Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2024;14(2):e2024117 1 Triamcinolone Injection in the Treatment of Malar Edema Wioletta Barańska-Rybak1, Zuzanna Świerczewska1, Agnieszka Lemiec2, Lee Walker3 1 Department of Dermatology, Venereology and Allergology, Faculty of Medicine, Medical University of Gdańsk, Poland 2 La Estetica Clinic, Płock, Poland 3 B City Clinic, Liverpool, England Key words: malar edema, aesthetic medicine, filler injection, hyaluronic acid Citation: Barańska-Rybak W, Świerczewska Z, Lemiec A, Walker L. Triamcinolone Injection in the Treatment of Malar Edema. Dermatol Pract Concept. 2024;14(2):e2024117. DOI: https://doi.org/10.5826/dpc.1402a117 Accepted: December 7, 2023; Published: April 2024 Copyright: ©2024 Barańska-Rybak et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Wioletta Barańska-Rybak, Department of Dermatology, Venereology and Allergology, Faculty of Medicine, Medical University of Gdańsk, Poland. E-mail: wioletta.baranska-rybak@gumed.edu.pl Introduction: Tear-through deformities can be a detectable sign of facial aging. Over recent years, minimally invasive procedures such as hyaluronic acid filler injections have been shown to be effective in improving this area. Malar edema is the accumulation of fluid over the malar eminence persisting for 1 month or more. Given its nature, the management remains problematic. The most commonly reported treatment modality is injection with hyaluronidase. Objectives: To determine the safety and efficacy of triamcinolone injection in the treatment of malar edema. Methods: A total of 15 female patients with malar edema, with a mean age of 43.77 years, were treated with triamcinolone injections. The volume injected was chosen by the investigator. Prior to the triamcinolone injection, all patients had been treated with hyaluronidase, which turned out to be ineffective in all cases. Patients were asked to note all adverse effects. Results: Satisfactory results were achieved after a single treatment session for 14 patients and after two treatments for one patient. Overall, injections with triamcinolone were well tolerated and no adverse reactions were reported. Conclusions: Injection with triamcinolone appears to be a safe and effective option for the manage- ment of malar edema following hyaluronic acid filler injection. Nevertheless, further research with larger patient groups is compulsory. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2024;14(2):e2024117 Introduction Tear-through deformities can be a detectable sign of facial aging; hence, rejuvenation of this area is essential to restore a more refreshed and youthful appearance. Over recent years, minimally invasive procedures such as hyaluronic acid (HA) filler injections have been shown to be effective in improving this area. Yet with the tear trough being recognized as the most challenging area to treat with HA filler and the spec- trum of complications, such as swelling, bruising, Tyndall ef- fect, or malar edema, it may pose a challenge especially when performed without proper precaution. Malar edema is the accumulation of fluid over the malar eminence persisting for 1 month or more. It has been re- ported with an incidence between 11%-25% of tear trough filler treatments [1,2]. The underlying cause of malar edema after dermal filler injection is most likely due to a band of connective tissue, called a malar septum, which divides the superficial suborbicularis oculi fat into a superficial and deep compartment. Although the lymphatic drainage of the deep compartment is contiguous with the cheek drainage, the su- perficial compartment lymphatic drainage is compromised [3]. This complication is proposed to be multifaced and re- lated to the depth of injection, the volume injected, the pa- tient degree of preprocedural lymphatic obstruction, and the physical qualities of the injectate [4]. Given its nature, the management of malar edema remains problematic. The most commonly reported treatment modality is injection with hy- aluronidase nonetheless, in clinical practice it has not proven to be effective in all cases thus new therapeutic options are emerging [5,6]. Triamcinolone is a corticosteroid widely used in derma- tology for a variety of conditions, including keloids, hyper- trophic scars, alopecia areata, granuloma annulare, or acne [7-10]. Regardless of its common use, the availability of reli- able guidelines is still lacking. Objectives The aim of this study is to report 15 cases with malar edema post tear-trough augmentation successfully treated with tri- amcinolone injection and to determine the safety and efficacy of triamcinolone injection in the treatment of malar edema. Methods A total of 15 female Caucasian patients, with a mean age of 43.77 years (range, 35-56 years), presented to our clin- ics in Poland complaining of malar edema. All 15 patients presented with bilateral edema following tear-trough aug- mentation with hyaluronic acid, with no signs of erythema, soft and not tender to the touch. Duration of the last filler injection varied from 1 month to 1.5 years before experienc- ing the edema. The injections were performed by dermatol- ogists or beauticians in different clinics. Patients injected by a beautician were unaware of the