I am still learning to inject the tear throughs using Restylane. I've been injecting product at the level of the bone. So far, what I am witnessing is after the initial swelling subsides it looks as though nothing was injected at all. This occured on a pt I injected 0.5cc to each eye (she does have deep hollows).

Questions:
How much product are you using on average per eye? Is there a "safe amount" or an amount not to inject over?
Can the lack of result be that my injection is too deep and that I should be injecting more subQ? Or just keep it along the periorbital rim but inject more product?

Any tips and advice from experienced injectors is appreciated. I'm going off the techniques outlined on the thederm.net.

Its a difficult area to inject but results can be fantastic. I would not go with a product thicker than Perlane, and usually use Esthelis Basic, but resty is fine. Try transfering your product to a 31g 0.3ml insulin syringe and inject droplets perpendiculat intop the area in a droplet shape so that some product is deep and less (the tail of the droplet) is superficial. Do not over correct. This can cause swelling in some patients which can require hyaluronidase. Or try Perlane and go deep linear thread technique. I use total 0.5 - 1 ml per pateint but some do require more, whcih I usually put in at a review visit. Beware bruising - always be prepared to apply pressure - easy to cause black eye which patients hate you for even if warned about. Fill in this area usually lasts twice as long as other areas in my experience.

I am having the same problem. I inject Restylane deep on top of the bone, into the trough. After initial swelling, product seems to disappear.

I inject linearly and never as deep as the bone. The trick is to be deep enough so as not to cause lumpy residues but still superficial enough to actually generate a filling pocket.
I never use Perlane(too viscous), since I reside in Europe I use Teosyal Global(excellent product) with quite good results.

Correct - go deep enough but not too deep! Some very fine products like esthelis can be placed closer to the surface in very small droplets or threads. Perlane is fine as long as it is deep enough - you can even use thicker products like Radiesse if placed deep enough.

Thanks. I thought I was injecting too deep!

LOL... so what exactly is "deep enough" but "not too deep"?

Well - it will vary from person to person. Inject too superfdicially and its prone to lumpiness and tindel effect. Inject just above the bone and there is less effct - but its much safer - so if in doubt go deep, and the thicker the product the deeper you go generally - so Perlane, Sub Q etc always very deep, Esthelis can go more superficial. Also older patients with thiner skin - go deeper. With restylane and Esthelis I sometimes inject what I call pillars - place a small bolus deep, them keep injecting as you withdraw - has a good lifting effect - and with the softer products you can usually massage away any lumps.

Ok, so why wouldn't we do all injections on the periosteum?

Ben T,

The theory is that it may be blocking the lymphatic drainage of the infraorbital region of the face. The lymph system is very low pressure and does not take much to hinder. How is the pt doing at this time? Did the steroids help? Another thing to think about is allergies as in our areas ragweed is a huge problem now that was not present a few weeks ago.

If it does not resolve you may have no choice but to remove the HA with hyaluronidase.

Well, the festoon decreased somewhat with prednisone and 3 weeks of waiting, but the bag is still there. Any advice on how to administer Vitrase?

You should not need to dilute it but you will only need a 0.1 to 0.2ml total and that should do most of it.