Eyelid Filler Injection
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Introduction
This article reviews the indications and management for filler injections in the eyelids.
Indications for eyelid filler injection
The main indication for eyelid filler injection is for cosmetic reasons to add volume around the eyes, although it is also used for functional reasons (such as mechanically altering the eyelid to help close the eye better).
Eyelid filler is injected into the hollows under eyes (tear trough area) to improve or eliminate dark circles or a tired appearance. It can also be injected into a hollow upper eyelid/brow area.
The hollowness around the eyes can be inherited but it is almost always worsened by continued fat loss around the eyes/face that occurs in the aging process. Adding volume in these hollow areas around the eyes (and face) can help create more youthful, rested appearance with natural results.
Anatomy of eyelid/orbit
A thorough understanding of the eye/orbit is essential when evaluating patients for possible eyelid filler injection. The thinness of eyelid skin and the bony and vascular anatomy of the orbit should be taken into account when using fillers in this region. Care should be taken to avoid the angular vessels medially when injecting the tear trough region. Likewise, the pretarsal eyelid should be avoided as the skin and subcutaneous tissue are extremely thin, increasing the likelihood of lumpiness and Tyndall effect.
Diagnosis
A thorough history should be elicited from the patient including a complete history of prior treatments and surgeries of the face and periocular region. Clinical examination of the eye, orbit, and surrounding structures is needed to determine the candidacy of the patient for eyelid filler injection. Relative hollow areas need to be examined.
Rarely, eyelid swelling or allergies or masses can create eyelid contour irregularity. These other etiologies need to be ruled out.
Signs/symptoms
Hollows under the eyes (tear trough deformity) create a tired, older appearance to the eyes and face with classic under eye dark circles. The same phenomenon hold true for the upper eyelid/brow area. Adding volume (via eyelid filler injection) in these hollow areas can help create more youthful, rested appearance with natural results.
Types of Eyelid fillers
It should be stated that filler injection is considered off-label when injected around the eyes, however they have been used for many years with a good safety record.
There are various filler materials available on the market. It is important to use safe, temporary, reversible filler types around the eyes. Hyaluronic acid fillers dominate the market currently. Low viscosity products are best suited for the periocular region. Hyaluronic acid gel products are reversible using hyaluronidase. These fillers, on average, last longer than one year around the eyes.
Technique
Eyelid filler is injected around the hollow areas around the eyes with the patient in a sitting position. Topical anesthesia can be placed but it is not usually necessary.
The filler is injected deep, usually on the orbital rim bone, in small amounts in retrograde fashion. This is particularly important in patients with thin skin to avoid lumpiness and the discoloration. The result is immediate and patient's input can be taken into account with a hand-held mirror. Usually, 1cc of filler in enough for lower eyelid hollows/tear troughs. The upper eyelid/brow may need more or less filler amount.
Post-procedure regimen
There is some bruising/swelling in the injected sites around the eyes, that lasts about a week. The recovery is painless and no restriction in physical or visual activity is needed. The effect of hyaluronic acid gel around the eyes is more than one year, on average. Additional filler can be injected in subsequent visits, but usually less would be needed.
Complications
- Undercorrection
- Overcorrection
- Contour irregularity
- Persistent edema
- Blue-grey dyschromia (Tyndall effect)
- Extremely rare vascular occlusion
- Blindness
- Filler migration to a distant site
- Posterior migration into the orbit (orbital mass masquerader)
- Delayed edema
- In the lower eyelid region, soft tissue fillers can often last for even years, and found even over 10-15 years later.
Additional resources
Shirin Hamed-Azzam, MD, Cat Burkat, MD, FACS, Abed Mukari, MD, Daniel Briscoe, MD, Narish Joshi, MD, FRCOphth, Richard Scawn, MD, FRCOphth, Eran Alon, MD, Morris Hartstein, MD, FACS, Filler Migration to the Orbit, Aesthetic Surgery Journal, Volume 41, Issue 6, June 2021, Pages NP559–NP566, https://doi.org/10.1093/asj/sjaa264
