Received: 14 February 2022 | Revised: 10 April 2022 | Accepted: 2 May 2022

DOI: 10.1111/jocd.15047

P R A C T I C A L A P P L I C AT I O N

Nonsurgical lower eyelid rejuvenation using injectable

poly-­d,l-­lactic acid in Asian patients

Jui-­Yu Lin MD1 | Chuan-­Yuan Lin MD1,2

1
Li-­An Medical Clinic, Taipei City, Taiwan
2
Kaohsiung Jourdenwell Aesthetic Clinic,
Abstract
Kaohsiung, Taiwan Background: Filler injection for lower eyelid rejuvenation remains a difficult subject

Correspondence
Chuan-­Yuan Lin, Li-­An Medical Clinic,
4F., No. 267, Lequn 2nd Road, Zhongshan
District, Taipei City 104452, Taiwan.
Email: linchuanyuan@doctortou.com
due to many complicated anatomic changes as the face ages.
Objectives: To propose an alternative, simple, and effective filler injection method in
lower eyelids for Asian patients.
Methods: Any patient who has tear trough deformities, infra-­orbital hollows, nasoju-
gal grooves, dark eye circles, as well as mild eyebags is a potential candidate for this
method. Our filler choice is injectable poly-­d,l-­lactic acid (PDLLA; AestheFill; REGEN).
PDLLA must be reconstituted with sterile water for injection (SWFI) before adminis-
tration. When the patient's troughs, grooves, or volume deficit are classes II and III,
3–­4 ml of SWFI and 1 ml of lidocaine are used. When the deficits are class I, 5–­7 ml of
SWFI and 1 ml of lidocaine are used. With the fanning injection technique, a wide re-
gion that covers all the deficits is evenly injected. The depth is under the dermis layer.
The total amount of filler injection is not more than 2 ml on each side.
Results: Since 2019, we have injected more than 100 patients by following these steps
in Taiwan. The level of patient satisfaction is high. Only some mild and transient post-­
injection complications such as edema, erythema, and ecchymosis were found.
Conclusions: We propose an alternative, simple and effective method for non-­surgical
lower eyelid rejuvenation for Asian patients. However, anyone who wants to perform
this procedure should be well-­trained and knowledgeable about the anatomy, prod-
uct, and procedure to prevent adverse events.

KEYWORDS
infraorbital hollows, lower eyelid rejuvenation, nasojugal groove, poly-­d,lL-­lactic acid, tear
trough deformity

1 | I NTRO D U C TI O N 2 | M E TH O D S

Injectable fillers have been increasing in popularity for facial rejuve-
nation in recent years. One of the most challenging areas for filler
injection is the lower eyelid. The area undergoes many anatomic
1–­3
changes as the face ages. Many kinds of fillers and injection tech-
niques have been proposed, but the results are variable.4 We pro-
pose an alternative, simple, and effective filler injection method in
this area for Asian patients.
Any patient who has tear trough deformities, infra-­o rbital hol-
lows, nasojugal grooves, dark eye circles, as well as mild eye-
bags is a potential candidate for this method. If the patient has
mid-­facial volume loss, we will inject hyaluronic acid (HA) filler
in the supra-­p eriosteum layer for correction at least 1 week be-
fore lower eyelid injection. The exclusion criteria are listed in
Table 1.

4328 | © 2022 Wiley Periodicals LLC wileyonlinelibrary.com/journal/jocd J Cosmet Dermatol. 2022;21:4328–4331.

