not com-
mercially available in the United States.16,35
Gorbea et alNP1059
The most commonly cited complication from soft tissue
fillers in the TT region overall was ecchymosis (12.32%). Some
authors contend that the use of cannulas for injection of filler
into the TT leads to decreased rates of ecchymosis.10,15,21,28
These authors believe the sharp needle tip may result in
more traumatic injury to the orbicularis, regional vasculature,
and lymphatic structures. Our results support this, given the
statistically significant difference in ecchymosis rates be-
tween patients who underwent needle injection of filler vs
cannula injection in the TT region. Nevertheless, random-
ized trials to look into this specific subject would be nec-
essary to further validate these findings. It is suspected by
some authors that the bleeding which causes ecchymosis
from filler injection to the TT comes from local trauma to the
orbicularis by the injection needle.15 For this reason some
authors advocate techniques which require only 1 “pass” of
the needle through this layer, as opposed to the multiple-
injection technique preferred by others.
As with most systematic reviews, our study likely is af-
fected by significant publication bias. Additionally, wide
variability in methods of reporting patient satisfaction are
a limitation of this systematic review. Authors report sat-
isfaction according to a variety of scales that are neither
standardized nor validated. Therefore, we have consoli-
dated graded scales of patient-reported satisfaction into
binary satisfied vs nonsatisfied categories, which provide
us with reliable input into patient contentment. This does,
however, blur subtle differences in satisfaction across
groups which could potentially be captured if there was a
consistent patient satisfaction scale across the literature.
Another limitation of our study is that some events, such as
ecchymosis and edema, are categorized by some authors
as complications, but others may consider these expected
side effects of the procedure. This phenomenon would
lead to underreporting of these events.
One final limitation of our study is that by excluding
articles reporting on fewer than 5 patients, we have likely
underreported rare complications. In particular, blindness
and skin necrosis from intravascular injection were not
reported in our cohort, but are of great relevance. For this
reason, we have cited the 3 articles we found throughout
our review of the literature which report a total of 4 pos-
sible cases of blindness related to filler injection of this
region.36-38 Granuloma formation is another potential
complication that has been reported as a complication
of TT volumization which was not reflected in the larger
cohort studies included for this systematic review.41
The true rate of these complications is unknown, but
they are an important risk of TT augmentation and should
be discussed with the patient during the consent process.
The absence of these complications in the larger-cohort
studies included in this systematic review may reflect ei-
ther very low incidence of these events or significant
underreporting of certain complications.
CONCLUSIONS
There is broad evidence demonstrating the efficacy of TT
rejuvenation with a variety of injectable fillers. The litera-
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ture further demonstrates high patient satisfaction and a
low risk of severe complications. Minor complications,
such as edema, ecchymosis, pigmentary changes, and
lumps, should be discussed with patients as potential com-
plications because they occur relatively frequently. Our re-
sults suggest that the use of cannulas for injection of this
region may minimize the risk of ecchymosis, although a
direct comparison study would be required to make this
assertion definitively. The rate of intravascular injections
and their devastating effects remains poorly understood
in the context of the numbers of patients receiving TT
augmentation.
Supplemental Material
This article contains supplemental material located online at
www.aestheticsurgeryjournal.com.
Disclosures
The authors declared no potential conflicts of interest with
respect to the research, authorship, and publication of this
article.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
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