Perioperative management of periocular Hyaluronic Acid fillers
Aoife Naughton FRCOphth1, Naresh Joshi FRCOphth2
1Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
2Cromwell Hospital, 164-178 Cromwell Road, London, United Kingdom
*Aoife Naughton, Oxford Eye Hospital, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU,
Figure 1: 1A. Persistent swelling of upper eyelid 30 minutes post administration of local anaesthesia for upper lid blepharoplasty. Hyaluronidase administered to the sub-orbicularis plane prior to superior orbicularis excision. 1B. Marked reduction in upper lid swelling following administration of hyaluronidase, facilitating completion of surgery.
On several occasions we have encountered evidence of fillers unexpectedly, whereby the patient had not disclosed the details preoperatively. We have observed a number of clues as to the presence of filler, the most striking of which is noted after injection of local anaesthesia. The anaesthetic solution fails to dissipate in the tissues and causes localised swelling of the lids, which may pose a challenge to the surgery (figure 1A). In these cases, our approach is to inject hyaluronidase at the beginning of the procedure. We find this is most effective if administered in the sub-orbicularis plane prior to dissection. Its short onset of action enables rapid dissolution of the filler, enabling the surgeon to safely proceed with planned surgery (figure 1B). We have also noted, intraoperatively, that the tissues tend to bleed more as a presumed inflammatory response to the previously placed HA. The HA filler is also often visible as a glistening material, usually in a sub-orbicularis, pre-septal location.
In summary, meticulous pre-operative assessment and targeted history and examination will help to identify patients with prior HA filler treatments in advance of undertaking upper or lower lid blepharoplasties. If this is encountered unexpectedly intra-operatively, with prolonged swelling post injection of local anaesthesia, intraoperative hyaluronidase is a valuable tool to mitigate any negative impact on blepharoplasty surgery.
Conflict of interest: None to declare
Funding/Support: None to declare
Abbreviations: HA, hyaluronic acid
Contributorship statement: Miss Naughton conceptualised the report, performed the literature review, and drafted and revised the manuscript. Mr Joshi conceptualised the report, critically reviewed and revised the manuscript for important intellectual content.
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