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08.10.2018 | Original Article

Managing Periocular Filler-Related Syndrome Prior to Lower Blepharoplasty

Aesthetic Plastic Surgery
Christopher I. Zoumalan



Hyaluronic acid (HA) fillers are extensively used in periocular volume augmentation. Although they have an excellent safety profile, filler-related issues such as visibility/palpability, contour abnormalities, malar edema, and blue-gray dyschromia can occur. Recognition and management of filler-related issues are critical prior to subsequent procedures. The clinical course of patients who had periocular HA filler-related issues and subsequently underwent lower eyelid blepharoplasty is described.


HA filler was dissolved with hyaluronidase (15–30 U/cm2) treatment. Visible lower eyelid fat prolapse after filler removal was corrected with transconjunctival blepharoplasty with fat repositioning and skin resurfacing. Complications and outcome were assessed and recorded.


Twenty-three patients (46 eyelids) were treated. All presented with contour abnormalities, 19 with contour abnormalities and malar edema, and seven with blue-gray dyschromia. In 15 patients, one session of hyaluronidase completely dissolved the filler, and in eight patients, two sessions were required. Of these eight patients, edema resolved after the second hyaluronidase injection in four; in the remaining four, mild edema persisted despite absence of visible/palpable filler. Postblepharoplasty, 19 patients had an acceptable outcome with no complications (82.6%). Four patients had prolonged edema postoperatively; three had a resolution by 6 months. In 23 patients who had skin resurfacing procedures, there was no incidence of postinflammatory hyperpigmentation.


HA filler-related issues need to be identified and managed prior to further intervention. Hyaluronidase treatment effectively dissolves the filler, but mild malar edema can persist. Outcomes are acceptable after subsequent blepharoplasty, but adequate patient counseling is necessary about expectations and limitations.

Level of Evidence IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.​springer.​com/​00266.

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