Delayed Hydration Swelling Policy - Dermal Filler

1. Purpose

Provide an evidence‑based framework to recognise, prevent, and manage delayed post‑filler swelling (especially periorbital/malar) while meeting Australian governance requirements. ¹ ² ³ ⁴

2. Scope

Applies to all NCD clinicians. Covers swelling arising >24 h to weeks after hyaluronic acid (HA) filler placement, excluding frank infection, abscess, or granulomatous disease (managed under separate SOPs).

3. Definitions

Delayed Hydration Swelling (DHS): non‑infective puffiness/pitting oedema after HA filler, often periorbital/malar, fluctuating with heat/salt/hormonal cycles; driven by water uptake and veno‑lymphatic stasis. ⁵ ⁶ ⁷
Late‑Onset Reaction (LOR): delayed inflammatory response (days—months) occasionally after triggers (URI, vaccination, dental procedures); may need steroids ± hyaluronidase. ¹¹
PHAREE: post‑HA recurrent eyelid oedema—recurrent eyelid swelling after periorbital/midface HA. ⁸

4. Pathophysiology

HA gel physics: hydrophilicity and cohesivity determine water uptake and spread; crosslinking level (and manufacturing) modulates swelling—risk is product‑line‑specific (not simply "high G′ = more swelling"). ⁵ ⁶
Veno‑lymphatic mechanics: volume/plane can compress lymphatics or reinforce barriers (e.g., malar septum), promoting stasis and oedema. ⁷
Inflammatory triggers: URIs, dental infection, vaccines may unmask LOR‑type swelling weeks to months later. ¹¹

5. Risk Stratification

Patient: periorbital laxity, festoons/malar mounds, lymphatic insufficiency, atopy/autoimmune disease.
Region: tear trough, medial malar; any plane superficial to the malar septum. ⁷
Product: high hydration capacity / low cohesivity → more water uptake and spread; choose line‑specific lower‑hydration gels for high‑risk zones. ⁵ ⁶
Technique: large static boluses; superficial continuous threads in TT; lack of ultrasound mapping in high‑risk zones.

6. Clinical Identification & Differentials

Typical DHS: soft, often painless puffiness; fluctuates; minimal warmth/erythema; normal vitals. Differentiate from infection (erythema, warmth, systemic symptoms) and granuloma/biofilm (induration, nodules). High‑frequency ultrasound (HFUS) distinguishes anechoic HA from nodules and guides management. ¹² ¹³

Red flags → escalate: spreading erythema, fever, fluctuance, severe pain, visual symptoms (activate ocular emergency pathway). ¹

7. Management Algorithm

A) First visit (non‑toxic, likely DHS/LOR):

Exclude infection by history/exam; photograph, map, and consider ultrasound.
Pharmacologic: non‑sedating antihistamine (e.g., cetirizine 10 mg daily × 5—7 d). If persistent and clearly non‑infective, short oral corticosteroid taper (e.g., prednisone 10—20 mg/d × 3—5 d).
Adjuncts: elevate head, cool packs, avoid heat/saunas, moderate salt.

B) If persistent/recurrent or US shows focal HA:

Ultrasound‑guided hyaluronidase micro‑dissolution (≈5—30 IU per point), reassess 48—72 h; repeat if needed. Warn about partial loss of correction. ⁹ ¹⁰

C) Refractory / atypical:

Re‑image; consider swab/biopsy if induration/nodularity; manage as delayed inflammatory nodule or biofilm per SOP (consider antibiotics). ¹¹

D) Any visual symptom at any stage → ocular emergency (stop, call 000, urgent ophthalmology transfer; do not delay). ¹

8. Prevention

Choose products by hydrophilicity/cohesivity profile; for TT/malar, prefer lower‑hydration lines (don’t assume G′ predicts swelling). ⁵ ⁶
Planes & volumes: deep, conservative anchoring in midface; avoid superficial continuous threads in TT; stage treatments. ⁷
Ultrasound mapping for periorbital/malar cases; document screenshots. ¹² ¹³
Follow‑up at 2—4 weeks to assess integration and modulate early.

9. Documentation & Governance (Australia, 2025)

Record: dose, product/line, lot/expiry, ARTG ID (if applicable), sites/planes, ultrasound images, adverse events and management.
Ahpra: comply with non‑surgical cosmetic procedure guidelines (practice & advertising). ¹
TGA: no public advertising of S4 injectables; follow cosmetic‑injection advertising FAQs/guidance. ²
RACGP/ACSQHC: apply IPC and NSQHS standards to workflow, medication safety, and clinical governance. ³ ⁴
Device adverse events: report via TGA (IRIS/MDIR) where reportable. ¹⁴

10. Quick Reference

Situation	First‑line	If persistent (non‑infective)	Escalate
Soft malar/TT swelling, afebrile	Cetirizine 10 mg daily 5–7 d; cool packs; elevate	Short oral steroid 3–5 d	US‑guided hyaluronidase 5–30 IU/site; reassess 48–72 h ⁹ ¹⁰
Focal bulge on US = HA deposit	—	—	Targeted micro‑dissolution; staged; warn partial reversal ⁹
Indurated nodule / systemic signs	—	—	Treat as LOR/biofilm per SOP; swab/biopsy/antibiotics ¹¹
Any visual symptom	Stop; call 000	—	RANZCO ocular emergency pathway (urgent ophthalmology) ¹

