Periorbital Edema following Hyaluronic Acid Gel Injection: A Retrospective Review

Abstract

Introduction: The purpose of this study is to investigate the incidence, clinical features, and treatment of prolonged periorbital edema following the injection of hyaluronic acid gel to the infraorbital hollows. Materials and Methods: Retrospective descriptive study. The medical records of patients from 4 physician practices with prolonged (≥1 month) periorbital edema following the placement of hyaluronic acid gel to the infraorbital hollows, diagnosed between January 1, 2008 and December 31, 2011, were reviewed. Results: A total of 51 charts were reviewed, of which 12 (24%) patients were diagnosed with prolonged periorbital edema with a mean follow-up time of 7.1 ± 4.2 months (range, 1.5–15.3 months). The mean patient age was 50.4 years (range, 36.4–64.9 years), and the edema lasted an average of 5.4 months (range, 2.7–5.3 months). A minority of patients had a preprocedural history of fluid retention (17%), seasonal allergies (25%), previous lower eyelid or midface surgery (25%), or festoons on examination (0%). Hyaluronidase was used to treat 3 of the 12 affected patients. Conclusions: In this retrospective review of patients undergoing hyaluronic acid gel injection to the periorbital region, prolonged periorbital edema of varying severity occurred in approximately 1 in 4 patients. There were no clinical symptoms or signs prior to injection that consistently identified patients susceptible to the edema. Most patients treated with hyaluronidase had successful improvement of their swelling.

Dermal fillers: pathophysiology, prevention and treatment of complications

“…1). 8,9 This reaction arises as a consequence of direct pressure of fillers on the lymphatics and the patient's preexisting compromised lymphatic drainage in the sub-orbicularis oculi fat. Malar oedema can last from days to months, or be permanent and is often refractory to treatment.…”

“…Initial management strategies should include head elevation, cold compresses, manual lymphatic compression and intralesional injection of hyaluronidase for HA fillers. 8 Although hyaluronidase is often used in practice when adverse reactions are encountered, a recent review by Rzany et al showed that hyaluronidase was effective in two clinical trials in decreasing injected depots of HA, but there was little evidence to suggest its usefulness in adverse reactions to HA-based fillers. 10 Skin testing is recommended in the use of non-recombinant animal-sourced hyaluronidase to avoid hypersensitivity reactions.…”

Anatomical Position of Hyaluronic Acid Gel Following Injection to the Infraorbital Hollows

“…Prolonged lower eyelid and malar edema is a recognized complication occurring in 6% to 25% of patients following injection of HA gel to the infraorbital hollows. 1,2,18 To date, there are no clinical symptoms or signs prior to injection that consistently identify patients susceptible to edema. 18 It is likely that underlying anatomical and physiologic tendencies, along with injection material and technique, determine an individual's chances of developing prolonged edema.…”

“…1,2,18 To date, there are no clinical symptoms or signs prior to injection that consistently identify patients susceptible to edema. 18 It is likely that underlying anatomical and physiologic tendencies, along with injection material and technique, determine an individual's chances of developing prolonged edema. While there are no direct means in the current study to evaluate baseline anatomical contributions to the development of periorbital edema, one may hypothesize that filler may pass superficially through involutional areas of contiguity between the deep and superficial fat pads 12 or through gaps in the orbicularis oculi muscle.…”

“…16 Relative advantages of HA gels compared with other means of volume enhancement such as autogenous fat grafting include their temporary nature, reversibility with hyaluronidase, ease of administration with a lack of need for special instrumentation or harvesting, and short patient downtime. 18 Individual HA gels differ sufficiently in their physical and chemical properties to influence their clinical performance. 19 Properties relevant to the performance of HA gels include the degree of cross-linking, cohesivity (the tendency of a gel to stick together and hold its form or shape under stress), gel hardness (G′), gel consistency, viscosity, extrusion force, HA concentration, and extent of hydration.…”