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Ziai et al. Plast Aesthet Res 2020;7:53 I http://dx.doi.org/10.20517/2347-9264.2020.151 Page 7 of 13

Table 2. Commonly used hyaluronic acid fillers and their properties with recommended needle size for administration
Filler Manufacturer HA composition (mg/mL) Presence of lidocaine Needle size (Gauge) G′ (PG)
Restylane-L Galderma 20 + 29-30 864
Restylane Lyft (Perlane) Galderma 24 - 27-29 977
Restylane Silk Galderma 20 + 30 -
Belotero Merz North America 22.5 - 30 128
Juvederm Ultra XC Allergan 20 + 27 -
Juvederm Ultra Plus XC Allergan 24 + 27 207
Juvederm Voluma XC Allergan 20 + 27 398
Juvederm Vollure XC Allergan 17.5 + 30 -
Juvederm Volbella XC Allergan 15 + 30 240
Versa Revanesse 22-28 + - -
This is not an exhaustive list of all HA fillers. The G′ properties and HA composition are adapted from Greene and Sidle [22] and Cho et al. [32] .
HA: hyaluronic acid; G′: elastic modulus

A B

Figure 3. Tear trough deformity injections: (A) pre-injection; and (B) four months post-injection of 0.5 mL each side into the infraorbital
hollows and 0.1 mL to the glabellar rhytids with Restylane-L

Tear trough
Different injection techniques exist. If using a cannula, an entry hole is made with a 21- or 25-gauge
needle depending on the cannula size below the infraorbital hollow. A cannula is then passed to the orbital
retaining ligament and dry tunnels may be created along the length of the hollow followed by injection
while withdrawing the cannula until the desired contour is obtained. If using a needle, one typically enters
superior to the upper nasolabial fold, again passing superiorly along the orbital retaining ligament until
meeting the resistance of the orbital rim, and injecting in a supraperiosteal plan. In younger patients or
those with shallow folds, as little as 0.2-0.3 mL of filler per side is adequate for restoring volume. Caution
should be made not to enter the orbit, injure the globe, and not to inject too superficial as this will result
in increased bruising, a grayish or bluish discoloration, or irregularity. The area should be massaged after
the injection to achieve a smooth contour [Figure 3]. If necessary to create a more rejuvenated appearance,
injections into the malar eminence with a high G’ filler may be combined with tear trough injections to
create a more natural lid-cheek junction and restore the Ogee line [Figure 4]. These injections should be
supraperiosteal and are typically injected in aliquots then massaged to provide a smooth contour. Examples
of HA fillers commonly used in the malar region include Juvederm Voluma (Allergan) or Restyalne Lyft
(Galderma).