Blog: Intervention may be necessary when too much filler is used under the eye

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The overfilling of tear troughs has become a common concern with the increasing number of individuals seeking nonsurgical tear trough fillers. Given the increase in the rate of tear trough filler treatment, it is a natural assumption that the incidence of ophthalmologic complications such as the Tyndall effect and overfilling have seen a proportional rise in occurrence. As we age, the under-eye area naturally becomes more sunken and hollow, often leading to a tired and aged appearance.

In an effort to combat this, patients and practitioners may overfill this delicate area, resulting in undesirable outcomes such as puffiness, swelling, or an unnatural look.

Hyaluronidase is a challenging enzyme to use as it requires finesse techniques to be used properly, especially for the periorbital regions. It has been utilized in both ophthalmology and aesthetic medicine for its specific and beneficial properties, including its rapid onset of effects, increased tissue permeability, breakdown of hyaluronic acid, and reduction of edema. In ophthalmology, it has specific uses as an adjunct to local anesthetics to improve their diffusion and effectiveness by breaking down local hyaluronic acids therefore reducing the viscosity and cohesion of the extracellular matrix.

It is particularly useful in retrobulbar, peribulbar, or episcleral blocks, such as during cataract surgery and other intraocular operations. Not only that, hyaluronidase is used before blepharoplasty as it improves surgical precision and aesthetic outcomes to remove unwanted hyaluronic acid before surgery.

To address these issues, the gentle use of hyaluronidase is recommended for the precise adjustment of overfilled tear troughs. This approach helps avoid the potential complication known as Post-Hyaluronidase Syndrome, where excessive use of hyaluronidase can lead to unintended volume loss. By carefully administering hyaluronidase, practitioners can effectively manage filler migration and overfilling, restoring a more natural and balanced appearance under the eyes.

It is crucial for practitioners to exercise caution and finesse when using hyaluronidase around the eyes, ensuring that adjustments are made conservatively and with the patient's overall aesthetic in mind. This careful approach helps to achieve the desired rejuvenation without compromising the natural contours and expressions of the face.

Hyaluronidase is used to address several complications that may arise from dermal filler injections. Overfilling is a common issue where excess filler results in a puffy or unnatural appearance. Incorrect placement of filler can lead to lumpiness and nodules, which are palpable lumps under the skin. Additionally, fillers can sometimes migrate from the initial injection site, causing uneven distribution and asymmetry, where one side of the face may look different from the other.

Superficial placement of filler can cause the Tyndall effect, a bluish discoloration of the skin. Hyaluronidase helps mitigate these issues by dissolving the filler, allowing for a more natural and balanced appearance.

By removing the filler prior to blepharoplasty, the surgeon can better visualize the patient's natural anatomy and achieve the desired aesthetic outcome more effectively. Ideally, even though King et. al. states it has a half-life of two minutes with a duration of effect between 24 and 48 hours, hyaluronidase should be injected 6 months prior to blepharoplasty as it allows time for the periorbital to restore to its native state, breakdown of lymphedema, and to clear lymphatic blockage.¹ If hyaluronidase treatment is too close to surgery, an ophthalmic surgeon will notice that the surrounding tissue can bleed excessively and is more inflamed.

The presence of filler can make it more difficult to accurately assess and manipulate the eyelid tissues, potentially leading to complications or suboptimal surgical results. Additionally, filler in the under-eye area can affect the natural contours and appearance of the eyelids. Visual assessment as well as palpation of that area helps identify the exact location and the extent of how much filler needs to be dissolved.

A "pinch test" can also be utilized, where the skin is gently pinched to assess the mobility and depth of the filler, ensuring precise targeting and effectiveness of the hyaluronidase treatment. This test is useful for distinguishing between filler and natural tissue, allowing for a more accurate injection of hyaluronidase.

Additionally, ultrasound technology can be employed to visualize the placement and amount of filler within the tissue. Ultrasound provides a detailed image, helping to identify the exact location and depth hyaluronidase and ensures that the dissolving agent is precisely targeted to the areas where it is needed most.

Ultrasound identification of lingering filler from past treatment can be helpful during both pre- and post-septal filler. Hyaluronidases in the United States are human-recombinant technology or ovine-recombinant. Therefore, skin tests are usually not needed. Additionally, to exercise further precaution, skin tests hyaluronidase sensitivity can be performed before treatment. From there, an injector needs to calculate the dosage.

