What is causing bulging when I smile after fillers/Botox? (photos)

Question

I have gotten under eye filler( may 2020 & June 2021) and cheek filler (Sept 2021) Jan 7, 22 I got filler for smile lines and Botox. This was the first time I did Botox around my eyes. When I smile, I’m noticing bulging/ indentation. I don’t like the fuller look. See before/after. I’m thinking it’s too much filler and needs to be dissolved?

John Diaz, MD · Answer

It appears as though either too much filler was used or the filler used was not placed deep enough. The best option is to dissolve this area using a hyaluronidase solution to reduce the bulging.

Nima Shemirani, MD · Answer

Hi @Taylorg1. There are a few reasons for this swelling. One being that the filler was not placed in the proper tissue plane. Most facial filler products that are injected into this area should ideally be placed in the tissue plane directly on top of the bone, or at least underneath the eyelid muscle layer. If a facial filler product is placed too superficial in the skin, or on top of the muscle layer, the product may settle in with an abnormal appearance and can look to be lumpy, swollen, or irregular. Another reason for the prolonged swelling can be due to the fact that too much facial filler product was used. The filler products that are preferred to treat this area will have some degree of affinity for water molecules so all of these products will exhibit some degree of hydration and swell once injected into the body. Hyaluronic acid facial filler products that were previously injected into an improper tissue plane can be dissolved by hyaluronidase injections. Best of luck, Dr. Nima!

Jonathan Kulbersh, MD · Answer

Hello, and thank you for your question. Cheek filler may cause the bulging or indentation from the elevation of the area which may have been accentuated with Botox. Fortunately, none of these results are permanent and can be corrected with additional filler into the area and/or dissolving the filler. It is not uncommon to seek revision following filler injections.

I also recommend seeking consultations and treatments from a reputable, experienced injector with expertise in cheek and tear trough filler. Such experts will know which product will best suit your needs, have the skill to precisely inject them, and have the aesthetic eye to produce natural-looking results. During an in-person consultation, your surgeon can assess your skin, determine the best approach to achieving your goals, and ensure the best possible outcome.

James R. Gordon, MD, FACS, FAAO · Answer

Thank you for sharing your question. You have too much filler in the area of your lower eyelid/cheekbone. It can be dissolved by and Oculoplastic Surgeon. Make a consultation for in person evaluation. Good luck.

Jason Emer, MD · Answer

It's difficult to say through pictures alone. I recommend you see an expert for a formal consultation. Botox results last up to 3 to 4 months and can be softened with Venus Legacy and Thermage treatments. I recommend getting a formal evaluation with a cosmetic dermatologist. Best, Dr. Emer

Nelson Lee Novick, MD · Answer

I have had a number of patients come to me with similar issues following treatment with fillers, particularly following the use of certain HA fillers to the upper cheek/under eye regions. Certain fillers, such as Restylane &  Juvederm have been associated in my experience with this kind of issue--the former more often associated with bumps and lumps and the latter, due to tissue water attraction, to tissue swelling. And all fillers, by compressing lymphatic drainage, can give rise to lymphedema swelling. If an HA filler was used, the injection of hyaluronidase would be reasonable. If lymphatic blockage is at the root of this, then the problem is usually more difficult to treat and the added injection of antiinflammatory agents, such as triamcinolone+/-5-FU in my experience can be quite helpflul. Make sure to consult with an experienced, board certified cosmetic dermatologist and best of luck.

Darryl J. Blinski, MD · Answer

Without detailed in person examination very hard to be sure if over HA filler used or periorbital fat pocket. You can try HA dissolver injections in very low dose over a 3 week sessions (1x a week). Expect fees in the $300-$1,000 ranges.