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Three Part Question

In [a patient seeking cosmetic treatment to the upper eyelid], how [effective] is [hyaluronic acid] and what technique should be used?

Clinical Scenario

Patient seeking a relatively safe, non surgical cosmetic treatment to the upper eyelid.

Search Strategy

PubMed
upper[All Fields] AND ("eyelids"[MeSH Terms] OR "eyelids"[All Fields] OR "eyelid"[All Fields]) AND ("hyaluronic acid"[MeSH Terms] OR ("hyaluronic"[All Fields] AND "acid"[All Fields]) OR "hyaluronic acid"[All Fields]) limited to humans, English language and last 10 years.

Search Outcome

20 results in total.
Only 4 studies were relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Choi HS 2011 Feb Singapore	Asian patients. All patients had eyelid crease asymmetry or undesirably elevated eyelid creases along with hollowing of the upper eyelids. seven patients (11 eyes) of various Asian ancestries. For all patients, hyaluronic acid fillers (Restylane, Medicis, Scottsdale, Ariz., or Juve´derm, Allergan, Irvine, Calif.) were injected into the retro-septal superior sulcus for eyelid hollowing and into the preseptal eyelid fold for crease asymmetry. Preoperative and postoperative photographs and Subjective assessment of results by the patient. Injection Technique: topical 2.5% lidocaine and 2.5% prilocaine cream were applied to the upper eyelid for 30 to 60 minutes. The injection area was then wiped with an alcohol pad. Using a 30-gauge needle, the hyaluronic acid–based filler was injected deep to the orbital septum for superior sulcus hollowing. For eyelid crease asymmetry, hyaluronic acid was injected deep to the orbicularis oculi muscle. Multiple small aliquots (0.1 cc) were injected into each region, depending on the individual appearance of the patient until symmetry between the upper eyelid creases and fullness of the superior sulcus were obtained as assessed by the surgeon. The filler was injected in a linear-threading, fanning fashion, advancing the plunger while the needle was being withdrawn. Removal and repuncture of the skin were minimized as much as possible to avoid unnecessary soft-tissue trauma. For lid crease asymmetry, the injection was given in a more superficial plane, anterior to the orbital septum but deep to the orbicularis muscle. External massage was used to diffuse the hyaluronic acid. Effect and volume of filler used were titrated based on appearance immediately after injection and massage.	Retrospective, interventional case series	Total volume injected	Average 0.61 cc per eye	Small sample size. Subjective assessment. Non validated assessment tool. Only Asian patients.
			Photo and Subject assessment	All 7 patients were satisfied. The treatment has remained effective for as long as 18 months.
			Complications	No adverse effects were noted.
Morley April 2009 UK	Twenty-seven patients were included with a mean follow-up of 13 months. More than 85% were white women with a mean age of 51 years (range, 24–65 years). standard serial puncture injections with preperiosteal placement of filler were administered at the superior orbital rim. Classification of upper eyelid volume deficiency as I) medial A-shaped hollow, II) generalized hollow, III) postblepharoplasty volume loss, and IV) upper eyelid hooding with subbrow volume deflation. Masked, independent assessment of pretreatment and post treatment photographs. Injection Technique: The patient’s upper eyelid skin was numbed with ice and wiped with an alcohol swab. With the patient supine and the eyes in downgaze, a needle puncture was created close to the junction of the lateral wall and roof. The needle tip was advanced in the suborbicularis plane until it reached the inferior border of the superior orbital rim and 0.1 ml hyaluronic acid gel was injected preperiosteally. The needle was withdrawn, and the raised bleb was molded over the anterior aspect of the orbital rim in a medial direction to achieve a smooth contour. The patient was asked to look straight ahead and the upper eyelid contour inspected. This process was repeated 2 or 3 more times, using a serial puncture technique, with each injection progressively more medial. The supraorbital notch was avoided to minimize trauma to the supraorbital neurovascular complex. After the injections, the patient was asked to raise the eyebrows, and the filler was molded onto the anterior surface of the orbital rim. With the brows relaxed, the upper eyelid contour was reassessed to evaluate any residual lumpiness or irregularity. Injection end points included symmetrical fullness of the preseptal skinfold and softening of any hollows. Patients were advised to avoid exercise and alcohol for 24 hours and direct pressure on the upper eyelid region area for 72 hours. Regular ice packs and analgesia were recommended. No routine postoperative visit was scheduled, but all patients underwent a telephone review the following day. Prompt follow-up was arranged if concerns were apparent.	Consecutive, retrospective, interventional case series.	Patient satisfaction	26 patients (96%) were satisfied, although 5 (19%) requested additional filler and 1 patient underwent dissolution within 3 months.	Non validated assessment tool.
			Volume of filler used	The mean volume was 0.4 ml/eyelid (range, 0.1–1 ml)
			Photographic assessment	Improved static upper eyelid contour in 23 patients (85%), little change in 3 patients (11%), and deterioration in 1 patient (4%).
			Complications	All patients developed mild bruising and swelling but no discoloration or lumpiness.
Liew October 2010 Australia	36 patients. All patients selected for treatment had volume depletion in the upper periobit and were potential candidates for structural fat grafting but refused because of the potential morbidities and downtime. The volumetric upper periorbital rejuvenation was performed with Restylane or Juvederm ultra. Long follow up to 3.5 years. Injection technique: Topical anesthetic cream for about 20 min, routine skin cleansing with chorhexidine aqueous solution, a 30-gauge hypodermic needle is used to inject the product at a 30 angle to the skin from lateral to mediala, with a small aliquot of not more than 0.1 ml deposited at the supraperiosteal level. Typically, two to three entry sites are used. The product is placed in a linear droplet fashion. The dermal filler then is massaged inferiorly into the desired area, reaching as low as the subbrow eyelid junction. The process is repeated until the desired volume has been added.	Case series.	The filler volume	The average volume required ranged from 0.2 to 0.6 ml of filler.	Non validated assessment tool. It is not clear what the authors actually measured. Level of evidence 5.
			Complications	Minor bruising and edema are the most commonly reported adverse outcomes, which can be camouflaged easily with makeup.
			Subjective assessment	Favourable outcome.
Mancini September 2009 USA	8 patients with upper eyelid margin asymmetry relating to relative upper eyelid retraction. 8 patients treated with hyaluronic acid gel injection to affect upper eyelid lowering. Digital photographs were used to quantitatively assess outcomes by comparing pretreatment and posttreatment differences between marginal reflex distance (MRD1) in the right and left eyelids. Image J was used for photographic analysis, and Student paired t test was performed. Injection technique: The conjunctiva is anesthetized with topical agents. The upper eyelid is everted, exposing the conjunctiva just superior to the upper tarsal edge. Using a 30-gauge needle, a single bolus of HAG is placed centrally in the subconjunctival levator-Muller plane. Alternatively, the injection can be given through the skin. However, it may be more difficult to find the levator plane, because the needle cannot be visualized, and the proper plane is very thin. Care should be taken with levator injections, because the globe is in close proximity in this region. Small volumes, 0.1 to 0.2 ml, of material are injected with the end point being adequate lowering with improved symmetry. This can usually be achieved with 1 to 2 injections in a single session.	Retrospective study.	The volume of filler injected	The average was 0.2 ml (range, 0.1– 0.4 ml).	Average follow-up was only 5.7 months (range 2–12 months). Small number of patients with different etiologies of eyelid asymmetry.
			Comparing pre and post MRD1	Improvement in symmetry with mean pretreatment MRD1 difference of 1.53 mm (range, 0.78 –3.36 mm) and mean posttreatment MRD1 difference of 0.70 mm (range, 0.02–2.03 mm), p 0.007.
			At 4 to 8 months’ follow-up	8 of 8 demonstrated persistent improvement in asymmetry with reduction in MRD1 difference when compared with pretreatment with average follow-up MRD1 difference of 0.74 mm (range, 0.11–1.65 mm), p 0.018
			Complications	Minimal and typically transient.

