Injections of hyaluronic acid are considered a safe and effective method of correction of the periorbital zone, which provides good results in filling the nasolacrimal and nasozygomatic grooves. Despite the number of benefits of HA, the hydrophilic nature of the gel can cause swelling, which usually resolves a few days after injection. However, sometimes swelling can persist for a long time , in particular, after correction of the infraorbital grooves. The article by estet-portal.com presents a clinical case from the practice of Ricardo Augusto Sandoval Vasques, Kelly Park, Katherine Braunlich and Shino Bay Aguilera.
- Description of a clinical case: prolonged swelling after filling the nasozygomatic groove with HA filler
- Possible causes of prolonged swelling under the eyes after and hyaluronic acid injections
Description of a clinical case: prolonged swelling after filling the nasozygomatic groove with HA filler
The patient, 61 years old, came to the authors' clinic with complaints of dark circles and furrows under the eyes. During the consultation, the authors suggested correcting the pronounced nasolacrimal and nasozygomatic grooves with fillers based on hyaluronic acid.
During the procedure, the patient was injected with 1 ml of filler based on stabilized hyaluronic acid at a concentration of 20 mg/ml with lidocaine 0.3%.
Photo 1: the patient during the initial consultation: the red line is the nasolacrimal groove, the blue line is the nasozygomatic groove
Photo 2: 1 year after hyaluronic acid filler injections; the area of the most pronounced edema is marked in white
Photo 3: patient 19 months after hyaluronic acid filler injections
Photo 4: patient 25 months after hyaluronic acid injections
Photo 5: patient 31 months after hyaluronic acid injections
The patient tolerated the procedure well and there were no immediate complications recorded. However, after a few months, the woman developed swelling under her eyes , most pronounced in the area of the nasozygomatic groove. A year later, the patient reported the problem to the doctor. 18 months after the filler injections, the patient came to see the doctor and, after consultation, decided on further observation. Only 19 months after the initial correction did she agree to hyaluronidase injections .
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In the area of the most pronounced swelling, 5 units (0.05 ml) of hyaluronidase were injected on both sides of the face. After this, there was immediate visible improvement.
25 months after the initial procedure, the patient returned to the doctor complaining of moderate swelling. She was then given 2 more units (0.02 ml) of hyaluronidase on both sides of her face in the same area with subsequent improvement.
31 months after correction, the swelling decreased significantly and the patient refused from further therapy.
Possible causes of prolonged swelling under the eyes after hyaluronic acid injections
In this case, prolonged swelling under the eyes after filler could have formed due to several factors:
- anatomical features of the patient;
- hydrophilic properties of the selected HA filler;
- introduction techniques.
The rheological properties of hyaluronic acid fillers must be taken into account when choosing a product for contouring:
- HA concentration;
- elasticity;
- viscosity;
- cohesiveness;
- cross-linking.
The concentration of HA (mg/ml) is proportional to the amount of cross-linked (insoluble) and free (soluble) hyaluronic acid. Cross-linked HA resists enzymatic degradation and provides longer-lasting correction results, while free HA breaks down easily.
Hyaluronic acid – viscoelastic gel:
- viscosity - the ability of HA to deform during injection;
- elasticity – the ability to restore its original shape.
Fillers with a high modulus of elasticity (G') exhibit greater resistance to movement and therefore retain their shape better. Fillers with a high modulus of elasticity are ideal for deep injection for lifting purposes, but are less suitable for areas of high muscle activity.
Cross-linking of HA increases gel density, elastic modulus, and gel cohesiveness.
Cohesiveness is the internal adhesion force that binds cross-linked HA. The higher the cohesiveness, the better the filler retains its shape. Fillers with low cohesiveness, accordingly, give less lifting effect. This is important to consider when choosing the depth of drug administration. Low cohesiveness can also lead to HA fragmentation and increase the effect of gravity on the product.
Filler injection technique
When augmenting the infraorbital region with HA filler, it is necessary to follow a specific injection technique. The filler should be injected below the ligament that supports the orbicularis oculi muscle , otherwise gel migration and prolonged swelling may occur after the filler is injected under the eyes.
There are various techniques for injecting HA to correct the nasozygomatic groove .
Injecting into the correct anatomical area is an important rule of any injection technique. Using a cannula, the doctor can feel the resistance of the suspensory ligament and avoid injecting the drug incorrectly. In general, the optimal technique is one that minimizes the amount of filler injected.
In the presented case, the patient had persistent swelling despite extensive knowledge of anatomy, clinical experience of the practitioner, and the correct choice of HA filler for the target anatomical area.
To choose the ideal filler for correcting a problem area, it is necessary to take into account its rheological properties, which affect the result of contouring.
Therefore, the authors suggest that long-term edema may be due to the high hydrophilicity of the selected filler , which can lead to increased gravitational traction, migration of the product to undesirable areas and/or long-term attraction of water, which entails the development of edema. However, the exact cause of this complication is unknown.
To avoid such complications, the authors recommend using homogeneous non-disperse cohesive gels based on low-concentrated hyaluronic acid to correct the nasolacrimal and nasozygomatic grooves.
Based on J Clin Aesthet Dermatol
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