Surgical Management of Intractable Lower Eyelid Filler Induration: A 15-Year Experience and Layer-by-Layer Approach

Background: Late-onset granulomas in the lower eyelid following non-biodegradable filler injections resist conservative therapies, necessitating surgical excision. Operating in this complex anatomy carries significant risks. Methods: A retrospective review of 282 patients undergoing excision of intractable lower eyelid granulomas (2011–2026) was conducted following a minimum of 6 months of failed medical management. A systematic subciliary approach utilizing sequential layer-by-layer delamination and release of the orbital retaining and tear trough ligaments accessed deep-seated materials. High-risk patients universally received prophylactic canthal support. Results: The cohort (261 females, 21 males; mean age 36.7 years) had diverse filler materials excised. Clinical success—defined objectively as the resolution of preoperative complaints without recurrence requiring surgery—was 100% (mean follow-up 277.4 days). In a high-risk subgroup (age ≥50, prior periorbital surgery), transient ectropion occurred in 61.7% despite 100% receiving prophylactic canthal support. All resolved conservatively within a mean of 62.2 days. Routine microbiological testing was omitted due to unequivocal chronic presentations. Conclusions: Systematic layer-by-layer exploration enables the safe removal of scattered lower eyelid foreign bodies. For infiltrative materials, maximal safe debulking prevents musculocutaneous devascularization. Temporary ectropion, exacerbated by traction-induced neuropraxia, is a common but self-limiting sequela.