amounts, nor the brand of the injected filler. Various brands of fillers were applied among patients injected by dermatologists. Demographic and clinical data, including comorbidities and previous pro- cedures, have been collected. No patient had any history of previous lower eyelid blepharoplasty, allergies, chronic ma- lar edema of unknown origin, infection, or thyroid disease. None of the patients were injected with permanent fillers before. Prior to treatment, patients were subjected to a brief general examination including an ultrasound examination performed by a trained practitioner. Each examination re- vealed subcutaneous tissue edema with no filler residue, and no granulomas. Each patient was treated by triamcinolone injection per side directly into edema with cannula retrograde under ul- trasound. The volume injected was chosen by the investi- gator (10 mg/1mL, 0.5 mL per each side with a TSK 25G 38 mm cannula). Patients were asked to note all adverse effects. Prior to the triamcinolone injection, all patients had been treated with hyaluronidase, which turned out to be ineffective in all cases. Different kinds and volumes of hyaluronidase were used by the injectors who performed tear trough treatment with HA and the authors have no knowledge regarding the used products nor amounts. Photographs were obtained at the baseline before every treatment session, after one week from the triamcinolone injection for evaluation of treatment response, and after additional 3 months for follow-up. Moreover, the evalu- ation of the subject general health was performed during each visit. Results The treatment response was evaluated by 2 independent practitioners after 1 week of the triamcinolone injection. Satisfactory results in the form of edema reduction were achieved after a single treatment session for fourteen pa- tients and after two treatments for one patient. Overall, in- jections with triamcinolone were well tolerated and no signs of edema could be detected after the product administration. No cases of skin atrophy, hypopigmentation, or necrosis were observed. Any other adverse reactions were also not reported. At the 3-month follow-up, all patients remained asymptomatic and full resolution of edema was maintained. All 15 patients reported high satisfaction with the treatment applied which was evaluated using a questionnaire prepared for the purpose of this study (Figure 1). Original Article | Dermatol Pract Concept. 2024;14(2):e2024117 3 Conclusions Fillers with hyaluronic acid have become one of the most popular nonsurgical facial treatments for the infraorbital area. There is a growing awareness of the vascular risks as- sociated with HA-based filler injections that can result in blindness. Nonetheless, the use of such fillers in the infra- orbital region should generally be considered as safe. The data regarding late complications (2–4 weeks or longer post- injection) of HA fillers is rather sparse, which could be a result of both low incidence and the fact that most complica- tions can be treated relatively easy, the second of which may result in a lack of reporting. Malar edema tends to occur days to weeks after injection however, it has also been re- ported to arise several years post-injection [11]. Although malar edema can be somewhat mitigated, such complication cannot be fully eluded. The underlying cause of malar edema is yet to be fully elucidated, since various theories have been proposed. Due to the rather impenetrable malar septum which divides the su- perficial sub-orbicularis oculi fat into a superficial and deep compartment, the tear trough region is specifically prone to edema. When injected too superficial to the malar septum, dermal fillers may hinder lymphatic drainage and result in malar edema. On the other hand, deeper injections, espe- cially with a high water affinity filler or with too great of a volume, may give rise to direct compression of the lymphatic vessels. What is more, the hypothesis has been given that at particular risk for developing edema are patients burdened with allergies, rosacea, or preexisting malar edema however, it has not been confirmed [11]. In order to reduce the inci- dence of malar edema, adequate filler, and patient selection, limiting filler volume, and placing the product deep into the malar septum are generally advised [12,13]. Since its first introduction in 1961, intralesional injec- tion with corticosteroids has been an important part of dermatological treatment [14]. Intralesional injections are found to be useful for a variety of indications, are sim- ple to administer, and are relatively safe. The aim behind intralesional therapy is to inject medicine directly into a particular skin region in order to treat local tissues while having minimal systemic effects. One of the most widely injected corticosteroids is triamcinolone. Due to its known, anti-angiogenic, anti-inflammatory, anti-proliferative, and Figure 1. The results of the treatment with triamcinolone injections. 4 Original Article | Dermatol Pract Concept. 2024;14(2):e2024117 7. Zhuang Z, Li Y, Wei X. The safety and efficacy of intralesional triamcinolone acetonide for keloids and hypertrophic scars: A  systematic review and meta-analysis. Burns. 