Expert Panel Issues Guidelines for Cheek Swelling After Hyaluronic Acid Fillers

Malar edema, the persistent swelling that appears under the eyes and across the cheeks after hyaluronic acid filler injections, affects an estimated 11 to 24 percent of patients receiving tear trough filler treatments. A multidisciplinary expert panel known as the Complication Assessment and Risk Evaluation, or CARE, board has now published a detailed set of recommendations in Dermatology and Therapy explaining why this complication occurs, how it can be prevented, and how it should be managed when it develops. The panel identified malar edema as a priority complication precisely because guidance on it has been lacking, despite the enormous popularity of hyaluronic acid fillers, which accounted for 77 percent of soft tissue filler use in the United States in 2020.

The anatomical explanation at the heart of the review is the delicate and poorly drained lymphatic system of the midface. Malar edema arises when injected filler interacts adversely with lymphatic vessels situated between two fibrous structures: the orbicularis retaining ligament above and the zygomaticocutaneous ligament below. This confined compartment has limited drainage and is therefore prone to excess fluid accumulation once filler is placed in or near it. The superficial lymphatic system travels above the orbicularis oculi muscle and drains laterally into preauricular lymph nodes, while medially it parallels the facial vein toward the mandibular and submandibular nodes. The deep system originates at the conjunctiva, passes through the tarsal plate, and runs beneath the muscle before entering the prezygomatic space. Critically, lymphatic vessels in this region have few or no valves, a feature that predisposes them to obstruction and prolongs swelling once it begins.

A further anatomical structure, the malar septum, is thought to divide the fat compartment into superficial and deep portions and may function as a relatively impermeable barrier, contributing to the restricted drainage. The review notes candidly that although this concept, first described by Pessa and Garza, has been widely cited in aesthetic and surgical literature, independent anatomical confirmation remains limited. The authors also distinguish malar edema from the broader descriptive term infraorbital edema, referring to any swelling beneath the orbit; the two entities are anatomically distinct but can overlap clinically after filler treatment because both involve impaired lymphatic drainage in the lower eyelid and midface region.

The timing and course of malar edema vary widely. It can appear within days of filler administration or emerge months or even years after injection, and once established it can be long-lived. When it becomes chronic, it may evolve into other presentations, including malar mounds and malar festoons. Malar mounds are permanent soft tissue bulges containing fat or orbicularis muscle, caused by chronic swelling in the infraorbital fat compartments. Malar festoons are cascading hammocks of skin and muscle below the infraorbital rim, typically seen in older adults. This diversity of clinical manifestations, the panel argues, underscores the need for a tailored management strategy rather than a one-size-fits-all approach.

The triggers for malar edema fall into three broad categories: patient-related, filler-related, and procedure-related factors. On the patient side, a prior history of malar edema is a strong indicator of recurrence risk, and the problem may become more noticeable in people who already have inconspicuous swelling. Allergies, rosacea, a tendency toward fluid retention noticeable shortly after waking, and sleep apnea are also associated with higher risk. Systemic conditions including hypothyroidism, cardiac, renal, or hepatic disease can produce whole-body edema that includes the infraorbital area, and autoimmune and inflammatory conditions may do the same. Viral infections can exacerbate or trigger malar edema, possibly through immunological interaction between the pathogen and the filler. Dental or maxillofacial procedures can induce inflammation in adjacent tissues, recent botulinum toxin treatment to lateral canthal lines may result in edema, and a history of blepharoplasty has also been linked to the complication.

Age emerges as a particularly important risk factor. Festoons and malar mounds appear with older age as tissues descend over the malar eminence, and skin laxity of the lower eyelid together with triangular-shaped malar mounds are significantly more common in patients aged 50 and above. Age-related weakening of facial structures can disturb lymphatic drainage even before any filler is placed. Regarding the product itself, fillers with a high elastic modulus, or G prime, are inappropriate for areas with high muscle movement or a tendency to edema. The molecular weight profile of hyaluronic acid may also matter: high-molecular-weight hyaluronic acid is generally considered antiinflammatory, whereas lower-molecular-weight fragments may promote inflammatory signaling, although the panel emphasizes that a direct association between molecular weight and malar edema has not been established.

