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In 2019, I went to a medspa with my heart set on getting undereye filler. Did I need it? In hindsight, probably not. Nevertheless, filler was injected into my tear troughs that day, and not to sound too dramatic, but my face hasn’t looked the same since.
Immediately after the procedure, I was left with small, raised mounds under my eyes that I was told would resolve in several weeks. Almost five years later, they haven’t dissipated entirely: in certain light, you can still see the puffiness. There’s a term for this: malar edema.
The name explains the condition: “malar” refers to the cheek region of the face and “edema” means swelling. “This can happen with patients who’ve had fillers around the cheek area or tear troughs,” says Kami Parsa, MD, a board-certified oculoplastic surgeon in Beverly Hills. It can also be simply hereditary, or the result of allergies or sinus inflammation. In any case, I’m now hyper-aware of the lasting effects overfilling can have on your face, and the particular challenges of injecting filler under the eyes.
When I started investigating my options (more on those in a minute), it became clear the fastest way to deflate the puffiness would be for a dermatologist to dissolve the filler by injecting hyaluronidase, a type of solvent, in the same area. But after doing some more research, I was afraid that doing so would create a hollowness under my eyes and leave me with loose skin. I decided to leave well enough alone.
To arm you with the knowledge to make your own decision, I asked experts to spell out everything you need to know about malar edema, including what can cause it, how you can help prevent it, and what treatment options are available.
Meet the experts:
Kami Parsa, MD, a board-certified oculoplastic surgeon based in Beverly Hills.
Robert Schwarcz, MD, a board-certified oculoplastic surgeon based in New York City.
David Shafer, MD, a board-certified plastic surgeon based in New York City.
In this story
What is malar edema?
“Malar edema is the accumulation of [lymphatic] fluid just above the cheekbones. It is also called festoons or malar bags,” says Robert Schwarcz, MD, a board-certified oculoplastic surgeon in New York City. The malar area is located below the eye socket bone, and malar edema will present as puffy pouches that sit a little closer to the cheek than directly under the eyes.
To really understand what’s going on inside the body and how malar edema presents, Dr. Parsa compares the lymphatic system to the plumbing in your house: “Its purpose around the eye is to remove fluid from the soft tissues, and when it’s blocked, it causes swelling in the places [where the fluid] isn’t flowing,” he explains.
What causes malar edema?
Though our focus here is within the realm of aesthetic procedures, there are other, natural causes of malar edema, including age. “The lymphatics in the malar area are very sensitive and slow down as we get older, which is why it is prone to fluid overload,” says Dr. Parsa, noting that there’s a genetic component, as well. So if your grandparents presented with malar edema, it is more likely that you may develop the condition at some point.
“[Malar edema] can also be seen after any surgical procedure where there is dissection of tissue in the lower eyelid or cheek region such as a face-lift or mid-face-lift, or from facial trauma caused by an accident,” adds Dr. Schwarcz. External factors such as smoking or unprotected sun exposure can also exacerbate the issue, he says.
But as filler has become increasingly commonplace, doctors are seeing more and more cases in which malar edema has been caused by improperly or overabundantly-placed filler in the undereye area, which can interfere with your lymphatic drainage system.
“There’s actually an epidemic of too much undereye filler because patients who are not good candidates are getting it,” says Dr. Parsa. “In reality, only 10-percent of people are true candidates for tear-trough filler.” In a patient who does not have volume loss in the undereye area, hyaluronic acid fillers can cause an inflammatory reaction, migrate, and cause blockage of the lymphatics, which may lead to on and off swelling, explains Dr. Parsa, noting that that swelling can last for up to 10 years.
Whether your undereye filler was needed or not, Dr. Parsa explains that the chances of developing malar edema increase greatly each time you get it injected — and can be compounded by a predisposition to fluid retention or chronic allergies.
The frustrating thing, Dr. Parsa adds, is that the swelling or fluid build up can fluctuate. “One day the swelling may be there, one day it may not.” Sounds familiar.
How do you know if you may be a candidate for undereye filler?
“Lower eyelid or tear trough filler can be a wonderful procedure if done on the right candidate. The problem lies in correctly defining the best candidate,” says Dr. Schwarcz. A “best” candidate has a hollow area in which filler can be placed and does not have large fat pads under the eyes. Contrary to popular belief, you are likely not a good candidate for undereye filler if you have “bags” or a significant amount of extra skin.
