Puffy Eyes After Juvederm Injections in Under Eye Hollows

Juvederm is a hyaluronic acid-based filler that is quite soft and well-tolerated in many clinical situations. One consideration in the setting of puffiness after injection is that this type of filler is hydrophillic, meaning it attracts water. For a few days, this can be seen as swelling or puffiness, which generally resolves. Some patients see some benefit by using warm compresses to help the fluid subside. If your swelling is within the first few days after having a filler injection, this may improve spontaneously.
Hyaluronidase is an injectable substance that can dissolve filler in the case that there are lumps or bumps caused by the filler itself, not filler-related swelling. Rarely is a hyaluronidase injection necessary when fillers are placed correctly.
Fillers under the eyes can supplant surgical options in many cases. We now understand that the appearance of under eye bags can be areas of fat that are accentuated by hollowing below. By filling the grooves under the eyelids, surgery may not be required in some cases. In fact, in some cases, removing fat can create an aged or even more hollow appearance to the eyelids! Current techniques may involve fillers alone, a combination of surgery and fillers, or using native fat to restore volume.

Juvederm isn't an ideal filler for under eye hollows because it is considered a hydrophilic filler.  Hydrophilic refers to it's ability to draw water towards itself.  Juvederm is one of the most hydrophilic fillers on the market.  Restylane can be hydrophilic but much less so than Juvederm.  Restylane is typically the go to filler for the under eye area.  

This is a common problem. People try and fix issues that require surgery with filler. Typically we are able to improve the issue just not solve it. We never want to make things worse. A few key things need to be answered. How long ago was the injection?  depending on that it could be swelling and edema still.  If it has been over two weeks then you can consider the antidote that can absorb the material.Another thing to consider is facial fat transfer that can help with this issue. It is worth looking into if you are against surgery for now.Hope this helps.Best of luck,DrC

Please wait at least a couple weeks to see if puffiness is actually temporary swelling.If puffiness is due to product, it is likely from too much product placed too superficially.  Product can be easily dissolved with hyaluronidase.  Under eyelid skin is very thin.  I place most of the product on the bone, and, only if needed, a few very thin strands superficially.  It is better to undercorrect in this area, then to have an unnatural or puffy result.

Juvederm and Restylane are interchangeable in a lot of filling areas, but in the lower eyelids, I see a difference.  Others have reported that Juvederm is more hydrophyllic (water-loving) than Restylane and in the lower lids, I see that as a disadvantage.  For that reason, I don't use Juvederm in the lower lids, and use Restylane cautiously. 

I’m surprised at your doctor’s response to the puffiness. Surgery is not necessary to fix this. The puffiness could be caused by swelling, which will gradually subside in about two weeks. If you still notice over-correction at that time, you can go back to your injector and get hyaluronidase, which will dissolve the excess product. Alternatively, you can simply wait until the results of the injection wear off, which would be in a few months. However, surgery is definitely not needed!

This is an issue I see quite often in consultation as I practice in an area that is very much like the "Wild West" - consumers do not do their research and choose wisely before choosing their injector. They tend to choose more based on price and convenience, with dentists, cardiologists, OB/Gyn, general surgeons, etc. doing quite a few injections. First things first, almost every key thought leader in the field agrees that Juvederm products should not be injected around the eyes. These products are fantastic, but they attract too much water for that particular location. There is no gentle way to put it, this is the sort of thing you should learn on the first day of your filler education, but unfortunately I see it all the time.When this mistake is made, Hyaluronidase is an excellent option to dissolve the filler in this location, not surgery, and anybody who tells you that it is not safely injected around the eyes just doesn't have the experience with it. In fact, it is commonly used as part of local anesthetic mixture for eyelid surgery.Again, I would be cautious of anybody who tells you that filler around the eye is a bad idea. Physicians who are skilled in rejuvenation of the periocular area (around the eyes) will have lots of good photographs and discussion of both their surgical and nonsurgical options. In my hands, I am often able to achieve near surgical results with filler, with the caveat being that filler does not last forever - surgery has a more permanent effect.To ensure you are receiving the highest level of care, seek out a dermatologic surgeon, oculoplastic surgeon, facial plastic surgeon or plastic surgeon who is board certified and fellowship trained in one of these "core four" cosmetic specialties.

It’s not unusual for patients with facial aging to note
changes in the periorbital region. When
these changes are severe, patients often need a blepharoplasty. When these changes are mild, temporizing
maneuvers with injectable fillers are often helpful. Under these circumstances, most patients are
treated with hyaluronic acid fillers such as Juvederm, Perlane and Restylane.When
dermal fillers are used to correct this problem, success is related to proper
patient selection. Unfortunately, it appears that a blepharoplasty might have
been a better choice in your case. In
this situation hyaluronic acid fillers such as Juvederm can be reversed with
hyaluronidase. Despite this maneuver
you’ll still have your original anatomic deformity which will ultimately
require a blepharoplasty.It’s
important to discuss your situation with your surgeon. Your surgeon should be able to formulate a
plan that’s appropriate for your problem.

Injecting fillers under the eyes can be very challenging because the deficit you are often dealing with is too much volume in the first place.  

Juvederm is a wonderful product but not for hollowness under the eyes. I like to use Restylane or even Belotero if the skin is really thin.  The product needs to be injected deep rather than shallow which can cause a puffiness effect. If injected correctly, filler under the eyes can make a huge improvement.

Filler under the eyes is one of the most technically demanding areas to inject facial filler.  Every injector will have specific nuances that he/she will use to provide smooth contours.  The key to a successful result here is to use an injector with the following factors:

-knowledge of facial anatomy- the eye area is intricate and delicate.  failure to understand the facial anatomy will result in unsatisfactory and potentially dangerous outcomes.  seek an injector with knowledge of the face and facial anatomy

-injection technique- i have modified my technique under the eyes to provide consistent outcomes without bulges and minimizing bruises.  an experienced injector will have a specific way to inject to provide consistent results