Table 4.

Treatment for Delayed-Onset or Long-Term (>4 weeks) Swelling

Swelling treatment
Massage with cortisone cream
Application of silicate compression cream
Antihistamines or diuretics
Triamcinolone and/or hyaluronidase Mild long term or delayed onset Inject 0.1 mL of 2.5 mg/mLa triamcinoloneb with a cannula in each area. Moderate long term or delayed onset Inject 0.1-0.2 mL of 2.5 mg/mL triamcinolone with a few units of micro-dose hyaluronidase.c Severe long term or delayed onset Inject 0.2-0.4 mL of 2.5 mg/mL triamcinolone with 15 units of low-dose hyaluronidased in each location depending on the breadth of swelling. No resolution with triamcinolone or low-dose hyaluronidase Dilute the hyaluronidase by half (75 units/mL) and slowly increase the dosee with of each treatment from 15 to 75 units until full resolution.
Cheek filler Inject with a cannula under the ZCL to volumize and then with a needle in a vertical retrograde technique along the lateral ZCL to camouflage swelling above the ZCL. NEVER inject medial to the lateral limbus deep with a needle.
Laser resurfacing Tightens the skin, preventing the accumulation of fluid.
Complete reversal with hyaluronidase If either no change occurs or swelling improves but then relapses quickly without overall improvement with the above options, inject 150 units per 1 cc of under-eye filler to completely dissolve and return to baseline. Warn the patient that it may look worse than baseline for 1-2 weeks until the native HA rebuilds, and the skin re-adjusts to the new volume (recommend silicate compression cream while waiting).

^aAbout 2.5 mg/mL of triamcinolone can be obtained by mixing 0.1 mL of triamcinolone 50 mg/5 mL with 0.3 mL of bacteriostatic saline or a combination of 0.2 mL saline and 0.1 mL of lidocaine with epinephrine^f;

^bDO NOT REPEAT triamcinolone injections more than once within a month or more than twice within 6 months;

^cMicro-dose hyaluronidase with 2.5 mg/mL of triamcinolone can be obtained by mixing 0.05 mL of hyaluronidase with 0.1 mL of triamcinolone (50 mg/5 mL) and 0.25 mL of saline (or 0.15 mL of saline and 0.1 mL of lidocaine with epinephrine)^f;

^dLow-dose hyaluronidase with 2.5 mg/mL of triamcinolone can be obtained by mixing 0.1 cc triamcinolone 50 mg/5 mL, 0.1 mL of hyaluronidase 150 u/mL (15U) with 0.2 mL of saline (or 0.1 mL of saline and 0.1 mL of lidocaine with epinephrine)^f;

^eIf using more than 0.1 mL of hyaluronidase, an intradermal test for allergy is recommended by placing 0.1 mL in the dermis to create a bleb and waiting 30 minutes to check for a reaction;

^fIf using lidocaine with epinephrine, warn the patient that the area will turn white in color for a few hours and will feel numb. The change in color outlining the treated area assures the injector of proper placement, and the immediate improvement assures the patient that it is swelling and not filler causing the volume change. The temporary improvement from the epinephrine constricting the vasculature may wane after a few hours. Topical vasoconstrictors such as Mirvaso/Rhofade can also be used for this purpose but are more expensive and less efficacious than the silicate creams. ZCL, zygomatico-cutaneous ligament.