The Rise and Fall of the Pale Puffy Lower Eyelid Pillow

April 2021 | Volume 20 | Issue 4 | Case Reports | 475 | Copyright © April 2021

Published online March 17, 2021

Margo Lederhandler MD,a Daniel Belkin MD,b,c Robert Anolik MD,b,c Roy G. Geronemus MDb,c

aDepartment of Dermatology, Weill Cornell Medicine, New York, NY
bLaser & Skin Surgery Center of New York, New York, NY
cThe Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, NY

This case series demonstrates an exaggerated form of the clinical presentation of a known distressing late complication of retained hyaluronic acid filler – the “pale puffy pillow.” This presentation is often, unfortunately for the patient, misdiagnosed as festoons. However, the correction with liberal hyaluronidase is simple. Additionally, we have demonstrated that ablative fractional carbon dioxide laser resurfacing is an excellent tool that may be utilized after hyaluronidase to correct the residual skin laxity.

J Drugs Dermatol. 20(4):475-476. doi:10.36849/JDD.5509


Hyaluronic acid (HA) dermal fillers are widely utilized given their generally safe profile and reversibility. The majority of well-described complications occur in the short-term after injection.1,2 However, delayed periorbital edema, in one case occurring seven years after filler placement,3 has also been described.4 The purpose of this case series is to bring awareness to an exaggerated form of this distressing late complication, which is often misdiagnosed. We highlight its simple correction with liberal hyaluronidase and, additionally, demonstrate that ablative fractional carbon dioxide (CO2) laser resurfacing is an excellent tool that may be subsequently utilized to correct residual laxity.

The authors have treated a series of six patients who presented for management of presumed festoons, but who were found to have periorbital edema as a late complication of HA filler. These patients share a common history of prior treatment with HA filler to the cheeks and/or tear trough region. All had a similar physical exam, with superficial edema of the lid-cheek segment that obscured the nasojugal groove and caused a translucent, white-hued fullness, which we have deemed to have a “pale, puffy pillow” appearance.


This is a retrospective case series reporting the history, clinical appearance, and treatment of six patients presenting to the authors’ private practice with a late complication of injectable filler manifesting in the tear trough region. Medical records and photographs of these patients were reviewed. Data collection proceeded according to the principles of the Declaration of Helsinki and privacy standards of the Health Insurance Portability and Accountability Act (HIPAA).


The six patients included in this series were women, ranging in age from 34 to 75 years. In five cases, filler was last placed at least one year prior, and, in one case, 19 years prior. All had resolution of the aforementioned “pale, puffy pillow” appearance with hyaluronidase treatment. In one case, residual laxity was successfully treated with ablative fractional CO2 laser resurfacing. Patient data are detailed below.


Case 1
A 67-year-old woman presented 19 years after filler placement to the cheeks with concern of festoons. She denied filler of the tear trough region. She was unsure of the filler utilized. She was treated with 7.5 units of hyaluronidase, reconstituted 1:5 with bacteriostatic normal saline for a total volume of 0.3 cc that was injected in multiple small aliquots to the bilateral tear trough regions with resolution.

Case 2
A 75-year-old woman with history of filler in the cheeks several months and years prior, presented with concern of left sided tear trough edema. Previous fillers included Juvéderm Ultra, Ultra plus, and Voluma (Allergan, Irvine, CA), and Restylane (Galderma, Lausanne, Switzerland). She was treated with 20 units of hyaluronidase (diluted to 0.2 cc). Due to deflation, she subsequently desired repeat filler to this area.

Case 3
A 40-year-old woman with a history of filler placement to the tear troughs one year prior presented due to concern of undereye edema. She was unsure of filler type. She had two separate treatments with hyaluronidase, 5 units (diluted to 0.2cc) total to the bilateral tear trough on each date. The day after the second treatment, she returned for filler placement to the tear trough.

Case 4
A 49-year-old woman who had received unknown filler to the tear trough three years prior presented for desired treatment of