Perioperative management of periocular Hyaluronic Acid fillers

Hyaluronic acid (HA) filler treatments are increasingly used in periocular rejuvenation, as they appear to offer a safe and versatile method of volume augmentation. Given their rising popularity among younger patients, it is increasingly likely that oculoplastic surgeons will encounter patients who have undergone prior periocular HA filler treatments, subsequently requiring blepharoplasties at a later time point.  Their longer-term effect on eyelid anatomy remains uncertain however, and careful consideration needs to be given to the perioperative planning and management of these patients.

Previous publications have detailed management of lower lid HA fillers prior to lower blepharoplasty.^{1, 2} The authors advocate careful history and examination to ascertain prior periocular HA filler treatments. The majority of these patients underwent dissolution of the HA with hyaluronidase pre-operatively. Anatomical alterations were noted intraoperatively with less delineation of surgical landmarks, leading the author to consider the procedure as a “revision” lower lid blepharoplasty. HA fillers are also utilised in upper lid volume augmentation and contouring³, which must also be borne in mind prior to embarking on upper lid blepharoplasty. This may not be disclosed by the patient pre-operatively.

Hyaluronidase has widespread use in the management of HA filler related complications, and to dissolve excessive or problematic HA filler.⁴ However, there is no current standardised protocol for the timing and dosage of hyaluronidase prior to embarking on periocular surgery. Our favoured practice is to inject hyaluronidase at least one week pre operatively, reconstituted with lignospan (to reduce pain and risk of bleed/bruise) and dexamethasone (to reduce swelling). Possible reported complications include allergy, which is rare. In addition to this, a bleed/bruise may complicate or delay the planned subsequent surgery.