REVIEW

Use of Hyaluronic Acid Fillers

ABSTRACT
Generally, the shape of women’s eyes are distinctly
different in intercatal height from that in men.
Ideally, in a woman, the lateral intercostal point
is positioned above the medial intercostal point,
which gives the eyes a cat-like appearance that
culturally suggests youth and health. Because
of aging and/or physiological changes, this area
to Correct Scleral Show:
A Review of Technique
by BRUNA SOUZA FELIX BRAVO, MD; JULIEN TOTTI, MD;
BERTA ELENA ALCALA GELPI, MD; STEPHANIE BIANCO DE SOUZA, MD;
and LEONARDO GONÇALVES BRAVO, MD
Dr. B. Bravo and Dr. Gelpi are with the Institute of Dermatology of Professor Rubem David Azulay in Rio de Janeiro, Brazil. Dr.
Totti de Bastos is with the Federal Hospital of Lagoa in Rio de Janeiro, Brazil. Dr. Biaco de Souza is with Gamboa Hospital in Rio
de Janeiro, Brazil. Dr. L. Bravo is a full member of the Brazilian Society of Plastic Surgery and is a plastic surgeon at the Burn
Center at Hospital Souza Aguiar in Rio de Janeiro, Brazil.
J Clin Aesthet Dermatol. 2018;11(6):38–40

can be altered with the inversion of the lateral
intercantal line lower than the medial intercantal
line, producing a tired and/or sad looking
appearance. Hyaluronic acid is a quick and safe
method of elevating the lateral intercantal area of
the eye. This article describes a technique for using
hyaluronic acid for the treatment of scleral show.
KEYWORDS: Scleral show, hyaluronic acid, fillers
S
Scleral show is an anatomical condition in
which the sclera area is visibly augmented
due to aging, trauma, endocrine disease, or as
a result of an unsuccessful blepharoplasty.1,2
Patients with constitutional scleral show
also typically have an inversion of the lateral
and medial corners of the eyes, which is not
considered aesthetically ideal in Italy.3
Recently, more advanced and broader use
of hyaluronic acid (HA) fillers has allowed for
the treatment of constitutional scleral show
in a quick, noninvasive, and safe manner. This
article describes the technique using HA for
the treatment of scleral show.
FEMALE VERSUS MALE EYE SHAPE
The eyelid is 700 to 800μm thick, protecting
the anterior surface of the globe and
maintaining the tear film, necessary for the
preservation of the cornea. Typically, the open
upper eyelid covers 1 to 2mm of the iris, while
the open lower eyelid covers the eyeball up to
the base of the iris. The so-called scleral show
occurs when the eyelid fissure is increased
by malocclusion of the lower eyelid or due to
physiological changes.4 The appearance and
dynamics of female eyes differ from male
eyes. The main difference is the angle of the
medial intercantal axis and the lateral axis.
In women, the lateral axis is discreetly higher
FUNDING: No funding was provided.
DISCLOSURES: Dr. B. Bravo is a consultant for Allergan. The other authors have no conflicts of interest relevant to the
content of this article.
CORRESPONDENCE: Bruna Souza Felix Bravo, MD; Email: Brunabravo@globo.com
in relation to the medial axis, termed by the
authors as a cat’s eye or an attractive eye. The
female eyebrow in conjunction with the eyes
has a lower medial angulation and a higher
tail compared to that of the male eyebrow. The
lateral third of the eyebrow has the highest
arch point and coincides with the lateral
limbus of the eyes. In men, these axes tend to
be oriented horizontally, and the eyebrow is
rectified.3 A schematic of the ideal patterns of
female and male beauty is presented in Figure
1.
HA FILLER FOR TREATMENT OF
SCLERAL SHOW
When a patient has an apparent scleral
show because of constitutional or iatrogenic
reasons, fillers with HA are suitable treatment
options. The filling of this area is performed
strategically to produce an elevation of the
lateral corner of the eyelid in relation to the
medial one in women. In men, the same
technique can be used to rectify the eye.3 In
this article, we present a technique using HA
as a treatment for constitutional scleral show.
The technique can also be used in patients
with postblepharoplasty scleral show, though
each case should be considered individually
and physicians should be cautious about the
greater risk of local postsurgical fibrosis.

