In case you haven't perceived it, the trends are shifting – aesthetic preferences are leaning towards a more natural appearance. BBLs have transformed from bold to subtle; extreme fox eyes are on the wane; and most conspicuously, people are resorting to hyaluronidase to dissolve hyaluronic acid (HA) fillers – including celebrities like Amy Schumer, Blac Chyna, and Courteney Cox. But is this the appropriate choice for you? Social media communities are sharing their experiences with this solution, with many highlighting terrifying side effects such as inflammatory problems, nerve damage, and even permanently misshapen faces after hyaluronidase treatment. And although it can be efficacious, it's actually being utilized off-label to dissolve fillers – so what do we know about hyaluronidase, and what are the consequences of using it?
What does hyaluronidase do, and when do providers use it?
According to Dr. Catherine Chang, a board-certified plastic surgeon in Beverly Hills, California, hyaluronidase is sanctioned by the U.S. Food and Drug Administration (FDA) to enhance the absorption of injected drugs and assist in the study of the urinary tract during radiography sessions. It's an enzyme that decomposes hyaluronic acid, so when applied to areas treated with HA fillers, it can dissolve them. (It can also be extremely painful – most patients report a strong stinging sensation during the procedure.)
In the majority of instances, providers employ hyaluronidase in emergency situations. "Hyaluronidase is frequently used to rescue tissue that has experienced vascular occlusion," states Dr. Amir Karam, a board-certified facial plastic surgeon in San Diego. In such cases, hyaluronidase can be a life-saving instrument – the risks of vascular occlusion encompass tissue necrosis, blindness, and even death in extremely rare circumstances. Hyaluronidase is also utilized to reverse filler treatment in patients soon to undergo plastic surgery. It's advisable to do this several weeks, if not months, prior to any plastic surgery to achieve the optimal outcome. "In our practice, we commonly use it to remove the fillers beneath the eyes when someone is overly filled and we are planning to perform fat transfer on them," said Dr. Karam. "I never recommend patients to remove it throughout their face – I have never done this before."
There's a reason why providers like Dr. Karam refrain from doing this: frequent and long-term use of fillers can lead to irreparable irregularities within the facial tissues. "Those who have received a significant amount of filler tend to have a more pronounced reaction to hyaluronidase because they have completely damaged the soft tissue," cautions Dr. Ben Talei, a board-certified facial plastic surgeon in Beverly Hills, California. "Not only does this expose all the stretching that occurs when you deflate it, but the skin doesn't rebound and rehydrate effectively – it lacks the resilience it once had."
These are the patients that Dr. Talei refers to as "filler-dependent." Once the filler is dissolved, you observe all the damage it has caused – and natural aging – over time. What was once rosy and healthy tissue appears shadowed and sallow. This can be exacerbated by the "reach" of hyaluronidase. "The consistency of hyaluronidase is similar to water, so it's possible that it can spread beyond the injection zone," says Dr. Chang. This makes it difficult to control and its outcome somewhat unpredictable, even when diluted, as stated by Dr. Talei. And the more filler you have, the greater the quantity of hyaluronidase you'll require. "In general, approximately five units of hyaluronidase are necessary to dissolve 0.1cc of hyaluronic acid," says Dr. Chang.
The shift away from filler
The first hyaluronic acid fillers were FDA approved nearly 20 years ago, so if you've been receiving fillers regularly since then, you likely have no notion of how much has actually accumulated in your face," remarks Dr. Talei. "Patients are made to believe that the filler lasts for only six months [to two years], because the representatives from the companies tell you that," he says. "[But providers] are aware that it can persist for longer – it can last indefinitely." So when patients come in for their regular replenishment of filler, they don't merely have a few cc already present. They could have anywhere from 15cc to even 40cc, depending on how frequently and for how long they've been treated. "People have been truly irresponsible regarding the amount of filler they've been placing in their faces – and not through their own fault," says Dr. Karam. "As an industry, we've created this paradigm that somehow, using fillers can slow down the aging process or address laxity." In reality, the sole solution for laxity is plastic surgery, and you only need a small amount of filler to restore the volume lost over time.
Dissolving filler isn't as straightforward as it appears
So what occurs when you've had a face full of filler for a long time and are prepared to have it dissolved? Your options might be limited. "Due to the substantial expansion over the years from the filler, the soft tissues are no longer healthy," says Dr. Talei. "They've been stretched in every direction because the filler absorbs like a sponge." Adds Dr. Karam, "because fillers are administered over years and often in multiple injection planes, attempting to remove them causes uneven loss of the fillers, creating an atypical appearance on the skin's surface."
When patients have been significantly overfilled, Dr. Talei will not undertake any procedures on their faces, as it becomes impossible to restore them to a refined appearance or even lift the tissues. If the patient's objective is a facelift and to be free of filler, it might not be feasible. "Even if we don't dissolve the filler, we end up having to replace it – because when they're under such high pressure within the skin, they escape as soon as the face is opened for the facelift," he says. Within minutes, 10cc of filler could escape from one side of your face during the surgery, resulting in a decidedly "unlifted" appearance. In such cases, your provider will then have to reinsert the filler, because your facial tissues rely on it for structure. In brief, when you've received such a large amount of filler, you can't simply eliminate it all, and you might be dependent on filler for the remainder of your life.
However, it's not all pessimistic news. Those who have been moderately or slightly overfilled or have received filler for only a few years, especially if their skin is in good condition, should be capable of recovering after treatment with hyaluronidase and observe their skin returning to its original state or close to it.
Hyaluronidase side effects
Side effects from hyaluronidase are highly uncommon. The majority of people undergo treatment without any problems, but "complications to be vigilant about include anaphylaxis, pruritus [itchy skin], urticaria [rashes/welts], and angioedema [swelling] as well as minor complications arising from the imprecise nature of hyaluronidase," says Dr. Chang.
You can also encounter temporary nerve issues and irritation from hyaluronidase, although long-term discomfort is not impossible. But typically, those nerve problems are caused by the significant inflammation in the face resulting from the filler. "The nerves have been somewhat numb for a long time, because they're pretty much soaked in water – if you have a puffy face, you don't sense things as well," says Dr. Talei. When you proceed to dissolve the filler, it will trigger a major inflammatory response in your body as the enzyme functions, which can occasionally trigger more significant issues in the body, although these complications are not well comprehended. "Out of a few hundred thousand people, you have one individual who has an inflammatory problem," says Dr. Talei. "When you're weighing the risks, the risk of retaining that substance in the face is likely worse."
Ultimately, providers and patients require more education on how to handle tissues that have been damaged by the long-term accumulation of filler. According to Dr. Talei, the majority of sessions at injectable conferences are dedicated to teaching how to inject, while a very limited time is allocated to treating vascular occlusion complications. Gradually but steadily, as we gain a better understanding of filler longevity in 2024, more interest has been directed towards hyaluronidase. As more mature, overfilled patients opt to exchange their injectables for surgery, more MDs will learn in the operating room that some of their patients' HA filler simply cannot be dissolved, regardless of the claims perpetuated by filler manufacturers.
