Permanent edema in tear troughs: is hyaluronidase the only solution? (Photos)

Question

I had hyaluronic filler in tear troughs more than one year ago, and since then l look swollen when I smile, frown or in backlights. I know that I should have hyaluronidase but, just asking, are there alternatives to it? Wouldn’t be possible, for example, to have a lipofilling over that areas so to “hide the flaws”? Or RF microneedling? Many thanks.

Camille Cash, MD · Answer

A good place to begin is a consultation with an experienced injector near you.  Hyaluronidase wouldn't be indicated unless there is still filler present. Other treatments can be considered such as Morpheus8 or potentially medication to address the swelling.

Nelson Lee Novick, MD · Answer

From the history and photos, it is very likely that this is another case of what has been called under-eye "puffy pillows" typically resulting from the injection of an inappropriate choice of filler for the tear trough region and/or too superficial placement of that filler. It can be a tough problem to treat and does not necessarily respond to hyaluronidase or hyaluronidase alone. I have had gratifying results in treating patients who have come to me with this issue employing varying anti-inflammatory agents in differing combinations, concentrations and amounts. RFmicroneedling is unlikely to justify its expense and potential risks, and lipofilling may simply add the problem of a permanent filler in the area, additional risk of spongey-looking skin and a problem that also cannot be easily removed should there be reason to do so. You would be wise to consult a board certified cosmetic dermatologist with experience in dealing with this difficult issue. Best of luck.

Saba Ghorab, MD · Answer

Hi,
Thanks for sharing your story and photos. 
1. Firstly, It is difficult to make definitive recommendations from the history and photos posted. A thorough clinical exam is needed to determine the nature of the swelling and overall eye aesthetics. 2. Under eye filler injection may lead to lymphedema. With lymphedema, the lymphatic channels of the lower eyelid are flooded with filler and unable to do their job in draining fluid from the surrounding areas. This leads to swelling that may fluctuate. The best way to overcome or correct lymphedema is to dissolve the excess filler. 3. The under eye area is quite delicate and I would be careful about injecting more material (be it fat or filler) to "chase" the current fullness. It may lead to an unnatural, puffy look. It's difficult to reverse this, especially if fat is used. 4. My general approach would be to consider:  a) Conservative hyaluronidase injection to first dissolve the filler fullness.  b) If you're left with unsatisfactory hollowing or contour issues after, I'd likely re-inject more filler. Seems counterintuitive, but filler injection technique and location of filler placement matter! It's important to inject from below, preferably with a blunt cannula, for a filling effect that abuts and lifts up/into the tear trough hollowing rather injecting directly into the hollowing and thereby running the risk of injecting into the delicate lower lid tissues (cue in tyndell effect and lymphedema). Additionally, filler selection matters! 
Side note - while hyaluronidase is a game changer for reversing unfavorable effects of hyaluronic acid (HA) filler injections, it will dissolve your native HA too. It's important to be conservative and do serial injections, if needed. Be sure your injector knows how to dose and treat your problem areas.
Perhaps a long-winded answer but I hope this helps with your question about hyaluronidase injection for under eye swelling after filler injection. Thanks and take care
Dr. GhorabSaba Plastic SurgeryScottsdale, AZ
This is a good question and an issue that I'm quite familiar

Permanent edema in tear troughs: is hyaluronidase the only solution? (Photos)

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Permanent edema in tear troughs: is hyaluronidase the only solution? (Photos)

Answers (3)

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Everything you need to know about Dermal Fillers

Our mission is to create a world where every investment in modern beauty is Worth It.