A general rule of thumb is that 1 cc of filler requires at least 400 units of hyaluronidase. In other words, plan to have 3 vials of dissolver for every syringe of undesired filler. When injected into a filled area, the effects of hyaluronidase are immediately noticeable. It is advisable to wait up to 2 weeks before adding more filler post-hyaluronidase treatment to allow the area to return to its native state.

It is especially important to not over-dissolve as it can lead to an overly hollow appearance that may require additional hyaluronic acid fillers to correct. In my practice, I always recommend to hyperdilute the hyaluronidase with lidocaine 1:1 concentration to avoid over-dissolving natural hyaluronic acid. The idea behind this is to not only help with patient comfort but also facilitate vasodilation and dispersion of the hyaluronidase. In other words, there is less hyaluronidase per volume, and therefore injectors can avoid over-dissolving the body’s natural hyaluronic acid. Remember, hyaluronidase is not only dissolving filler but naturally produced hyaluronic acid.

When injecting, the following techniques and procedural care should be exercised:

Injection Technique

• Use of Cannulas: For enhanced safety, blunt-tip micro-cannulas are preferred over needles. Cannulas minimize the risk of vascular injury and provide better control over the enzyme’s distribution. Additionally, cannula use has been shown to lower the rate of ecchymosis by 10.0%1.
• Superficial vs. Deep Placement: The depth of injection should correspond to the depth of the filler. Superficial fillers that cause the Tyndall effect require superficial hyaluronidase placement, whereas deeper nodules require deeper injections.

Hyaluronidase is also well known in aesthetic medicine as a hyaluronic acid dissolver and is used for several reasons, particularly for the correction of hyaluronic acid filler-related complications. According to data reported by Gorbea et. al. in a systematic literature review of patient satisfaction after nonsurgical tear trough volumization, complications were fairly common with 44.3% of the entire patient cohort reporting some level of complication although all complications reported were minor.

The reviewers of this study did note that there was likely a large amount of publication bias in their analysis. Both aesthetics and ophthalmology share a commonality of using hyaluronidase for treating complications associated with hyaluronic acid filler in the periorbital area. It is a very tricky area and injectors have to exercise extreme caution due to the high risk of complications associated with this complex area. When administering hyaluronic acid dermal filler products the incidence of vascular complications is between 0.01% and 0.05% per treatment (Oxford Academic).

The periorbital area is anatomically complex with numerous vital structures with thin delicate skin making it more susceptible to bruising, swelling, allergic reaction, infection, vision impairment, and other adverse reactions. To minimize complications when injecting, it is important to understand the periorbital anatomy. Here are the key landmarks, anatomical considerations, and indications when using hyaluronidase for the periorbital area.

Post-procedure care

Lymphatic massage can be beneficial post-procedure to help promote fluid drainage and reduce swelling. This type of massage can assist in clearing any residual filler and lymphatic blockages, enhancing the overall outcome of the treatment. Patients need to be scheduled for follow-up appointments to assess the need for additional treatments and to ensure satisfactory results.

Conclusion

The use of hyaluronidase in the periorbital region demands a meticulous approach due to the delicate anatomy and high risk of complications. Understanding the intricate periorbital anatomy, including key landmarks and anatomical considerations, is essential for safe and effective injections.

From avoiding vital structures to calculating proper dosages and employing precise injection techniques, injectors must exercise caution and finesse. By adhering to these principles and post-procedure care protocols, clinicians can mitigate risks and achieve optimal outcomes, ensuring patient safety and satisfaction in this challenging yet rewarding area of aesthetic practice.

Key landmarks

The Tear Trough (Nasojugal Groove) is a depression that runs from the inner corner of the eye (medial canthus) obliquely downward and outward. It is a common site for filler injections to address under-eye hollowness. Positioned on the cheek, the Malar Fat Pad provides support and contour to the midface, and injections in this area can help lift the lower eyelid region.

Anatomical considerations

The Orbicularis Oculi Muscle encircles the eye and is involved in blinking and facial expressions. Understanding its position helps avoid intramuscular injections, which can cause functional disturbances. The Levator Labii Superioris runs alongside the nose and contributes to facial expression, so awareness of its location is crucial to avoid inadvertent paralysis or asymmetry. Regarding fat compartments, the Suborbicularis Oculi Fat (SOOF) is located under the orbicularis oculi muscle and can be targeted for deeper injections, while the Preseptal Fat within the eyelids should be avoided to prevent complications like ectropion (eyelid turning outwards). The Tear Trough Ligament, a structure that separates the palpebral and orbital portions of the orbicularis oculi muscle, requires proper technique to ensure fillers do not migrate into the orbital space.