Procedure-related factors offer some of the clearest opportunities for prevention. Injecting high volumes of filler in one location has been shown to increase the risk of malar edema, and overcorrection can displace filler into superficial fat compartments. Improper placement is another culprit: filler entering the fibrous layer when a needle or cannula tip goes too deep, or material deposited superficial to the malar septum, can impede lymphatic drainage and cause fluid accumulation. Notably, a meta-analysis of clinical trials evaluating infraorbital hyaluronic acid filler safety found that cannula administration was associated with a statistically significantly greater incidence of edema compared with needle administration. Where a cannula is used, the CARE board recommends a lateral or inferior entry point and staying deep to the orbicularis oculi muscle. Based on extensive clinical experience, the panel also suggests that multiple small deposits in aliquots may lower edema risk compared with a linear threading technique.

Prevention, the panel concludes, rests on appropriate patient and product selection, proper aseptic technique, and diligent posttreatment care, though it cautions that malar edema can still develop despite careful screening. Before any periorbital injection, a thorough medical history should assess preexisting malar edema, illnesses that could cause periorbital swelling, hypersensitivity to hyaluronic acid, fluid retention, and previous permanent or nonpermanent fillers, with ultrasound used where appropriate to supplement the assessment. The board has developed a preinjection patient questionnaire to support this process. Rapid changes in the infraorbital area over weeks or months, rather than gradual changes over years, may signal an underlying medical issue, and one-sided changes, although extremely rare, may indicate serious conditions including primary cutaneous B-cell lymphoma or peripheral T-cell lymphoma. A physical examination should assess existing edema and skin laxity, using pinch and squeeze tests, and current medications should be reviewed, since steroids, acetaminophen, and nonsteroidal antiinflammatory drugs are common examples of drugs that may contribute to malar edema.

Product and technique recommendations are equally specific. Only nonpermanent, licensed soft hyaluronic acid fillers with low hydrophilicity and an approved indication for the infraorbital area should be used; permanent or nondissolvable fillers are not recommended because of their increased side-effect risk. Most filler should be placed deep, below the muscle, at a supraperiosteal level, injected just above the zygomaticocutaneous ligament and below the orbital retaining ligament, with minimal product in the infraorbital hollow. Because injection volume is directly related to the risk of short-term swelling, the board advises small volumes, ideally 0.5 cubic centimeters or less in total. Injectors should avoid placing a needle or cannula in the infraorbital area even when treating other indications such as the cheek, keep the number of injections and entry sites to a minimum, and maintain strict aseptic technique, including regular needle changes and a clean, makeup-free face. After treatment, patients should avoid dental work for at least two weeks, refrain from touching or massaging the area, avoid makeup and tap water exposure, and stay away from sun exposure, saunas, steam rooms, swimming pools, alcohol, and strenuous activity initially, with hats and helmets avoided for a week.

When malar edema does develop, the board’s management algorithm begins with clinical assessment and watchful waiting for two to three weeks, followed by noninvasive first-line treatments such as head elevation, massage, and lymphatic drainage. If there is no improvement, hyaluronidase, given in up to three sessions two weeks apart, and oral corticosteroids for five days may follow. For non-responders, intralesional triamcinolone can be injected, with a maximum of two sessions three weeks apart, a recommendation supported by published clinical data on triamcinolone efficacy for malar edema together with the board’s clinical experience. A retrospective study suggesting that intralesional 10 mg/mL doxycycline hyclate may help treat malar edema and festoons is noted, but the panel stresses that further prospective studies with larger samples and longer follow-up are needed. Two case studies illustrate the approach in practice: in one, two patients with swelling two years after tear trough filler received hyaluronidase three times, ultrasound confirmed no residual filler, and a single triamcinolone injection resolved the swelling with no recurrence over three months of follow-up. In a second case, swelling that appeared after abdominal surgery six months post-injection resolved completely with 15 units of hyaluronidase. The panel emphasizes that its algorithm is a guideline rather than a rule, that cases must be evaluated individually, and that persistent cases should be referred to a local expert.

Subject of Research: Expert recommendations on the etiology, prevention, and management of malar edema after hyaluronic acid dermal filler injection

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

Article References: Baranska‑Rybak, W., Lajo‑Plaza, J. V., Walker, L., & Alizadeh, N. (2026). Malar Edema after Hyaluronic Acid Dermal Fillers: Expert Recommendations on Etiology, Prevention, and Management. Dermatology and Therapy, 16(11), 5429-5443. https://doi.org/10.1007/s13555-026-01920-w

Image Credits: AI Generated

DOI: 10.1007/s13555-026-01920-w

Keywords: malar edema, hyaluronic acid filler, dermal fillers, lymphatic drainage, infraorbital region, complication management, patient selection, injection technique, hyaluronidase, triamcinolone, malar festoons, aesthetic medicine