The Injection for the Lower Eyelid Retraction: A Mechanical Analysis of the Lifting Effect of the Hyaluronic Acid

  • Wenjing Xi
  • Sheng Han
  • Shaoqing Feng
  • Ke Li
  • Beniamino Brunetti
  • Davide Lazzeri
  • Yun TongEmail author
  • Yixin ZhangEmail author
Original Article Non-Surgical Aesthetic



It has been reported that the injection of the hyaluronic acid (HA) into the lower lid area could improve lower eyelid retraction. However, the published studies offered few insights into the mechanism of this treatment. When the underlying mechanism is not clear, many surgeons will not trust the method enough to apply it in their clinical practice. The purpose of this article was to propose a possible explanation for the underlying mechanism of the treatment and further verify the method by a series of cases.


The authors performed a mechanical analysis on the physical impact of HA on the lower eyelid. In the clinical cases, we injected the fillers under the orbicularis muscle to correct lower lid retraction. The results were evaluated by the standardized marginal reflex distance 2 (MRD2) immediately and 9 months later.


From October 2013 to October 2015, the injections were carried out in 27 cases (14 post-blepharoplasty and 13 involuntary). In 26 cases (96.3%), the retraction was completely corrected and did not recur through the last follow-up. The average improvement of the standardized MRD2 was 0.84 mm immediately after the injection and 1.19 mm 9 months later. Complications were not reported.


Lower eyelid retraction could be treated by the injection of HA under the orbicularis muscle. The filler in this situation acted as a lifter because the filler changed the balance of force of the lower lid, forcing it to shift upward to gain the new balance. The ‘lifter’ mechanism could be applicable to other facial injections that generate elevating effects.

Level of Evidence IV

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Lower eyelid retraction Hyaluronic acid Injection Mechanical analysis 



This study was funded by Clinical Research Program of 9th People's Hospital affiliated to Shanghai Jiao Tong University School of Medicine (JYLJ027) and National Natural Science Foundation of China (81772098).

Compliance with Ethical Standards

Conflict of interest

None of the authors has financial conflicts or interests to report in association with the contents of this paper.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

For this type of study formal consent is not required.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2019

Authors and Affiliations

  • Wenjing Xi
    • 1
  • Sheng Han
    • 2
  • Shaoqing Feng
    • 1
  • Ke Li
    • 3
  • Beniamino Brunetti
    • 4
  • Davide Lazzeri
    • 5
  • Yun Tong
    • 6
    Email author
  • Yixin Zhang
    • 1
    Email author
  1. 1.Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s HospitalShanghai JiaoTong University School of MedicineShanghaiChina
  2. 2.ZenrayShangmei Medical Aesthetics’ ClinicBeijingChina
  3. 3.School of Civil EngineeringChongqing UniversityChongqingChina
  4. 4.Plastic Reconstructive and Aesthetic Surgery DepartmentCampus Bio-Medico UniversityRomeItaly
  5. 5.Cosmetic Surgery UnitVilla Salaria ClinicRomeItaly
  6. 6.Department of Plastic Surgery, Jinhua Central HospitalZhejiang UniversityJinhuaChina

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