Comment(s)

Hyaluronic acid is a natural component of the extracellular matrix, it has been widely used as a cosmetic gel filler. However, there is lack of evidence in its use in the upper eyelid. At best, the level of evidence is 3. Injection techniques described were similar apart from Mancini paper which describes a technique that is more suitable for eyelid retraction. Maintenance injections can be provided as needed.

Clinical Bottom Line

HA injections into the upper eyelid are safe and effective in correcting upper eyelid margin asymmetries, replacing soft tissue loss and providing volume to recreate the aesthetically appealing fullness of the upper eyelid. HA should be injected preperiosteally, massaged and toped up to create the desired effect. The supraorbital notch should be identified and avoided.

References

1. Choi HS, Whipple KM, Oh SR et al. Modifying the upper eyelid crease in Asian patients with hyaluronic acid fillers. Plast Reconstr Surg. 2011 Feb;127(2):844-9..
2. Morley AM, Taban M, Malhotra R et al. Use of Hyaluronic Acid Gel for Upper Eyelid Filling and Contouring.. Ophthal Plast Reconstr Surg 2009;25:440–444.
3. Liew S, Nguyen DQ. Nonsurgical Volumetric Upper Periorbital Rejuvenation: A Plastic Surgeon’s Perspective Aesth Plast Surg (2011) 35:319–325.
4. Mancini Nonsurgical Management of Upper Eyelid Margin Asymmetry Using Hyaluronic Acid Gel Filler Ophthal Plast Reconstr Surg Vol. 27, No. 1, 2011