Purpose

Hyaluronic acid (HA) fillers are widely used for tear trough deformities; however, suboptimal outcomes are common, particularly in patients with underlying structural abnormalities such as orbital fat herniation. In such cases, filler treatment may worsen rather than correct the deformity. Hyaluronidase-assisted dissolution has become an important step prior to definitive surgical correction.

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Methods

We present a case series of 21 patients with persistent lower eyelid deformities following prior HA filler injection. The median age was 45 years (range, 34–66), and the cohort consisted of 20 females and 1 male. All patients were evaluated for anatomical abnormalities and filler-related complications. Management included hyaluronidase-assisted filler dissolution with or without subsequent surgical intervention.

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Results

Nine patients were managed with hyaluronidase injection alone, resulting in improvement of edema and contour irregularities. Twelve patients underwent staged management with hyaluronidase-assisted dissolution followed by lower eyelid blepharoplasty due to persistent deformity and underlying fat herniation. In several cases, dissolution unmasked pre-existing orbital fat prolapse, increasing the visibility of lower eyelid bags and clarifying the need for surgery.

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Conclusion

HA filler use in patients with unrecognized structural periorbital abnormalities may lead to unsatisfactory outcomes. Hyaluronidase serves both therapeutic and diagnostic roles by revealing underlying anatomy. Patients should be counseled that filler dissolution may accentuate lower eyelid bags and necessitate blepharoplasty. A staged approach provides effective and predictable outcomes.

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Additional Authors

First name	Last name	Base Hospital / Institution
Ezgi	Duztas	Yeditepe Universtity Hospital

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