Malar Edema after Hyaluronic Acid Dermal Fillers: Expert Recommendations on Etiology, Prevention, and Management

Malar edema is a relatively common complication following injection of hyaluronic acid (HA) filler into the infraorbital area. The Complication Assessment and Risk Evaluation (CARE) board, established to develop guidelines on prevention and management of adverse reactions after HA filler use, identified malar edema as a priority complication. This review presents the CARE board recommendations on etiology of malar edema, prevention, and management. Malar edema is a result of HA injection interacting adversely with a delicate lymphatic system situated between the orbicularis retaining ligament and zygomaticocutaneous ligament, which has limited drainage and is, therefore, prone to excess fluid accumulation. Risk factors for malar edema include patient-related characteristics, such as older age, previous periorbital surgery, allergies, infection, and certain systemic diseases. Risk factors relating to injection technique include high volume of filler or incorrect placement (e.g. superficial to the malar septum). Fillers should be nonpermanent, with low hydrophilicity and elastic modulus (G′), and should be approved for use in the infraorbital area. Prior to injection, a thorough medical history should be conducted to evaluate patient suitability for treatment. The CARE board has developed a questionnaire to aid patient selection. This should be accompanied by physical examination to assess for existing edema and other abnormalities such as skin laxity. Patients should be fully educated in posttreatment care to avoid development of edema in the weeks following injection. When malar edema develops, management should be tailored to the individual patient and situation. The CARE board provides an algorithm to support the management of malar edema, including clinical assessment, noninvasive treatments, and medication. Hyaluronic acid (HA) filler injections are used to smooth fine lines and restore volume, helping to keep skin looking youthful. Swelling under the eyes and cheeks, known as “malar edema,” is a common side effect of HA filler injections in the under-eye area. The Complication Assessment and Risk Evaluation (CARE) board is a panel of experts tasked with developing guidelines on how to prevent and manage complications associated with HA filler injections. This paper describes the CARE board’s recommendations for malar edema. Malar edema occurs when HA filler interacts with the fragile lymphatic system in the midface, making the area prone to swelling. Risk factors for developing malar edema include older age, previous surgery in the eye area, allergies, and infections, as well as injection technique-related issues, such as using too much filler or injecting it into the wrong layer of tissue. To reduce the risk of malar edema after HA filler injection, only nonpermanent fillers that are approved for under-eye use should be chosen. Prior to injection, doctors should take a full medical history and perform a physical exam to check for swelling or skin laxity. The CARE board has developed a questionnaire that doctors can use to assess patients’ risk. Patients should also be informed about aftercare to minimize the risk of swelling. As treatment for malar edema depends on the individual patient, the CARE board has developed a step-by-step guide to help doctors choose the right management process.