Complications from Under Eye Facial Filler
The worsening of appearance of dark circles or shadowing under the eyes is a frequent problem that often brings people to seek cosmetic improvement. The “tear trough” is the name given to the hollow area that starts at the inner corner of your lower eyelid and extends down into your cheek. Although the presence of a tear trough depression can be found in some people even in childhood, this area can become more apparent over time due to the following reasons:
- Normal loss of thickness of the eyelid skin with age
- Normal loss of volume and support for the cheek with age, causing the cheek to sag and the underlying rim of bone to become more visible
- The lower eyelid fat bags have become larger over time, making the hollow of the tear trough appear to stand out more (think about how much deeper a valley would look if you were standing on a mountain next to it)
For people who have deeper set eyes, the appearance of hollow areas under the eyes can also affect light reflectance patterns of the face, and can make the entire area around the eyes appear darker by creating some undesirable shadowing.
In recent years, tear trough rejuvenation has become a more popular procedure, as many people are seeking to improve the appearance of dark circles under the eyes, without the time or financial commitment of surgical rejuvenation. When successful, patients are often very pleased with their appearance, and will feel that they look overall more refreshed, energetic, and youthful. The eyes are a central area of focus on the face, and they have been scientifically proven to be the most common first area that other people notice when they look at you. For some patients, non-surgical, tear trough rejuvenation may be a reasonable procedure that gives excellent results to improve the dark shadowing, or even to camouflage the appearance of larger fat pockets (bags) under the eyes.
It is important to understand that the eyelid skin and surrounding areas of the face are some of the most sensitive areas of the body, and unfortunately, Tear trough rejuvenation may not be ideal for every individual patient. Additionally, due to the delicate and complex anatomy around the eyes, not every injector who is able to pick up a syringe and perform facial filler injections is qualified with the specific knowledge and advanced technical experience necessary to perform this procedure appropriately and effectively.
Complications from improper under eye facial filler injections have become much more common recently, and these complications can be very noticeable and disturbing in the very visible area of the face around the eyes. The most common complication associated with under eye facial filler Injections is prolonged swelling that can create an unnatural or “overdone” appearance, which can be quite devastating. Although more significant complications with under eye facial filler injections (tear trough rejuvenation) are rare overall; unfortunately, they can occur, as with any facial filler procedure, even if the injection was performed by a qualified and skilled injector.
Some of the most common reasons for complications from under eye facial filler injections leading to unsatisfactory results can include the following:
The wrong type of facial filler product was used for your eyelid anatomy.
Facial fillers that are derived from hyaluronic acids (HA) are generally considered to be the safest options for treating the sensitive under-eye area. These products include options such as the Juvéderm® family of products, the Restylane® family of products, and Belotero Balance®. One major reason for the general safety of these products is that they can all be dissolved to reverse the effects of the product. The medicine that dissolves these facial fillers is called hyaluronidase, and it works as an enzyme to break down these products.
In the United States, hyaluronidase is only commercially available for purchase by a physician or for use in a medical or surgical facility. Although HA fillers are generally known to last in other areas of the face for shorter time periods of six months to one year, it is common for HA filler products to last in the under-eye area for much longer periods of time. Often, HA facial fillers can still be observed in the under-eye area for many years after they were injected (in some cases, this can be five years later or more). For this reason, hyaluronidase injections remain a major therapy option to treat unwanted facial filler product in the lower eyelids.
If hyaluronidase injections are recommended for your condition, these will likely be incorporated into your treatment plan, and you will be required to return for an additional visit to examine the treated area after the hyaluronidase injections have been given sufficient time to work. In some cases, the results from hyaluronidase injections may be seen very quickly (within minutes), although it generally takes a little more time for the area to stabilize before a proper evaluation for additional treatment options can be performed. Dr. Lewen will typically schedule patients receiving hyaluronidase injections to return to the office for recheck a few days after having the treatment performed.
Even though there are many facial filler products that are composed of hyaluronic acids, this does not mean that all HA facial filler products are created equally. There are some products that are much more ideal for treating this delicate area of the face, while other products may tend to absorb more water or spread out more in the tissue, and are therefore more likely to cause long-term issues with swelling in this area after injection. Dr. Lewen only utilizes very specific facial filler products to treat this sensitive area of the face, based on scientific properties that have been studied and well-demonstrated to produce smooth and reliable results, along with less risk for unwanted side effects.
There are several other facial filler products that have been used to treat the lower eyelid hollows, and that are not made of hyaluronic acids. These products include: silicone, collagen, Sculptra®, Radiesse®, and Artefill®, as well as some others that are not commercially available in the United States, and in some cases, are not meant to be injected into the body at all. These products cannot be dissolved with hyaluronidase, and often cause significant issues when injected into the under-eye areas that can be very difficult to treat. While some of these products can give excellent results in other parts of the face and body, unfortunately, complications from these types of products used in the lower eyelid areas may require more extensive surgical revision procedures, and often there are still significant risks of permanent scarring, as well as other long-term issues.
