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Topic 25 - 3
Hyaluronic Acid Injections
For Lower Eyelid Bagginess
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A number of physicians from ophthalmologists to dermatologists to plastic surgeons to family practitioners have begun to promote hyaluronic acid injections around the eyes as a viable non-surgical alternative to lower blepharoplasty. Is it?

The Aging Process

Facial aging involves two basic processes: sagging and deflation. Beneath the eyes, the "sagging" component consists of weakened support within the lower eyelid that allows fat to protrude forward and create "bags." As a separate change in the tissue just below the eyelids (that is, in the upper cheek), a depression may sometimes form due to loss of underlying volume ("deflation") and/or a downward migration driven by gravity ("midface descent").

tear trough

What results is a rim of cheek depression just below the bone known variously as the "tear trough," an "infraorbital depression," an "orbital rim hollow," or, more commonly, "dark circles beneath the eyes."

In essence, the lower eyelid sagging creates a convexity while the cheek deflation results in a concavity. One contour abnormality "plays off" the other and accentuates the difference in each other's height, like a small hill standing next to a small valley, a difference that can be made even more noticeable by shadowing.

The Rationale Behind Use of a Filler

The basic idea behind the injection of hyaluronic acid (or other commercial fillers) is camouflage rather then correction. By filling in the cheek depression with a biochemical substance obtained from a syringe, a flatter contour can be achieved at the eyelid-cheek interface and the visual impact of the baggy eyelid thereby lessened.

Does It Work?

The most popular temporary filler is hyaluronic acid available under several brand names: Restylane ® (Medical Aesthetics), Juvederm ® (Allergan), and Hylaform ® (Inamed).

Injectable fillers will indeed help to plump up any under-eye cheek hollows, although sometimes they "help" too much and leave the hollow looking obviously over-plumped.

Other methods of filling such areas entail real surgery: midface lift to try to pull the cheek fat upward, eyelid fat repositioning designed to drape eyelid fat downward, and placement of synthetic permanent implants designed to add volume in a different way. Fat obtained by liposuction may also be injected in a manner similar to a commercial filler.

Of course, a lower blepharoplasty designed to conservatively remove bulging fat while also reinforcing sagging muscle and tendons will not only blunt the convexity but in doing so help smooth the eyelid-cheek interface.

Is Hyaluronic Acid an Effective Alternative to Lower Eyelid Surgery?

That depends upon on whether you're after the quick fix or more definitive rejuvenation.

For early or minor changes in a relatively young person worried mainly about the dark circles, a filler may seem a good option because the procedure is so minimally invasive and may delay the need for cutting surgery with its attendant risks such as hollowness.

Be aware, however, that such a convenience comes at a certain cost: price and effort. Hyaluronic acid can cost $500-$800 per syringe, two syringes may be needed to treat both eyes, and yet the substance will degrade and disappear in anywhere from four to six months. Not only are you always headed back to your doctor, but the mounting costs for just a few years of treatment can quickly surpass that of more definitive surgery.

Hyaluronic acid injections, then, should be viewed more as a "maintenance" effort than a "correction," much like getting your hair permed.

Do patients like such temporary fixes? Some doctors seem to think so. Unfortunately, this has not been our experience, especially if the eyelid changes are anything more than minor. We routinely see patients who have tried temporary fillers, been disappointed by their lack of longevity, high expense, or minimal results, and are now seeking surgery.

Do doctors like such temporary fixes? Despite the high cost of treatment, injecting fillers is really not very profitable unless one can do so at high volume. However, it's a wonderful way to get new patients into an office, new patients who may eventually decide to seek out real surgery.

Is It Worthwhile?

There is no one answer. Today's temporary fillers can indeed help out in certain situations, and they are a nice adjunct in the world of facial surgery. Newer hyaluronic acid deriatives now under study are said to last two to four times longer than the current product and should be arriving in the United States fairly soon.

To us, though, the use of currently-available products seems overly hyped. Whether they or other temporary fillers seem right for you, however, is entirely your call.

Next: Chemical Blepharoplasty

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