Post-Hyaluronic Acid Recurrent Eyelid Edema: Pathophysiologic Mechanisms and a Proposed Treatment Protocol

Abstract Background Hyaluronic acid (HA) filler injections for facial augmentation are commonly administered but can lead to post-hyaluronic acid recurrent eyelid edema (PHAREE). The pathophysiology of this condition has not been fully understood. Objectives To report the successful treatment of PHAREE using serial hyaluronidase and fractionated radiofrequency microneedling, with additional carbon dioxide laser skin resurfacing in selected patients. Methods Five patients with PHAREE were treated with serial hyaluronidase injections and fractionated radiofrequency microneedling, with 2 patients receiving carbon dioxide laser treatment. The patients were followed up for a minimum of 24 months. Results All patients reported a resolution of PHAREE signs/symptoms with no adverse effects or recurrence. One patient demonstrated complete resolution after a single treatment; 4 required a series of treatments. Conclusions The proposed treatment protocol may provide advantages over hyaluronidase alone for PHAREE. The impermeable malar septum, vulnerable eyelid lymphatics, and potential immunogenicity of HA fragments likely contribute to PHAREE pathophysiology. Further research on pathophysiologic mechanisms is warranted. Level of Evidence: 4