36.1.1 Case 1

A 39-year-old man presented for persistent swelling of the lower eyelids, which began approximately 2 years ago (Fig. 36-1). He had a history of Restylane and Perlane injections from 2002 to 2007 every 6 months. The patient reported that 6 months prior to the swelling, he was involved in a car accident without significant facial fractures. He also reported a sinus infection that resolved without complication 3 months prior to the onset of the lower eyelid fullness. One year ago, he had Botox injections.

36.1.2 Case 2

A 52-year-old woman presented with a 1-year history of lower eyelid fullness (Fig. 36-2). She received Radiesse to the lower eyelid approximately 1 year before the lower eyelid swelling began. She was treated with hyaluronidase injection and antibiotics without benefit. An MRI of the orbits found no masses. She had a history of bilateral upper and lower eyelid blepharoplasty at age 27 and no other surgeries. She had prior treatments of Botox to the glabella and lateral canthal region.

36.1.3 Case 3

A 57-year-old woman presented with a history of an unknown filler injection to the lower eyelids in Paris 3 years ago (Fig. 36-3). She reported that a physician attempted hyaluronidase to the lower eyelid 1 year ago without much effect.

36.2.1 Case 1

This patient was injected multiple times and over time developed overvolumization of the lower eyelid. This may have become more obvious with time as the orbicularis muscle became “stretched” and weakened from the mass effect of the filler.

There was no Tyndall’s effect noted; therefore, the level of injection was likely suborbicularis and potentially retroseptal rather than subcutaneous.

36.2.2 Case 2

This patient received an irreversible filler to the lower eyelids, which resulted in palpable masses at the inferior orbital rims and festoon formation.

Injecting fillers in the lower eyelid and cheek (i.e., tear trough or nasojugal region) can be challenging. Complications often arise from poor placement, overinjection, and the tendency for swelling in this location. Retroseptal injection can result in a pronounced “bag” under the eye, while injection anterior to the infraorbital rim or anterior to the orbitomalar ligament often results in edema just inferior to the orbital rim, often referred to as festoons or malar bags. Injection of neuromodulator affecting the orbicularis in the area can exacerbate fluid collection.

Edema and festoons may result from filler injection due to the hydrophilic nature of the hyaluronic acid material. In addition to the ability of the material to imbibe water, we have also found profoundly decreased lymphatic drainage in one patient (case not presented) who had previously received Perlane and Restylane injections to the lower eyelids. This patient underwent lymphedema studies with Tc-99m injected into the central lower eyelid and lateral canthus. After 24 hours, there was virtually no lymphatic drainage noted on lymphoscintigraphy. Intralesional injection of hyaluronidase into reversible fillers may also correct edema as a result of removal of product, and result in improved lymphatic outflow as a result.

36.2.3 Case 3

This patient had a more complicated course. There was overinjection of an “unknown” filler material into the preseptal and premalar region of the lower eyelids and resultant edema and firm nodules. There was also significant lower eyelid laxity of both lower eyelids, which resulted in significant ectropion and lower eyelid retraction after removal of the filler.

36.3.1 Case 1

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  Hyaluronidase injection, about 200 IU to each lower eyelid (Fig. 36-4).

  
  
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  One week later, about 50 IU hyaluronidase injection was repeated to each lower eyelid.