Ultrasound-guided Minimally Invasive Correction of Postblepharoplasty Lower Eyelid Hollowing Using Hyaluronic Acid: A 5-case Series

Abstract

Summary: Lower eyelid hollowing is a challenging complication following transconjunctival blepharoplasty, particularly in Asian patients with limited midface projection. Surgical revision is often unpredictable due to fibrosis, thin skin, and compromised vascularity. Minimally invasive alternatives that provide reliable contour restoration with minimal downtime are desirable. This case series includes 5 female patients presenting with persistent lower eyelid hollowing at least 3 months after transconjunctival fat removal. All patients underwent ultrasound-guided hyaluronic acid (HA) injection using a blunt cannula, with selective adhesiolysis when indicated. HA fillers were chosen based on rheological properties: VYC-17.5L for sub–orbicularis oculi fat and periosteal augmentation, and VYC-15L for periosteal and sub–orbicularis oculi muscle tear trough correction. One patient with extremely thin skin and vascular dark circles received adjunctive subcutaneous human-derived collagen. Outcomes were assessed clinically and via standardized photography at 1 and 3 months, with patient satisfaction measured using a 5-point Likert scale. All patients demonstrated visible improvement in lower eyelid contour at both follow-up visits. Patient satisfaction was high, with 4 of 5 patients reporting being very satisfied and 1 reporting being satisfied at the 3-month follow-up. Transient edema and ecchymosis occurred in 2 patients each and resolved spontaneously. No Tyndall phenomenon, vascular complications, nodules, or contour irregularities were observed. Ultrasound-guided HA injection may represent a safe and minimally invasive option for selected patients with postblepharoplasty lower eyelid hollowing, achieving favorable short-term aesthetic outcomes with high patient satisfaction.