Dr. Parsa adds that the ideal candidate also does not have allergies nor frequently wake up with puffy eyes, which can be an indication of a predisposition to swelling.
What are the treatment options for malar edema after filler?
The doctors I spoke with say the treatment for malar edema is very individualized, and based on each patient’s lifestyle and history. “We may remove old hyaluronic acid fillers with dissolving agents, leave old filler in place, or utilize radiofrequency technology to promote lymphatic drainage, de-puffing, and tightening of the skin,” says Dr. Parsa.
In an ideal scenario, simply dissolving existing filler can make a big difference. “If you were injected with a hyaluronic acid-based filler under the eyes, there is an antidote or ‘melting enzyme’ called hyaluronidase which helps the body metabolize the filler much faster,” says David Shafer, MD, a board-certified plastic surgeon in New York City.
In Dr. Parsa’s practice, he utilizes ultrasound technology to pinpoint exactly where the filler is located. “Depending on the severity, it is always best to reduce a little at a time to avoid complete deflation at once. We typically wait two to four weeks between dissolving appointments.”
When dissolving filler under the eyes, Dr. Shafer will sometimes combine hyaluronidase with a steroid in order to help swelling dissipate faster. However, he says that if you were injected with a non-hyaluronic acid based filler like Radiesse, Sculptra, or Belafil then you have fewer options for treatment. So make sure to ask your doctor what type of filler you’re getting (and if it’s dissolvable) before it’s injected.
Radiofrequency microneedling, such as Genius RF or Morpheus 8 can also be utilized to stimulate collagen production around the eyes, which can help tighten the skin. Sometimes, Dr. Parsa will use a fractional CO2 laser as well which “works to simultaneously tighten the superficial and internal layers of the skin, and can help with malar edema.” He notes that this option is only safe for lighter skin types due to the strength of the laser.
If none of these treatment options yield satisfactory results for the patient, they may consider surgery. “There is a small percentage of patients who do not respond to therapy, and at times, surgery is needed to tighten the stretched tissue caused by chronic swelling,” explains Dr. Parsa. Surgery can include either a blepharoplasty — in which excess skin around the eyes is cut away — or an undereye lid lift, and can be combined with fat grafting “for a long lasting and very natural result,” says Dr. Schwarcz.
Of course, there’s also the route I took: I allowed my undereye filler to dissolve naturally. Dr. Shafer says that while it’s difficult for malar edema to resolve on its own, it can happen — if you’re willing to exercise a whole lot of patience. Most undereye fillers take one to three years to dissolve, though some remnants often stick around even longer, confirms Dr. Schwarcz. And every patient is different.
How to help avoid getting malar edema
An ounce of prevention is worth a pound of cure. To avoid having to treat malar edema in the first place, seek out an experienced injector — ideally a board-certified dermatologist or plastic surgeon — and opt for a conservative treatment plan when getting undereye filler. This can require more appointments using smaller doses of filler, but may ultimately save you a whole lot of time and frustration in the long run. In retrospect, I wish I had never walked into a medspa to get a treatment that required such precise skill, and had the potential to alter my appearance for years. [Ed. note: Allure recommends seeing a board-certified dermatologist or plastic surgeon for any procedures that go into or past the skin barrier.]
You and your doctor can also discuss injecting a hyaluronic acid-based filler like Voluma along the cheekbones. This can help improve the appearance of hollows under the eyes — without putting anything directly under the eyes and risking malar edema.
And restoring lost volume using your own fat is another treatment option that can minimize the possibility of malar edema. Fat grafting involves removing fat from one part of your body (through liposuction) and then injecting it somewhere else, in this case under your eyes.
Though the procedure is much more costly (around $4,000 to $9,000 depending on your provider and geographic location) and requires local anesthetic, the main benefit of getting facial fat transfers versus filler is that fat is autologous, meaning it comes from your own body, says Dr. Parsa.
"Fat grafting won’t block the lymphatics because it’s not a foreign substance, and your body won’t form a reaction to it,” explains Dr. Parsa. “Therefore it won’t cause malar edema unless the patient had fillers prior to the procedure which were not fully dissolved."
Read more about aesthetic procedures:
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Originally Appeared on Allure