2021;47(5): 987-998. DOI: 10.1016/j.burns.2021.02.013. PMID: 33814214. 8. Gallagher T, Taliercio M, Nia JK, Hashim PW, Zeichner JA. Der- matologist Use of Intralesional Triamcinolone in the Treatment of Acne. J Clin Aesthet Dermatol. 2020;13(12):41-43. PMID: 33488919. PMCID: PMC7819588. 9. Garelik J, Babbush K, Ghias M, Cohen SR. Efficacy of high- dose intralesional triamcinolone for hidradenitis suppurativa. Int J Dermatol. 2021;60(2):217-221. DOI: 10.1111/ijd.15124. PMID: 32808305. 10. Song Y, Guo Y. Granulomatous Reaction to Intralesional Kenalog (Triamcinolone) Injection in Acne: A Case Report. Am J Der- matopathol. 2019;41(9):652-654. DOI: 10.1097/DAD.00000 00000001342. PMID: 30601208. 11. Mustak H, Fiaschetti D, Goldberg RA. Filling the periorbital hol- lows with hyaluronic acid gel: Long-term review of outcomes and complications. J Cosmet Dermatol. 2018;17(4):611-616. DOI: 10.1111/jocd.12452. PMID: 29130598. 12. Funt DK. Avoiding malar edema during midface/cheek augmen- tation with dermal fillers. J Clin Aesthet Dermatol. 2011;4(12): 32-36. PMID: 22191006. PMCID: PMC3244361. 13. Singh K, Nooreyezdan S. Nonvascular Complications of Inject- able Fillers-Prevention and Management. Indian J Plast Surg. 2020;53(3):335-343. DOI: 10.1055/s-0040-1721872. PMID: 33500603. PMCID: PMC7822713. 14. HOLLANDER A. Intralesional injections of triamcinolone acetonide; a therapy for dermatoses. Antibiotic Med Clin Ther (New York). 1961;8:78-83. PMID: 13715299. 15. Nauck M, Karakiulakis G, Perruchoud AP, Papakonstantinou E, Roth M. Corticosteroids inhibit the expression of the vascu- lar endothelial growth factor gene in human vascular smooth muscle cells. Eur J Pharmacol. 1998;341(2-3):309-315. DOI: 10.1016/s0014-2999(97)01464-7. PMID: 9543253. 16. Penfold PL, Wen L, Madigan MC, Gillies MC, King NJ, Provis JM. Triamcinolone acetonide modulates permeability and intercellu- lar adhesion molecule-1 (ICAM-1) expression of the ECV304 cell line: implications for macular degeneration. Clin Exp Im- munol. 2000;121(3):458-465. DOI: 10.1046/j.1365-2249.2000 .01316.x. PMID: 10971511. PMCID: PMC1905725. 17. Sosnowski J, Stetter-Neel C, Cole D, Durham JP, Mawhinney MG. Protein kinase C mediated anti-proliferative glucocorticoid- sphinganine synergism in cultured Pollard III prostate tumor cells. J Urol. 1997;158(1):269-274. DOI: 10.1097/00005392 -199707000-00084. PMID: 9186373. 18. Friedman SJ, Butler DF, Pittelkow MR. Perilesional linear at- rophy and hypopigmentation after intralesional corticosteroid therapy. Report of two cases and review of the literature. J Am Acad Dermatol. 1988;19(3):537-541. DOI: 10.1016/s0190 -9622(88)70209-1. PMID: 3049699. 19. Siperstein R, Montes JR, Speranza A. A Retrospective Review of the Safety and Efficacy of Low-dose Triamcinolone Mixed with Hyaluronic Acid Fillers to Reduce Post-injection Infraorbital Swelling. J Clin Aesthet Dermatol. 2022;15(4):13-19. PMID: 35465031. PMCID: PMC9017664. 20. Siperstein R. Infraorbital Hyaluronic Acid Filler: Common Aesthetic Side Effects With Treatment and Prevention Options. Aesthet Surg J Open Forum. 2022;4:ojac001. DOI: 10.1093/asjof /ojac001. PMID: 35386936. PMCID: PMC8982019. especially anti-edematous effects, triamcinolone has great potential in the treatment of malar edema [15-17]. Although the administration of triamcinolone has multiple benefits, it is not without ramifications. Among the most common side effects atrophy, telangiectasia, and hypopigmentation can be distinguished, thus it is of high importance to be aware of the occurrence of such events [18]. It is of high importance to use a proper dilution and a minimal amount to achieve satisfactory results. A study by Siperstein et al discussed the use of triamcin- olone in the infraorbital region in aesthetic medicine when 1 mg of triamcinolone was mixed with a 1-cc syringe of hy- aluronic acid filler for the prevention of the post-injection swelling, not in the treatment of malar edema [19] Further- more, in 2022, Siperstein proposed triamcinolone for the treatment of mild-long term or delayed onset swelling in a dose of 0.1 mL of 2.5 mg/mL triamcinolone with a cannula in each area [20]. Nonetheless, the author suggests triamcin- olone being effective only for 2-6 weeks before the edema returns. In our analysis, the patients did not improve after the previous treatment with hyaluronidase nonetheless, all responded to the triamcinolone alone which proved to be effective for the period of 12 weeks at the follow-up. According to our observations, injection with triam- cinolone is a safe and effective option for the management of malar edema following hyaluronic acid filler injection. Nonetheless, further research with larger patient groups is needed to validate our results and to establish the most effec- tive and safe concentration of triamcinolone injection. References 1. Murthy R, Roos JCP, Goldberg RA. Periocular hyaluronic acid fillers: applications, implications, complications. Curr Opin Ophthalmol. 2019;30(5):395-400. DOI: 10.1097/ICU.0000000 000000595. PMID: 31261189. 2. Griepentrog GJ, Lucarelli MJ, Burkat CN, Lemke BN, Rose JG. Periorbital edema following hyaluronic acid gel injection: a ret- rospective review. Am J Cosmetic Surg. 2011;28(4):251–254. 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