title: Nonsurgical management of upper eyelid margin asymmetry using hyaluronic acid gel filler.
abstract: OBJECTIVE
  To evaluate the efficacy of hyaluronic acid gel fillers as a nonsurgical alternative for the management of upper eyelid margin asymmetry in cases of relative retraction.
  
  
  METHODS
  This is a retrospective study of 8 patients with upper eyelid margin asymmetry relating to relative upper eyelid retraction 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.
  
  
  RESULTS
  Eight patients (2 male; mean age, 50.9 years; range, 30-69 years) were injected with hylauronic acid gel in the upper eyelid. The etiology of upper eyelid margin asymmetry included Graves eyelid retraction (n = 3), asymmetry following reconstructive surgery (n = 1) and aesthetic surgery (n = 1), contralateral Horner syndrome (n = 1), Bell palsy (n = 1), and contralateral involutional ptosis (n = 1). The average volume injected in the upper eyelid was 0.2 ml (range, 0.1-0.4 ml). One of 8 patients was injected bilaterally. Average follow-up was 5.7 months (range, 2-12 months). Two of 8 patients requested repeat injection within a 6-month period for undercorrection. No overcorrections were noted, and no patient requested reversal with hyaluronidase. There was a statistically significant 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 statistically significant 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.
  
  
  CONCLUSIONS
  This pilot study suggests that upper eyelid injection with hylauronic acid gel filler may be an effective nonsurgical alternative to improve upper eyelid margin asymmetry in cases of relative upper eyelid retraction.
authors.affiliation: Division of Oculofacial Surgery, Department of Ophthalmology, Jules Stein Eye Institute, Los Angeles, California 90095, USA. Mancini@jsei.ucla.edu
authors.forename: Ronald
authors.initials: R
authors.lastname: Mancini
authors.forename: Nicole M
authors.initials: NM
authors.lastname: Khadavi
authors.forename: Robert Alan
authors.initials: RA
authors.lastname: Goldberg
mesh_terms: D000328:Adult; D000368:Aged; D003357:Cosmetic Techniques; D005124:Eye Abnormalities / Q000628:therapy*; D005143:Eyelids / Q000002:abnormalities*; D005260:Female; D006801:Humans; D006820:Hyaluronic Acid / Q000008:administration & dosage / Q000031:analogs & derivatives*; D007271:Injections, Intradermal; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D012189:Retrospective Studies
chemical_list: D006820:Hyaluronic Acid; C445361:Restylane