Risks of Restylane on Upper Eyelids for Sunken Eyes

Hi London2011,

Injecting Restylane or any other injectable filler to the upper eyelid hollow is considered "off-label."  This means that the filler is not approved for this usage.  I firsted started treating upper eyelid hollowing in 2006 with fat grafting.  I began doing this as part of my upper eyelid surgery.  In addition, to removing a conservative amount of skin, I was also adding back fat into the upper eyelid hollow.  In 2008, I had a patient who did not want to have an upper eyelid surgery for fear of keloids.  Her main issue was really the hollowing.  However, I did not have a way to place the fat into the upper eyelid hollow.

 

I thought was possible to use Restylane in the same manner as I was surgically placing the fat, so I did a test session using Injectable saline.  This filled the area nicely.  A couple of weeks later, I followed that up with Restylane injections.  

 

Most patients will upper eyelid hollowing, have too much eyelid showing, in particular in the inner corner of the eye.  This can also be worsened with a doll's eye deformity, where there is so much hollowing of the upper eyelid, that it causes the upper eyelid skin to vacuum inside of the eye socket.  This can result in an older looking eye, especially when the person's eyes are closed.

 

The main risks, are lumpiness and overcorrection.  I believe there is a correct way to inject the upper eyelid filler, to simulate the configuration of the upper eyelid brow complex of youth.  The upper eyelid complex is 3 dimensional, but since the upper eyelid opens and closes, it is really 4 dimensional.  It should not only look normal when the eyelids are open, but it also needs to look normal when the eyes are closed.  If the injection is performed in the wrong pocket, it will look very lumpy when the eyes are closed, and you can see where the filler injection ends.  

I get emails from people all over the world.  I have seen photos of patients with improperly injected in the upper eyelid area.  They usually show a photo of their eyelids when they are closed, and the filler can be clearly seen.

If there is not enough filler injected, it is easy enough to add more.

Best,

Dr. Yang

New York Facial Plastic Surgeon

Upper eyelid hollowness is a dramatically underappreciated, yet incredibly important component of aging in the eyelids. With normal aging, our upper eyelid fat pads tend to retract and expose this upper lid hollowness, those with “deep set eyes“ are especially prone, and unfortunately old-school upper eyelid surgery that is overly subtractive can artificially create this hollowness early, actually looking worse than it did before surgery - the before and after photo in the link below resulted from overly subtractive upper eyelid surgery with another surgeon, and you can see the results after revolumization of the upper lids. Correcting this hollowness can happen with fat or filler injections into very specific planes of the upper eyelid, or transposing and rearranging the upper eyelid fat pads to provide fullness, as you see in this surgeon’s view video, borrowing the excess fat to move into the areas lacking fullness!
To ensure you are receiving the highest level of care, seek out a modernly trained, new-school 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. Membership in organizations like the American Academy of Facial Plastic and Reconstructive Surgery help to identify a highly trained surgeon.
Cameron Chesnut
#realself100 Physician

I have injected, off-label, Restylane and Juvederm into the outer aspect of the eybrow and slightly onto the preseptal upper eyelid but not the pretarsal lid. This helps augment volume that is lost with time and creates a lowering of the upper eyelid and hooding. It is done cautiously and with very low amounts. If it were injected into the upper eyelid skin in the lower aspect, it would have a higher chance of leaving you with uneveness, lumpiness, and prolonged swelling and may cause signficant bruising for a couple of weeks after treatment.

The placement of filler in the upper eyelids is very tricky and not commonly done, though not impossible. Placement of filler products or fat grafting often leads to more prolonged tissue swelling compared with treatment in other areas of the face. Additionally, the very thin tissue in this region makes irregularities or lumps a possibility.

Treatment to the eyelid/brow complex may improve the sunken appearance you're noting. I'd consult with a board certified physician with experience in treating this area to see what specific options may be best for you.

Hi London.  We would not suggest using a dermal filler like Restylane on the upper eyelid.  This is a very delicate area and could lead to serious complications if done imperfectly.

Dear London

The anatomy of the upper eyelid is more complex than that for other parts of the face.  Additionally, the skin in the upper eyelid is quite thin.  Irregularities of the upper eyelid contour are more likely.  Also within the orbit but close to the skin is a relatively large vascular structure called the superior orbital vein.  There is a risk that an inexperienced injector could inadvertently inject filler into this vein.   While this type of therapeutic misadventure has not been reported, it remains a clinical possibility.  Because this vein communicates directly to the cavernous sinus at the base of the brain, the clinical outcome of such an event could be visual loss or stroke.  For this reason, experienced injectors typically lift the lid and inject the material along the orbital rim or alternatively treat very superficially and accept a certain level of skin irregularities.  Do to these considerations, there are limits to what can be accomplished with these type of treatments.

Fat grafting can provide a permanent and natural looking result to the brow upper lid junction, or to almost any area of the face, provided you find a very experienced, well trained and talented plastic surgeon. Please view the attached videos and other videos on realself that discuss fat grafting in the brow / upper lid junction.Physicians with special interest in fat grafting of the eye area will have galleries on their websites to demonstrate their expertise in this procedure. The before and after images on Realself can be a great place to start. 

I do not recommend Restylane for treatment to the upper eyelid. The risks of undesirable result in this area is too great.

Restylane is most commonly used under the eyes for eyelid rejuvenation. Restylane can also be injected below the eyebrow but above the eyelid to add fullness to the area. Due to the complex nature of the anatomy around the eyelid and the thinness of the skin, this area is best treate by a very experienced injector.

Restylane and other fillers are great when used properly. The upper eyelids are not the place for filler. See an oculoplastic surgeon to evaluate your complaint and outline your options.