Dr. Lindsey's Newsletter #22: Post-Hyaluronic Acid Recurrent Eyelid Edema

This week I am doing something a little different from my usual newsletters. In this “Journal Club Edition” I am going to review a recently published article that is relevant to a growing number of people. In residency we used to have monthly journal club meetings where we would read papers on an assigned topic and then come together with leaders in the field to discuss the articles over dinner. The goal of journal club is to critically evaluate an article and when appropriate adopt the principles of the article into your own practice in order to improve your own patient outcomes. In the world of medicine, training ends but learning never does. 

Plastic surgery dates back to 600 BC (I’m not kidding - google “Shushruta rhinoplasty”) and since then the fundamentals of surgery have been established with ample time for refinement. Now contrast this long history of humans developing, studying, and refining surgical principles with the new practice of cosmetic fillers. The first injectable cosmetic filler was approved by the FDA in the 1980s. Cosmetic injectables are a new frontier. What does this mean for patients? It means that we are all still learning about longterm outcomes after use of cosmetic filler. 

There are additional complicating factors that make the cosmetic filler industry inconsistent in outcomes. Any procedure delivered by a person will be dependent on the proficiency of the person performing the procedure. In the current aesthetic market cosmetic filler is injected not only be expertly trained plastic surgeons but also by facial surgeons, dermatologists, nonsurgical general doctors (family medicine doctors), dentists, and physician extenders (ie, nurse injectors, nurse practitioners, and physician associates). Not to mention aestheticians, albeit illegally, are also known to run injection businesses. 

I invite you to learn with me as I read, analyze, and review a journal article about lower eyelid edema caused by Hyaluronic Acid filler injections. If you have ever consulted with me for injectables you have probably heard my speech about lower eyelid lymphatics, possible outcomes of poorly placed filler, and know that I have a very conservative approach to treating the lower eyelid. The article I am reviewing today is written about the outcome that I work so hard to avoid. Please join me in learning about a proposed algorithm for treatment of Post-Hyaluronic Acid Recurrent Eyelid Edema, or PHAREE. 

In brief, the article we are going to discuss today is about lower eyelid edema after injection of the area with cosmetic hyaluronic acid (HA) filler. Here is a picture from the paper showing an example of significant lower eyelid edema:

Let’s dive in! 

The paper was published on December 3rd of 2023 in the Aesthetic Surgery Journal Open Forum and is titled, “Post-Hyaluronic Acid Recurrent Eyelid Edema: Pathophysiologic Mechanisms and a Proposed Treatment Protocol”. This is a well known, reputable journal in the field of plastic surgery. 

Authors: Dr. Karlin is Assistant Professor of Ophthalmology at the Stein and Doheny Eye Institutes, University of California, Los Angeles; Dr. Vranis is a plastic surgeon in private practice, Dr. Dayan is a plastic surgeon in private practice, Dr. Parsa is an oculoplastic surgeon in private practice.

Pertinent Disclosures: Dr. Parsa is a consultant for Inmode Inc. (Irvine, CA) - this is a company that produces some of the most widely known and used RF devices in the US.

The Lymphatic Design 

The authors discuss the anatomy of the lower eyelid that makes it susceptible to swelling/edema. They attribute the development of posthyaluronic acid recurrent eyelid edema (PHAREE) to 2 features:

1.Few and delicate skin lymphatics exist in the lower lid region

2.Lymphatic drainage in the lower lid/cheek region has a watershed region (where drainage is poor)

This description of lymphatic drainage is the scientific theory behind something that you probably already knew about - whether you realized it or not. You have probably noticed that your lower eyelids are one of the most sensitive areas of your body and that they are quick to show evidence of seasonal allergies, dehydration, high salt intake, or too much alcohol. No matter the cause, we all know that lower eyelids are sensitive and hold onto fluid easily. 

How HA Filler May Cause Lower Eyelid Edema 

The authors rely on what the scientific community knows about lymphedema in other parts of the body (where it is better studied and understood). They speculated that

“a repeated injection of HA fillers to the lower eyelid or midface will cause tissue compression, mechanical lymphatic obstruction, lymph stasis, and localized lymphedema in the delicate superficial lymphatics.”

Click the link below to subscribe to my newsletter and continue reading this edition. You will learn about the treatment of this pathology and also how many patients benefited from the treatment and their results. 

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