About the author

Kay Durairaj, MD, is a facial plastic surgeon practicing in Pasadena, California. As both a USC and UCLA-trained surgeon, Kay has built a reputation in the Los Angeles area and across the nation as a top facial plastic surgeon when it comes to dermal fillers, Botox, chemical peels, skin resurfacing, skin tightening, and other areas of plastic surgery. Kay specializes in faces, including surgery for eyelids, rhinoplasty, facelift and neck lift. Her expertise in Botox and neurotoxins, facial injectables and fillers and was voted one of the top 100 injectors in the country by her peers. She is chairman of the Department of Ear, Nose and Throat Surgery at Huntington Memorial Hospital and she serves as an advisor to multiple aesthetic industry organizations such as Merz, Allergan, Evolus, Prollenium and Galderma. Visit her website at www.beautybydrkay.com.

References

1. DeLorenzi, C. (2013). “Complications of Hyaluronic Acid Fillers and Their Management.”Dermatologic Surgery, 39(7), 927-939. This review discusses complications related to fillers andthe use of hyaluronidase for management.

2. Wang, J. C., & Gottlieb, R. (2014). “Hyaluronidase for the treatment of hyaluronic acid nodules.” Journal of the American Academy of Dermatology, 70(2), 413-415. This article provides case studies on the effective use of hyaluronidase in resolving nodules.

3. Hirsch, R. J., Stier, M. A., & Cohen, J. L. (2007). “The use of hyaluronidase in aesthetic practice.” Journal of Drugs in Dermatology, 6(8), 781-784. This publication offers practical insights and techniques for using hyaluronidase in aesthetic treatments.

4. Cotofana, S., & Waldman, H. A. (2019). Facial Anatomy for Filler Injection: The SuperficialMusculoaponeurotic System (SMAS) and the Facial Fat Compartments. Plastic andReconstructive Surgery, 143(4), 39S-48S. DOI: 10.1097/PRS.0000000000005528.

5. Onesti, M. G., et al. (2020). Hyaluronic Acid Fillers: Adverse Events and Complications.Aesthetic Plastic Surgery, 44(4), 1224-1231. DOI: 10.1007/s00266-020-01661-7.

6. Robinson, D. J. C., & Ross, E. V. (2017). Tear Trough Deformity: A Comprehensive Review o Anatomy, Treatment Options, and Outcomes. Journal of Drugs in Dermatology, 16(1), 43-49.PMID: 28095546.

7. Rzany, B., & Sattler, N. H. (2010). Complications of Cosmetic Botulinum Toxin and FillerInjections. Journal of Cosmetic and Laser Therapy, 12(4), 196-203. DOI:10.3109/14764172.2010.505418.

8. Rüschen H, Aravinth K, Bunce C, Bokre D. Use of hyaluronidase as an adjunct to localanaesthetic eye blocks to reduce intraoperative pain in adults. Cochrane Database Syst Rev. 2018 Mar 2;3(3):CD010368. doi: 10.1002/14651858.CD010368.pub2. PMID: 29498413;PMCID: PMC6494176.

9. Murray G, Convery C, Walker L, Davies E. Guideline for the Safe Use of Hyaluronidase inAesthetic Medicine, Including Modified High-dose Protocol. J Clin Aesthet Dermatol. 2021 Aug;14(8):E69-E75. Epub 2021 Aug 1. PMID: 34840662; PMCID: PMC8570661. http-wwwjarcetcom-articles-Vol12Iss1-Vol1220Iss1Silversteinpdf.pdf (researchgate.net)

10. Hyaluronidase for Dermal Filler Complications: Review of Applications and DosageRecommendations - PMC (nih.gov) Joel L. Cohen, Brian S. Biesman, Steven H. Dayan, Claudio DeLorenzi, Val S. Lambros, Mark S. Nestor, Neil Sadick, Jonathan Sykes, Treatment of Hyaluronic Acid Filler–Induced Impending

11. Necrosis With Hyaluronidase: Consensus Recommendations, Aesthetic Surgery Journal, Volume 35, Issue 7, September/October 2015, Pages 844–849,https://doi.org/10.1093/asj/sjv018

12. 1- King, Martyn et al. “This month's guideline: The Use of Hyaluronidase in Aesthetic Practice (v2.4).” The Journal of clinical and aesthetic dermatology vol. 11,6 (2018): E61-E68.