Tear trough edema: 4th round of Hyaluronidase to no avail. I’m close to despair, what can I do? (Photo)

Question

Had a tear through filler in 2022 with high density hyaluronic acid that gave me permanent edema on the right side. This year I decided to dissolve it, but after 3 rounds of ultrasound guided hualuronidase (36 U total) and one more round with 40 U, nothing changed, the lump is still there when I frown or smile, except that my skin appears more wrinkled by Hyaluronidase. Why it doesn’t dissolve and what can I do? I’m losing hope.

Kenneth D. Steinsapir, MD · Answer

If I read your history correctly, in addition to the funky filler service, you have also had a radiofrequency treatment and possibly microneedling to the lower eyelid skin. It is important to know precisely which of the hyaluronic acid filler was used. Some of them have confusing marketing terms that imply that they are a high G prime filler when in fact they are low G prime filler. Talking about density is one way marketers confuse consumers and injectors. I would recommend a significantly higher dose of Hyaluronidase. Generally I use 150 to 300 units of Hyaluronidase in these cases. One or two rounds may be needed. If this does not clear edema, it is not caused by filler and may represent a complication from one of the services you had attempting to clear the filler. Be aware that the use of ultrasound in guiding the injection of the enzyme is well meaning but not of proven value. Generally an experience injector can simply examine you and know from visual inspection. Hyaluronidase does not wreck skin. Underdosing Hyaluronidase is common and this can leave residual hyaluronic acid with persistent edema. This under treatment is often confused for "wrecked" skin. The treatment for this is simple: an adequate enzyme dose.

Shaden Mohammad, MD · Answer

I'm sorry to hear about your experience thus far and that you are losing hope. It perhaps is related to undertreatment with the hyaluronidase. We also have found that 1-2 vials of hyaluronidase may be needed for the under eyes. Best of luck!

Nelson Lee Novick, MD · Answer

I have written about this condition many times already, which is typically the result of too superficial placement of a filler into the thin skin of the under-eye region and/or the use of inappropriate choice of  filler for this region. The puffy pillows that result are actually lymphedema (lymphatic obstruction), which can be a persistent problem and difficult to treat and does not usually respond to hyaluronidase.
I have had gratifying results helping individuals who have come to me with this problem employing an algorithm of varying combinations, concentrations and amounts of intralesional anti-inflammatory agents. There is no need for the use of ultrasound as the swellings are so prominent and well defined. 
You would be wise to consult an experienced, board certified cosmetic dermatologist. Hope this helps and best of luck.

Tear trough edema: 4th round of Hyaluronidase to no avail. I’m close to despair, what can I do? (Photo)

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