The use of hyaluronic acid filler to carry out aesthetic procedures in the periocular area is now a very popular and sought-after procedure, since it is considered a minimally invasive ophthalmoplastic procedure that provides rapid and - not least - pain-free aesthetic benefits.
However, working on the periocular area carries certain risks, not least because of the changes that ageing brings about in the orbicularis muscles, malar and post-septal adipose tissue, orbital septum and ligaments, such as the zygomatic-cutaneous ligament and the orbicularis ligament. Due to ageing, the elasticity of the skin under the eyes is reduced, fat and muscles atrophy and herniation occurs due to weakening of the orbital septum and ligaments. Reduced muscle support and redistribution of adipose tissue promote oedemas and malar accumulations under the eyes, which contribute to a swollen face that is one of the causes of people's dissatisfaction with their appearance and prompts them to resort to aesthetic treatments. In these cases, improper or excessive use of fillers can lead to complications, such as the migration of the filler, i.e. its diffusion to an area other than the injection site, and the formation of a foreign body granuloma.
Recent studies have shown that hyaluronic acid fillers can persist for years, compared to the previously assumed duration of 3-12 months, with the risk that too frequent injections can lead to unwanted swelling and the formation of granulomas. These lesions are the result of an inflammatory response to the injected material and are caused by macrophages fusing into giant multinucleated cells. Injecting hyaluronic acid fillers into the wrong area or periocular plane can also lead to the same complications.
The set of changes induced by a hyaluronic acid injection treatment include: sagging of the facial tissue, oedemas, visible nodules, Tyndall effect, which consists of a bluish discolouration of the skin caused by light scattering and occurs when hyaluronic acid is injected too superficially.
Intramuscular injection of HA can lead to mobility problems, altering natural periocular movement.
A consolidated experience in injection therapy and a thorough knowledge of the ocular anatomy are, therefore, crucial. Strict patient selection must also be carried out, treating only individuals with good skin elasticity and mild to moderate volume loss. These types of patients are generally the ones who achieve the best results compared to those with more than 1 cm of excess skin.
Imaging techniques, in particular computed magnetic resonance imaging (MRI), are very useful to visualise the soft tissues and the vascular network that feeds them, to monitor filler placement and, if necessary, to manage any complications.
To combat complications due to migrated fillers, one must first reconstruct the patient's medical history and acquire information on the type and volume of substance which was injected.
At this point, a specific solvent, to be handled with extreme caution, is used, the hyaluronidase, which is a toxin whose action is similar to the effect of phospholipases.
There is currently no established protocol for the administration of hyaluronidase, which is an enzyme capable of degrading certain components of the extracellular matrix, such as hyaluronic acid. The hyaluronidase acts by breaking the glycosidic bonds present in hyaluronic acid.
Improper and incorrect use can lead to the so-called 'posthyaluronidase syndrome', characterised by sagging and loss of volume of the facial tissue, depigmentation and loss of elasticity of the periocular skin, which may even lead to a worsening of the aesthetic situation that had been determined before the injection treatment and its complications.
About hyaluronic acid see also:
- Sodium hyaluronate and dry eye after cataract surgery - Oculista Italiano
- Hyaluronic acid and xanthan gum for the wellbeing of the ocular surface
- Hyaluronic acid in ophthalmology
- Wilde CL, Jiang K, Lee S, Ezra DG. The Posthyaluronidase Syndrome: Dosing Strategies for Hyaluronidase in the Dissolving of Facial Filler and Independent Predictors of Poor Outcomes. Plast Reconstr Surg Glob Open. 2024 Apr 23;12(4):e5765. doi: 10.1097/GOX.0000000000005765. PMID: 38655103; PMCID: PMC11037726.
- Master M, Azizeddin A, Master V. Hyaluronic acid filler longevity in the mid-face: a review of 33 magnetic resonance imaging studies. Plast Reconstr Surg Glob Open. 2024;12(7):e5934. doi:10.1097/GOX.0000000000005934
- Kim HJ, Kwon SB, Whang KU, et al. The duration of hyaluronidase and optimal timing of hyaluronic acid (HA) filler reinjection after hyaluronidase injection. J Cosmet Laser Ther. 2018;20:52-57.