Will Juvederm fill in under eye wrinkling and volume loss after a blepharoplasty that removed too much tissue?

Question

I had a Blepharoplasty a few years ago, and a lot of tissue was removed under the eye. Now, five years later, I am getting a lot of wrinkling and the under eye area seems to be sinking in, making me appear older. Will any cosmetic filler like Juvederm be helpful at this point since I have had tissue removed? I really need a good answer to this before having a major nightmare scenario.

David L. Mobley, MD, FACS · Answer

The use of dermal fillers for hollow areas along the lower eyelids is common, especially in the area sometimes called the tear trough. This is the area some people think of as the dark circle under their eye. I have used Juvederm and Restylane successfully for these hollow areas. Fat grafting may also be successful but does require harvesting of the fat from your hip or abdomen.

	Since you have had surgery one key issue is how thin is the remaining eyelid tissue. If I were seeing you as a patient I would carefully examine this area since anything placed in this area is more likely to show or not look natural if the remaining skin/tissue is thin.

	My first choice to try to fill this area in some would be Juvederm since it has a smoother, thinner consistency. I think it would be less likely to cause lumps. Although if they occur, lumps can be dissolved rather easily with Hyaluronidase.

	Since you also note wrinkling in this are sometimes the addition of a laser treatment is necessary to get the best results. My preference for this area is the Active FX Fractional CO2 laser.

	Often the best results in your situation is when you combine these two treatments since the laser essentially shrink wraps the skin slightly to improve the wrinkles while the filler helps fill in the concavity.

	As you might have guessed this problem is not easy to fix. I spend a good bit of time explaining the treatment to patients before proceeding since sometimes more than one treatment with the Juvederm is needed and lumps are possible.

	Overall, though, success is likely.

Ron Shelton, MD · Answer

Although it is an off-label use, Juvederm or Restylane is being used by many physicians for this exact indication. It is placed underneath the muscle so that the thin skin of the lower eyelid wouldn&rsquo;t show lumps of the filler.
The overlyling skin might improve very little in texture, but this can be improved with Portrait plasma or laser resurfacing, such as Fraxel.

Michael A. Persky, MD · Answer

Hi Venus,
Restylane is an excellent filler for filling lower eye lid hollows, even in patients who have a history of blepharoplasty. 
The lower eye lid area is very delicate and requires an experienced cosmetically trained physician. 
Good luck and happy holidays.
Dr. P

Kris M. Reddy, MD, FACS · Answer

Dermal fillers can be performed to improve the hollow areas of the lower eyelids. Restylane is probably the best product for this area, but juvederm can be used as well. The risks are plentiful so it should be only done by expert injectors who are experienced in this use.

Pat Pazmino, MD, FACS · Answer

Juvederm is an excellent hyaluronic acid based injectable that can be used effectively for facial contouring.

	Juvederm is commonly used around the lips, the smile lines, the marionette lines, under deep wrinkles, under deep scars, and even under the area of the eye.

	However, keep in mind that the area under the eyes has some of the thinnest skin in the body and can bruise very easily because of the high concentration of blood vessels. For this reason it is essential that you work with a board-certified plastic surgeon who has experience in blepharoplasty, facial rejuvenation and with dermal fillers. Such an expert is very familiar with the anatomy of this area and will be able to inject the Juvederm in the correct location and in a smooth fashion.

Steven Wallach, MD · Answer

Facial fillers like Juvederm or Restylane may be helpful to fill in the area that appears sunken in the lower eyelid.  Be careful because it can also leave bumps.

Kenneth R. Francis, MD, FACS · Answer

Venus,
Indeed, it was more common to resect, perhaps, too much fat from the lower eyelids years ago.  This fact resulted in many prior blepharoplasty patients developing hollowing in their lower lids.  Newer blepharoplasty techniques have helped to avoid this long term effect.  There are several methods of refilling the lost volume in, what is known as the tear trough area.  These range from implants that are surgically placed to injections of fillers and even fat from your own body.  The hyaluronic acid fillers (Restylane, Perlane, Juvederm) are effective in this area.  However, you need to be aware of a few things.  Their use here is not FDA approved, their effect is temporary (lasting 6-12 months, depending on the material used) and they tend to cause significant swelling and sometimes bruising.  I often recommend the use of Sculptra to my patients for revolumizing the tear trough.  It is also an off FDA label use and requires a highly experienced injector to avoid bump formations, but the effects can be as long lasting as 2 years.  Fat taken from another part of your body can also be used effectively, but be sure to get a well experienced physician if you are considering this option.  Good luck!

Bryan K. Chen, MD · Answer

Hyaluronic acid fillers such as Juvederm and Restylane are probably the safest of the temporary fillers for the lower eyelid/upper cheek hollows.  A relatively small volume of filler material can produce a significant improvement in this location.  Besides avoiding the major blood vessels and nerves under the lower eyelid area, it is important for the practitioner to place the material in the appropriate tissue plane which in most cases is just above the surface of the bone.  When placed too superficially, there is a tendency for the material to appear bluish. 
Since you mentioned wrinkling as well, you might wish to consider laser or non-laser resurfacing in addition to soft tissue filler.
I hope you are able to find a qualified practitioner who makes the effort to address all of your concerns.

George J. Beraka, MD (retired) · Answer

Hi.
The under eyes are a very tricky area.  So first you need a really experienced plastic surgeon or dermatologist with a very good eye.  In Manhattan, we use Restylane rather than Juvederm for the under eyes, because I think it is less likely to leave bumps.  And the filler must be injected deep and in very small quantities.

Marc Cohen, MD (retired) · Answer

Fillers are very effective in treating under eye hollowness (not a good for fine wrinkles).  Juvederm is a great filler however I have found that, for under the eyes, Restylane works best.  Restylane and Juvederm are very close relatives.  Each has certain advantages.  Juvederm tends to swell more under the eyes.  A certain percentage of people develop swelling that looks like bags. This problem can last  for months.  Juvederm can be dissolved, however it is better to avoid the problem in the first place.
Restylane also can cause some swelling, but it is much less common than the swelling that occurs around the eyes with Juvederm.  Before getting Restylane under your eyes be sure that you do not swell very easily.  Do you have ocular allergies (eyes red and itchy)?  Do you swell a lot in the morning after having salty food?  If the answer to these questions is yes you may swell even with Restylane.

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