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.