4 years after under eye dermal filler. Problems have remained - what can I do? (photos)

Hi, Two points: 1. Your intermittent swelling may be due to an immune reaction to the fillers. 2. Even though you were told that the filler may go away over a year or so, I can tell you from experience that fuller around the eyes can last many years with minimal reduction of the filler. Solution for both: Get some hyaluronidase injections to dissolve the fillers to start. After it is dissolved you can re-evaluate whether or not to refill using a different brand of hyaluronic acid filler or switch to a different method of restoring facial volume (Fat Transfer/Grafting, Renuva, etc). Backstory: The longest patients that I have had for both lower and upper eyelid fillers have had their fillers done more than 7 years ago and still not asking for a a touch up to add more filler. Many factors can happen over several years which is natural aging, weight gain or loss which can make the filler look different from the original result. The patients who have the best and longest lasting results usually do not gain or lose weight. If anything they gain a pound at most over the many years. Patients who had their filler when they were very thin or later lose even more body/facial fat may want more filler thinking that they body metabolizes the filler quickly. It may actually be that the patient is losing even more fat off their face making it appear that the filler is going away. Additional filler is actually just making up for additional fat loss over the years. Swelling Reactions: The hyaluronic acid (HA) portion of the filler is not unlike our naturally made hyaluronic acid. Our naturally made hyaluronic acid does not last very long but is constantly being replenished. The artificial hyaluronic acid is cross-linked to make it last longer, but requires a manufacturing process. When making the artificial HA, some manufacturing process uses bacteria to grow the product, and they clean and wash the HA so there is no live bacteria, but some trace amounts of bacterial proteins may be present. Our immune system may recognize these and cause an inflammatory reaction which will look swelling and sometime be confused with a possible infection. Another possibility is that the filler has a biofilm which means the filler is contaminated with bacteria and a bacterial film is attached to the HA filler. Antibiotics can help reduce the swelling, but if the antibiotics are stopped, the swelling can return. The solution for both is to remove the HA filler so the cause othe inflammation is gone and for the biofilm (example: why do old kitchen sponges smell bad? Biofilm on the sponge. Solution: throw it out and get a new sponge) get rid of the HA filler so the bacteria/biofilm has no place to attach and hide and the immune system can take care of the rest. Hope this provided you with some volume. Good luck. Best, Dr. Yang

Unfortunately this filler cannot be dissolved with Vitrase / hyaluronidase. A combination of fractional laser or radiofrequency, Venus Legacy treatments, and 5FU/steroid injections could help with the lump. Otherwise, aside from waiting to see if it goes away, the only other permanent option is surgical removal. I suggest getting a formal evaluation with a cosmetic dermatologist. Best, Dr. Emer.

From the history and the photos, it would appear that the filler has led to what has been called under eye "puffy pillows." More medically, these bulges result from lymphatic obstruction, which is more likely to occur when an inappropriate HA filler is chosen for the job and/or the filler is injected too superficially where it can obstruct the delicate lymphatic drainage under the eyes. If this is indeed the case, I have had success in manage this admittedly very difficult too treat problem using the injection of a varying amounts and concentrations of intralesional anti-inflammatory agents along with hyaluronidase. Several treatment sessions are typically required. Make sure to consult an experienced, board certified cosmetic dermatologist. Best of luck.