The injected facial filler product was not placed in the proper tissue plane or anatomic area.
The tear trough area of the lower eyelid is generally a tight space with very delicate anatomy. The normal structures that are usually found in this area include lower eyelid skin, eyelid muscle, and the tissue covering over the bone of the eye socket. 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.
As previously stated, some hyaluronic acid products will tend to spread out more than others after they are injected, and these products may not be the ideal choice for treating the tear trough or lower eyelid hollows. In most cases, hyaluronic acid facial filler products that were previously injected into an improper tissue plane can be dissolved by hyaluronidase injections. After the undesired product is fully dissolved, a more complete assessment of the affected area can be performed to decide upon the best treatment options for rejuvenation.
In some cases, additional facial filler injections properly placed in the tear trough or other facial areas may still be able to give excellent cosmetic results. Other surgical and non-surgical options may also be explored.
Too much facial filler product was used.
The tear trough and lower eyelid hollows represent areas of the face that have some of the thinnest skin in the body. For this reason, the addition of tiny amounts of facial filler volume can have a much more significant impact than anticipated. Additionally, the hyaluronic acid facial filler products that are preferred to treat this area will have some degree of affinity for water molecules, and so all of these products will exhibit some degree of hydration and swell once injected into the body.
When performing injections in this area, it is advisable to go slow, with the idea that you can always go back and add more volume at another time if it is needed. Sometimes, too much facial filler product may have been placed in the lower eyelid hollows, creating an overfill effect that can make the area look extra puffy.
The Tyndall effect can occur in some patients who have had hyaluronic acid facial fillers injected into an area. The Tyndall effect describes the scattering of light that occurs due to particles of matter in its path. Hyaluronic acid facial filler particles that are placed too close to the skin surface can cause the light that hits the area to be scattered in such a way that it can create a bluish hue in the skin overlying the treated area. The Tyndall effect is also referred to as Rayleigh scattering, and this phenomenon also explains why the sky appears blue (on most days).
For some patients who have very light skin color, the Tyndall effect can sometimes be seen after hyaluronic acid facial filler injections, even if the product was injected into the correct tissue plane. Without much pigmentation, the thin eyelid skin is not always able to effectively shield the facial filler product from light, thus causing scattering of light in the area, and the appearance of the bluish color in the treated area. This can also sometimes be seen in other thin-skinned areas of the body, such as around the mouth. If you have a lower eyelid area that appears to have the Tyndall effect, hyaluronidase injections will usually correct the problem by dissolving the facial filler product.
Your eyelid or facial anatomy might not be ideal for this procedure.
Not every patient who has the appearance of tear troughs or lower eyelid hollows is a good candidate for facial filler injections in this area. In some cases, the anatomy of the lower eyelids can cause some people to have undesirable results with attempted tear trough rejuvenation. In these cases, surgical rejuvenation of the lower eyelids is often the most appropriate management, and surgery may be required to attain the best possible cosmetic result. Some examples of these eyelid or facial conditions include:
- Patients who have too much laxity (looseness) of the lower eyelids do not have the proper tension of the lower eyelids on the surface of the eye. With normal blinking, loose lower eyelids will bump along the surface of the eye, much like loose windshield wipers would bump along the windshield on your car. This creates an uneven tear film, which can contribute to chronic dry eye issues, and can also sometimes cause problems with chronic tearing, which can be quite annoying. Some causes for this condition can include: normal aging, chronic eye rubbing, floppy eyelid syndrome, sleep apnea or other sleep disorders, previous eye or eyelid surgery, chronic sun damage, and conditions that cause scar tissue formation in the skin near the eyes. This condition can contribute to issues with chronic inflammation in the lower eyelids, and may cause prolonged or excess swelling to be present at some point after having facial filler products injected into the area. Hyaluronidase injections are typically used to dissolve the facial filler product, and then a surgical repair of the lower eyelid tension issue can be performed.
- Patients who have too much laxity (looseness) of the lower eyelid muscle (orbicularis oculi) can also develop issues with the positioning of the lower eyelid on the surface of the eye. While normal eyelid muscle tissue will snap the eyelids shut quickly with every blink, loose eyelid muscle tissue can cause the blink reflex to be much weaker. Along with chronic dry eye issues, this can also contribute to prolonged or excess inflammation in the lower eyelids, and may cause prolonged or excess swelling to be present at some point after having facial filler products injected into the area. Hyaluronidase injections are typically used to dissolve the facial filler product, and then a surgical repair of the lower eyelid muscle issue can be performed.
- Patients who have larger lower eyelid bags are usually not ideal candidates for facial filler injections into the tear trough or lower eyelid hollows. The pre-existing larger volume and heaviness of the eyelid bags may not be well concealed by facial filler injections in this area, and sometimes, the added volume here can create a very unnatural look. Additionally, many of these patients may require cheek augmentation and support of some kind, and the absence of volume in this area relative to a much fuller lower eyelid area can result in some abnormal facial proportions that can create an unbalanced and undesirable appearance. Hyaluronidase injections are typically used to dissolve the unwanted facial filler product, and then a proper surgical rejuvenation with an individualized cosmetic lower eyelid blepharoplasty can be performed.