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Technique. The HA filling to treat scleral

show can be performed using a 27-gauge
cannula and low crosslinking HA. If the
technique is done with a needle, aspiration prior
to the injection of the filler is required in order
to avoid intravascular injections. Asepsis should
be performed with alcoholic chlorhexidine 2%,
and materials should be sterile.
The technique consists of introducing a
cannula in the submuscular plane using an
entry point located at the lateral corner of
the eye. The cannula is inserted immediately
below the lateral raphe of the lower eyelid in
a medial direction in the infratarsal region of
the eye, with positioning of the cannula close
to the inferior margin of the palpebral limbus
of the eyelid. The application can be done by
retroinjection, and about 0.01mL is injected in
each side. HA filling can also be used in the tear
trough and palpebromalar groove for better
results.
Immediately after the procedure, if a small
nodulation at the site of the application occurs,
it should be massaged into the product.
In our practice, Juvederm Volbella® (Allergan,
Dublin, Ireland) is our HA filler of choice for this
procedure because it is the product with which
we have the most experience; however, other
low crosslinking HA products could be used.
Low crosslinking HA is malleable, making local
massage easy and reducing the occurence of
nodules and overcorrection.
Examples scleral show correction of the lower
lids are shown in Figures 2 and 3. Noteworthy
improvement with elevation of the lateral
corner of the eyes relative to the medial corner
can be seen in the figures, yielding more
attractive eyes that follow the ideal beauty
standards that are recommended in the
literature.4

DISCUSSION
HA fillers have vast uses in aesthetic
dermatological treatments for rejuvenation
and beautification, as well as in therapeutic
treatments. As noted in this paper, HA fillers
can improve scleral show as well as provide
elevation of the lateral corner of the eye in
correspondence with the medial corner by
adding volume, expanding the local tissue, and
raising the lateral corner of the lower eyelid. In
addition to constitutional scleral show, HA also
offers therapeutic options for addressing scleral
show due to acquired lesions.
FIGURE 1. The intercantal line before and after in patient with scleral show; we see the lateral line rises relative to the medial
after the treatment
The success of HA treatment for cicatricial or total improvement of aesthetic ectropion
ectropion was described by Fezza5 in a study and related symptoms, such as conjunctival
with 15 patients, with significant correction and corneal dryness, in 11 treated patients.
of ectropion and no complications except for The main complication observed was irregular
temporary bruising and Tyndall effect.5 fullness. However, the authors suggested that
Romero et al6, using HA for the correction this treatment should be considered only for
of cicatricial ectropion, demonstrated partial patients with surgical restrictions or those who

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FIGURE 2. The intercantal line before and after in pacient with constitutional scleral show

FIGURE 3. The intercantal line before and after in pacient with constitutional scleral show

do not want to undergo a surgical procedure.
Simon and Hariri2 reported successful outcomes
in two patients treated with 0.8cc of HA
for the correction of ectropion, caused by
traumatic injury due to thermochemical burns
in one patient and following blepharoplasty
in the other patient. Both patients showed
improvement of the cicatricial ectropium
without the need for additional surgery.2
Our experience has shown an improvement
in the appearance of constitutional scleral show
using this HA technique, and we believe our
results are very close to that of ideal beauty
standards in Italy. We have observed no adverse
effects following the treatment, and the
complications have been similar to those of
tear-trough filling.
Possible complications related to filling with
HA for the treatment of scleral show, such as
bruising, overcorrection, nodulation, Tyndall
effect, and ischemia (which is rare because
the procedure is performed with cannula), are
similar to those reported in the filling of dark
circles.8
Additional research is needed to better
evaluate benefits, long-term results, and safety
using HA fillers for the treatment of scleral
show.
REFERENCES
1. Loeb R. Scleral show. Aesthetic Plast Surg.
1988;12(3):165–170.
2. Simon J, al Hariri AB. The role of hyaluronic
acid injections in the management of
cicatricial ectropion. Abstract presented at
the Southern Medical Association Annual
Scientific Assembly; Oct. 30–Nov. 1, 2014;
Destin, FL.
3. Prendergast PM. Facial proportions. In: Erian
A, Shiffman MA, editors. Advanced Surgical
Facial Rejuvenation. Berlin, Germany:
Springer-Verlag; 2012:15–22.
4. Fábio Meneghini, Paolo Biondi. Clinical
Facial Analysis: Elements, Principles, and
Techniques. 3rd ed. New York, NY: Springer;
2005:59–63.
5. Palermo EC. Anatomia da região periorbital.
Surg Cosmet Dermatol. 2013;5(3):245­56.
6. Fezza JP. Nonsurgical treatment of cicatricial
ectropion with hyaluronic acid filler. Plast
Reconstr Surg. 2008;121(3):1009–1014.
7. Romero R, Sanchez-Orgaz M, Granados
M, et al. Use of hyaluronic acid gel in the
management of cicatricial ectropion: results
and complications. Orbit. 2013;32(6):
362–365.
8. Lafaille P, Benedetto A. Fillers:
contraindications, side effects and
precautions. J Cutan Aesthet Surg.
2010;3(1):16–19. JCAD

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