LIN and LIN | 4329

The lower eyelid pre-­injection routines are as usual. After sign-
ing informed consent, washing faces, and taking pre-­injection pho-
tographs, local anesthetic cream is applied on the patient's lower
eyelid and cheek regions for 15–­20 min.
Our filler choice is injectable poly-­
d,l-­
lactic acid (PDLLA;
5
AestheFill; REGEN). We reconstitute injectable PDLLA while the
patient is prepared. The amount of sterile water for injection (SWFI)
used for reconstitution of a vial of injectable PDLLA depends on
the severity of the deficit. Clinically, the periorbital pattern of vol-
ume loss can be categorized into three classes. Class I patients have
volume loss limited medially to the tear trough. Class II patients ex-
hibit volume loss both in the medial and lateral orbital areas. Class
III patients present with a full depression circumferentially along
3
the orbital rim medially to laterally. When the patient's troughs,
grooves, or volume deficit are class II to III, 3–­4 ml of SWFI and 1 ml
of lidocaine are used. When the deficits are class I, 5–­7 ml of SWFI
and 1 ml of lidocaine are used.
During injection, the patient lies on an operating table in a su-
pine position. After sterilizing with alcohol, a 23G cannula is in-
serted from an entry point 10 mm lateral and inferior to the lateral
canthus. The depth is just beneath the dermis layer. To ensure that
the injection layer is correct, inserting the cannula horizontally and
superficially just after penetrating the dermis layer is the best way
of choice. The shape of the cannula should be visible through eye-
lid skin throughout the whole procedure. With the fanning injec-
tion technique, a wide region is evenly injected (Figure 1). The total
amount of filler injection is not more than 2 ml on each side. After
injection, gently massage the injection region for 5–­10 s. Ice-­packing
of the region is recommended, for 10 min at a time, several times a
day for 3 days. Massage is not needed at home. Patients who have

TA B L E 1 Indications and contra-­indications of lower eyelid filler injection

Indications Contra-­indications

• Tear trough deformity
• Nasojugal groove
• Infra-­orbital hallowing
• Dark eye circle
• Mild eyebag
• Too loose and/or saggy of the lower eyelid
• Have received any kind of lower eyelid surgery or filler injection within 1 year
• Allergy to any components of the filler
• Tendency of keloid formation
• Pregnancy or breastfeeding
• Coagulation disorders
• Taking anti-­coagulative drugs
• Unrealistic high expectations
• Any other medical or psychological problems that are not suitable for injection

F I G U R E 1 Schematic illustration of injectable PDLLA injection technique. (Left) Frontal view of the face. The injection borders are:
Inferior border of pre-­t arsal fullness superiorly, naso-­cheek junction medially, 10 mm lateral to lateral canthus laterally, and 20–­30 mm
inferior to tear trough deformity inferiorly. (Middle) Pre-­injection cross-­sectional view of the lower eyelid. (Right) Post-­injection cross-­
sectional view of the lower eyelid. The injection depth is just beneath the dermis layer
4330 | LIN and LIN

(A) (B) (C) (D)

F I G U R E 2 A 51-­year-­old male who had class III tear trough deformities, naso-­jugal grooves, and mild eyebags received two sessions
of PDLLA injection. A vial of PDLLA was injected at each time (reconstituted with 3 ml of SWFI and 1 ml of lidocaine, 2 ml of suspension
was injected on each side), spaced 2 months apart. (A) Preoperative view; (B) immediate result after injection of the right lower lid, the 1st
injection session; (C) immediate result after injection of both lower lids, the 1st injection session; and (D) postoperative view, 9 months after
the 2nd injection session. (Photographs courtesy of Chuan-­Yuan Lin, MD)

(A) (B)

F I G U R E 3 A 24-­year-­old female who had class I tear trough deformities and dark eye circles received 1 session of PDLLA injection. A vial
of PDLLA was reconstituted with 7 ml of SWFI and 1 ml of lidocaine, and 2 ml of suspension was injected into each side. (A) Preoperative
view and (B) 8-­month postoperative view. (Photographs courtesy of Chuan-­Yuan Lin, MD)

