Facial filler and Thyroid Eye Disease.
Let’s cover the basics first. Filler is a gel-like substance commonly composed of hyaluronic acid that augments volume, and well, “fills.” Understanding how filler works, especially in patients who have an underlying disease process such as thyroid eye disease (TED) is important to help achieve a natural looking aesthetic. The important properties of filler include its viscoelasticity (how runny and pliable the filler is) and cohesivity (how the implant behaves once it is injected in the face).
Viscoelasticity:
In short, a filler needs to be viscoelastic. A highly viscous filler would deform and never recover if a shear force is applied (think honey). A highly elastic filler would theoretically deform but then recover entirely when shear force is applied (think rubber band). Both properties must exist in any filler that is used today. When the filler is being injected, it needs to be very viscous and once the filler is implanted into the face, it needs to have elastic properties to ensure it can provide an adequate amount of volume enhancement.
Cohesivity:
This property tells you how the filler behaves in the face. Filler is made up of many different hyaluronic acid molecules that are cross-linked together. The more cross-linking there is, the thicker and firmer the filler is, allowing the filler to “stick together.” Think about a bowl of pasta – elbow pasta can be easily separated from each other vs. spaghetti which is often difficult to isolate. A filler with a higher cohesivity can provide more volume augmentation but its drawbacks include increased rigidness and fluid retention.
Hydrophilicity:
This property describes how filler is “water-loving”. Fillers with a higher cohesivity and increased cross-linking tend to absorb more fluid. Filler, in general, acts like a sponge and can hold onto fluid in the areas that it is placed in the face. For some patients, this added fluid retention can provide even more volume enhancement.
How does this all relate to patients with thyroid eye disease?
Thyroid eye disease can cause fluid retention and facial swelling.
Facial filler can also cause fluid retention and facial swelling.
Coupled together, a patient may end up with an undesired result of looking puffier.
This doesn’t mean that filler is an absolute no for patients with thyroid eye disease. This just means that it is important to seek out an expert who has an in depth understanding of both thyroid eye disease and facial aesthetics. A good starting point would be to find a local oculofacial plastic surgeon in your area.
The swelling related to thyroid eye disease tends to occur in the 1. periorbital area – upper and lower eyelid puffiness and 2. Lid cheek junction area - including accentuation of malar mounds in certain patients and in the lower face where there is a widening due to fat expansion. Often, patients come in wanting to address these areas. However, if these areas are actively inflamed or edematous, placing filler in this area can often worsen the problem and appearance. Instead, I like to focus on other areas of the face that are often affected by the aging process, irrespective of thyroid eye disease, but may not be as noticeable to the patient given their primary focus is naturally on what has recently changed due to thyroid eye disease. Specifically, I focus on the temples, piriform aperture (right next to the base of the nose), and chin. I also generally like to stick to products with low cohesivity since they tend to be less hydrophilic or water-loving. Overall, I would say that filler can have a significant role in the care plan of patients with thyroid eye disease, along with careful patient selection, a good discussion about the pros/cons and patient expectations. As a patient, it is also important to accept that sometimes filler may not have a role based on the current state of the disease and though that may change in the future, it is best to listen to the doctor’s advice to avoid filler related complications.
Lastly, I strongly recommend seeing an expert such as a board-certified oculofacial plastic surgeon, facial plastic surgeon, or dermatologist who specializes in both thyroid eye disease and aesthetic services such as filler. They are well versed in how to manage placement of filler and can also have a deep understanding of how thyroid eye disease affects the face, what stage in the disease process a patient is in, and what treatment options are best suited for the patient.