- Festoons (also known as malar mounds) are typically seen as a pouch of tissue that may appear puffy or filled with fluid, and are located in the cheek area just below the border of the lower eyelid. Festoons are thought to be the result of sun damage over time, and are related to various muscle forces in the face. In some cases, facial filler injections that are placed underneath the eyes can lead to additional swelling, and can make a festoon pocket appear more evident or larger. At times, the festoon pocket may persist for a longer period even after an unwanted facial filler product is dissolved with hyaluronidase. Effective treatments to eliminate festoons may include a more extensive version of lower eyelid blepharoplasty surgery, as well as possible CO2 laser resurfacing to eliminate the festoon pocket.
You might have chronic issues with prolonged inflammation around your eyes.
Chronic inflammatory conditions that affect the eyes and the areas surrounding the eyes can predispose patients to having prolonged swelling in the lower eyelids. Due to the normal, thin-skinned nature of the lower eyelids, this area of the face can also show swelling from fluid retention more than some other areas of the body. Even in healthy individuals, various facial filler products will have a variable affinity for water molecules, and can sometimes cause some additional tissue swelling to occur.
For people who are already predisposed to additional swelling in this area, tear trough rejuvenation with facial filler products may not be an ideal option for cosmetic improvement of the lower eyelids. Some conditions that are known to cause additional eyelid swelling include:
- Chronic dry eyes
- Chronic allergies or sinus congestion
- Eyelid or eyelid muscle laxity (looseness)
- Chronic blepharitis or inflammation of the eyelid skin
- Chronic conjunctivitis (pink eye)
- Other inflammatory skin conditions
- Floppy eyelid syndrome
- Obstructive sleep apnea and other sleep disorders
- Excess alcohol intake
- Excess sodium intake
In these cases, hyaluronidase injections are typically used to dissolve the unwanted facial filler product, and proper management of your underlying inflammatory condition is an important part of attaining your best cosmetic improvement. Once your condition is under better control, you will be able to have a much better long-term result from any cosmetic rejuvenation procedure for the lower eyelids.
The person who performed your treatment was not appropriately qualified to perform this specialty injection.
Facial filler injections have now become wildly popular non-surgical treatments both in the United States and around the world. Nowadays, there are several types of medical practitioners who perform facial filler injections.
Although there is a core group of physicians who are traditionally trained in these treatments for cosmetic enhancement, this also includes many other types of doctors who were originally trained in other specialties, and who may not have the same extensive training or background in the delicate anatomy of the eyelids or similar areas of the face. In many areas of the country, this also includes a group of non-physician extenders such as nurse practitioners, registered nurses, physician assistants, and medical aestheticians. Depending on local laws, these practitioners may or may not be directly supervised by a physician.
Unfortunately, there are also people who illegally perform facial filler injections without any medical training at all, and sadly, these are typically the horror stories you may see on the evening news. With all of these different types of doctors and medical professionals performing facial filler injections, there can be a large amount of variability in the treatments that are performed. In other words, a syringe of Restylane® injected by one person is NOT the same as the same syringe injected by another person!
When considering a revision procedure after an unsatisfactory result from under eye facial filler injections (non-surgical tear trough rejuvenation), it is very important to do your homework regarding the education, background, training, and experience of a qualified surgeon. For issues involving this delicate area of the face, it is highly recommended to seek the care of a fellowship-trained oculofacial plastic surgeon for such revision procedures.
An oculofacial plastic surgeon should have a board certification in general ophthalmology, and advanced sub-specialty fellowship training in the field of oculofacial plastic surgery (aka: oculoplastic surgery or eye plastic surgery).The main reason why this is so important—particularly for revision procedures following unsuccessful under eye facial filler injections—is because the health and safety of your eyes and vision must be maintained, while also achieving a cosmetic improvement, in order to attain your best results.
After having a complication from under eye facial filler injections, your eyelid tissues may be somewhat compromised, and you may experience other significant symptoms such as blurry vision, eye pain, tearing, burning, dry eyes, an inability to close the eyes completely, double vision, and/or problems with your normal blinking.
If any such symptoms are present, these important issues must be examined and effectively addressed as an important part of any plan for a successful revision after a complication from under eye facial filler injections. It is also important to understand that revision procedures after an unsatisfactory result from previous under eye facial filler injections can sometimes be more complex than the original procedure, and there may be certain steps that must be followed as part of a treatment plan in order to properly address the area of concern.
During your consultation, Dr. Lewen will perform a careful examination of the affected lower eyelid area. Afterwards, he will work with you to create a customized treatment plan that best addresses your specific and individual condition, including your best cosmetic revision options to give you the best possible results.