severe volume deficits may need a second treatment 1 month later
(Figures 2 and 3).
3 | R E S U LT S
Since 2019, we have injected more than 100 patients by following
these steps in Taiwan. The level of patient satisfaction is high. Only
some mild and transient post-­injection complications such as edema,
erythema, and ecchymosis were found. They all subsided within
1–­2 weeks. We have encountered no complications such as infec-
tion, hematoma, allergy, Tyndall effect, product migration, fluid col-
lection, itching, yellow disc, overcorrection, lumpiness, granuloma
formation, or vessel embolism.
4 | DISCUSSION
The most common filler employed for lower eyelid injection is
HA.1–­4 Some practitioners use calcium hydroxyapatite (CaHA) or
other products.4,6 We use Injectable PDLLA as our filler of choice.
Injectable PDLLA is a subdermal collagen-­
stimulating filler that
has a lasting effect for up to 2 years.5 It is supplied as lyophilized
powders in vials. Reconstitution with SWFI to form a homogeneous
suspension is needed before injection.7 It can be quickly prepared
by vacuum-­assisted hydration and then the back-­and-­forth recon-
stitution method.7–­9 Its unique properties of quick preparation, easy
injection and adjustable thickness make PDLLA an ideal filler for this
method. We recommend wide placement of the filler, not just cor-
recting the “troughs” or “grooves.” Because there are no definite bor-
ders of these “troughs” or “grooves,” it is easier for us to inject widely
to correct all deficits.10 We also recommend superficial placement
of the filler. There are many fascia, ligaments, and muscles deep in
this region.1–­3 They separate this region into compartments so it is
difficult to evenly distribute filler product in the deep layers. When
the filler product is not evenly distributed or entrapped inside mus-
cles, irregularity or nodules formation is the result. Besides, dark eye
circles can be camouflaged by the wide and superficial placement of
the filler. There is almost no large vessel existing in superficial skin
layers. In addition, vessels being punctured by a large caliber cannula
LIN and LIN
seldom occur. Therefore, we believe that injecting using a large ca-
liber cannula in a superficial layer can avert intravascular injection.
After PDLLA injection, there are no Tyndall signs, persistent edema,
and pseudoxanthoma which HA and CaHA may have. 2–­4,6
However, there are some disadvantages to this procedure. Due
to the superficial placement of the filler, post-­injection erythema
and edema are more apparent than the deep injection method. Wide
injection means that the possibility of ecchymosis is higher than in-
jection only in limited areas. Furthermore, there is no antidote for
injectable PDLLA. It is difficult to deal with once nodules or irregu-
larities occurred after injection.
In conclusion, filler injection for tear trough deformities, nasoju-
gal grooves, infra-­orbital hollows, dark eye circles, and mild eyebags
are challenging. We propose a simple and effective method for solv-
ing these problems. However, any kind of procedure is technically
demanding. Anyone who wants to perform this procedure should
be well-­trained and knowledgeable about the anatomy, product, and
procedure to prevent adverse events.
AC K N OW L E D G E M E N T
The authors especially thank Sasa Chen for her kind assistance with
manuscript editing, and also Tung-­Hsuan Lin for her kind assistance
with making the artwork.
C O N FL I C T O F I N T E R E S T
Dr. Lin J-­
Y and Dr. Lin C-­
Y are medical consultants of Jiangsu
Wuzhong Aesthetic Biotech., and medical directors of REGEN
Biotech.
DATA AVA I L A B I L I T Y S TAT E M E N T
Data sharing is not applicable to this article as no new data were cre-
ated or analyzed in this study.
PAT I E N T S C O N S E N T
Patients provided written consent for the use of their images.
E T H I C A L S TAT E M E N T
The authors confirm that the ethical policies of the journal, as noted
on the journal’s author guidelines page, have been adhered to. No
| 4331
ethical approval was required as this is a review article with no origi-
nal research data.
ORCID
Chuan-­Yuan Lin https://orcid.org/0000-0003-2306-478X
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How to cite this article: Lin J-­Y, Lin C-­Y. Nonsurgical lower
eyelid rejuvenation using injectable poly-­d,l-­lactic acid in Asian
patients. J Cosmet Dermatol. 2022;21:4328–­4331. doi:10.1111/
jocd.15047
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