Sources

Ahpra (2025). Performing non‑surgical cosmetic procedures — Guidelines hub., viewed 05 November 2025, https://www.ahpra.gov.au/Resources/Cosmetic-surgery-hub/Cosmetic-procedure-guidelines.aspx ↩
TGA (2025). Advertising health services & cosmetic injections — FAQs (HTML)., viewed 05 November 2025, https://www.tga.gov.au/products/regulations-all-products/advertising/specialised-advertising-issues-and-topics/advertising-health-services-and-cosmetic-injections-frequently-asked-questions-and-answers ↩
RACGP (2024). Infection prevention & control guidelines (primary care)., viewed 05 November 2025, https://www.racgp.org.au/running-a-practice/practice-standards/racgp-infection-prevention-and-control-guidelines ↩
ACSQHC (2021, upd. 2024). NSQHS Standards (2nd ed.) — PDF., viewed 05 November 2025, https://www.safetyandquality.gov.au/sites/default/files/2021-05/national_safety_and_quality_health_service_nsqhs_standards_second_edition_-_updated_may_2021.pdf ↩
Enright KM et al. (2024). Hydrophilic, cohesive, and physical properties of HA fillers. Plast Reconstr Surg Glob Open. (Open access), viewed 05 November 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC10790663/ ↩
Guo J. et al. (2023). Injectable fillers: physicochemical properties & cohesivity. Aesthet Surg J Open Forum. (Open access), viewed 05 November 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC10413051/ ↩
Schelke L. et al. (2023). Malar oedema after periocular filler—veno‑lymphatic compression (duplex US). J Cosmet Dermatol., viewed 05 November 2025, https://onlinelibrary.wiley.com/doi/pdf/10.1111/jocd.16012 ↩
Karlin J. et al. (2023). Post‑Hyaluronic Acid Recurrent Eyelid Edema (PHAREE). ASJ Open Forum. (Open access), viewed 05 November 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC11140515/ ↩
Hilton S. et al. (2014). Hyaluronidase for eyelid oedema — retrospective series (low IU effective). Eur J Med Res. (Open access), viewed 05 November 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC4063423/ ↩
Kroumpouzos G. (2024). Hyaluronidase for dermal filler complications: dosage & indications. JMIR Dermatology. (Open access), viewed 05 November 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC10836581/ ↩
Artzi O. et al. (2020). Delayed inflammatory reactions to HA fillers—algorithm. Clin Cosmet Investig Dermatol. (Open access), viewed 05 November 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC7244356/ ↩
Jung JY. et al. (2024). Recommendations on ultrasound‑guided HA injections. J Cosmet Dermatol. (Open access), viewed 05 November 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC11684153/ ↩
Vasconcelos‑Berg R. et al. (2024). HFUS guidance — middle third, nose & tear troughs. Diagnostics (MDPI)., viewed 05 November 2025, https://www.mdpi.com/2075-4418/14/22/2544 ↩
TGA (2025). Reporting of medical device adverse events by healthcare facilities / MDIR/IRIS guidance., viewed 05 November 2025, https://www.tga.gov.au/safety-and-shortages/adverse-events/medical-device-adverse-events/obligations-report-adverse-event-medical-devices ↩
Hong GW. et al. (2024). Review of adverse effects associated with dermal fillers. Medicina (Kaunas). (Open access), viewed 05 November 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC11311355/ ↩
Eshraghi B. et al. (2024). Late‑onset periorbital oedema after HA fillers. JPRAS (abstract)., viewed 05 November 2025, https://www.jprasurg.com/article/S1748-6815(24)00615-6/abstract ↩

Disclaimer for Newcastle Cosmetic Doctor Policies & Procedures

The policies and procedures contained within this document are the exclusive property of Newcastle Cosmetic Doctor and are provided for internal clinical governance and educational purposes only. These materials represent the internal operational framework, safety standards, and evidence-based protocols developed and implemented by Dr. Bart John Scanlon and the Newcastle Cosmetic Doctor team. They are designed specifically for use within Newcastle Cosmetic Doctor and reflect our clinic’s own professional standards, risk assessments, and compliance obligations under Australian law and regulatory authorities. External individuals, practitioners, or organisations must not copy, reproduce, distribute, or rely upon these materials, in whole or in part, for their own clinical, commercial, or educational use without prior written consent from Newcastle Cosmetic Doctor. These materials do not constitute medical, legal, or professional advice and are not intended to be adopted as official protocols or procedures by any other entity. Any external use or adaptation must be independently reviewed and modified to meet the relevant laws, guidelines, and standards applicable to the user’s own jurisdiction, scope of practice, and facility operations. Newcastle Cosmetic Doctor and Dr. Bart Scanlon accept no liability for any loss, injury, or damage arising from the unauthorised use, reliance upon, or misinterpretation of this material.