Nonsurgical Management of Eyelid Asymmetry

Ronald Mancini, MD

Article by
Dallas Oculoplastic Surgeon

Nonsurgical Management of Upper Eyelid Margin
Asymmetry Using Hyaluronic Acid Gel Filler

Ronald Mancini, M.D.*†, Nicole M. Khadavi, B.S.†, and Robert Alan Goldberg, M.D.*†

*Division of Oculofacial Surgery, Department of Ophthalmology, Jules Stein Eye Institute; and †David Geffen School of Medicine at UCLA, Los Angeles, California, U.S.A.

Purpose: To evaluate the efficacy of hyaluronic acid gel
fillers as a nonsurgical alternative for the management of upper
eyelid margin asymmetry in cases of relative retraction.
Methods: This is a retrospective study of 8 patients with
upper eyelid margin asymmetry relating to relative upper
eyelid retraction treated with hyaluronic acid gel injection to
affect upper eyelid lowering. Digital photographs were used
to quantitatively assess outcomes by comparing pretreatment
and posttreatment differences between marginal reflex distance
(MRD1) in the right and left eyelids. Image J was used
for photographic analysis, and Student paired t test was

Results: Eight patients (2 male; mean age, 50.9 years;
range, 30 – 69 years) were injected with hylauronic acid gel
in the upper eyelid. The etiology of upper eyelid margin
asymmetry included Graves eyelid retraction (n  3), asymmetry
following reconstructive surgery (n  1) and aesthetic
surgery (n  1), contralateral Horner syndrome (n  1), Bell
palsy (n  1), and contralateral involutional ptosis (n  1).
The average volume injected in the upper eyelid was 0.2 ml
(range, 0.1– 0.4 ml). One of 8 patients was injected bilaterally.
Average follow-up was 5.7 months (range, 2–12
months). Two of 8 patients requested repeat injection within
a 6-month period for undercorrection. No overcorrections
were noted, and no patient requested reversal with hyaluronidase.
There was a statistically significant improvement in
symmetry with mean pretreatment MRD1 difference of 1.53
mm (range, 0.78 –3.36 mm) and mean posttreatment MRD1
difference of 0.70 mm (range, 0.02–2.03 mm), p  0.007. At
4 to 8 months’ follow-up, 8 of 8 demonstrated persistent
improvement in asymmetry with statistically significant reduction
in MRD1 difference when compared with pretreatment
with average follow-up MRD1 difference of 0.74 mm
(range, 0.11–1.65 mm), p  0.018.

Conclusion: This pilot study suggests that upper eyelid
injection with hylauronic acid gel filler may be an effective
nonsurgical alternative to improve upper eyelid margin asymmetry
in cases of relative upper eyelid retraction.
(Ophthal Plast Reconstr Surg 2011;27:1–3)
Subtle upper eyelid margin asymmetry can impact overall
facial harmony and aesthetics. Addressing these asymmetries
can significantly improve facial aesthetics and complement
other surgical and nonsurgical rejuvenative facial procedures.
To date, surgical correction is the intervention of choice for
addressing upper eyelid margin asymmetry with few, if any,
alternatives. Hyaluronic acid gel (HAG) fillers have demonstrated
efficacy in the periocular region in the management of
paralytic lagophthalmos, retraction of the lower eyelids, and for
pediatric eyelid malpositions such as congenital ectropion and
epiblepharon.1–4 HAG fillers have several distinct advantages:
they allow for precise placement and control, they are usually
reversible with hyaluronidase, and they are easily used in the
office setting, providing an alternative to patients who decline
surgery or are poor surgical candidates. Botulinum toxin injection
as a temporary treatment of upper eyelid ptosis and
retraction has previously been described.5,6 Here, we describe
the use of HAG injection in the upper eyelid to treat upper
eyelid margin asymmetry of various etiology.

Ophthal Plast Reconstr Surg, Vol. 27, No. 1, 2011 Nonsurgical Management of Upper Eyelid Margin Asymmetry
© 2010 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. 3