Question 1

What is hyaluronidase?

Accepted Answer

Hyaluronidase is a naturally occurring enzyme that’s used to break down hyaluronic acid–based fillers, including Juvéderm, Restylane, and Belotero.

The hyaluronic acid (also known as hyaluronan or HA) that’s the key ingredient in many dermal fillers is a polysaccharide that occurs naturally in the body. In skin, it resides in the extracellular matrix, alongside collagen, elastin, and connective tissue, to provide plumpness and structure—the very qualities you may desire when pursuing filler. However, if you’re unhappy with your HA filler results or are experiencing complications, the use of hyaluronidase can resolve the situation.

Left alone, an HA filler is eventually broken down by your body’s own enzymes, but that process can take months or even years, depending on your metabolism, the type of filler used, and where it’s placed (fillers that were injected under the muscle or in areas without a lot of movement tend to last longer). “Hyaluronidase enables you to dramatically accelerate the breakdown process,” explains Dr. Brian Biesman, an oculoplastic surgeon in Nashville.

The most common formulations used for cosmetic purposes are Hydase, Hylenex, Amphadase, and Vitrase—all approved by the United States Food and Drug Administration (FDA), though not specifically for disintegrating dermal fillers. Such products are created with bovine testicular hyaluronidase (from cows), ovine testicular hyaluronidase (from sheep), or recombinant human hyaluronidase, made with genetically engineered hamster ovary cells.

In 2023, patients in the U.S. should also have the option to reduce fillers with Topilase, a topical hyaluronidase cream. Learn how Topilase works.

Question 2

What are the pros and cons of hyaluronidase?

Accepted Answer

Pros

It’s quick. One hyaluronidase treatment typically takes less than 10 minutes and goes to work immediately after it’s injected. Some patients see a nearly instant deflation; for others, it can take several rounds of injections to achieve the desired result.
It’s relatively painless. Hyaluronidase injections feel very similar to hyaluronic acid–based filler injections and are frequently done without pain medication. (You may opt for numbing cream prior to the injections, but it’s not necessary and rarely done.)
It’s considered low-risk. “I’m unaware of any contraindications for hyaluronidase injections,” says Dr. Biesman.

Cons

The use of hyaluronidase to counteract fillers is technically off-label, which means it’s not approved by the FDA for this practice. However, it has been used by doctors to deflate hyaluronic acid fillers for more than 20 years—and doctors on RealSelf report that they rarely see hyaluronidase complications.
It’s imprecise. Unlike hyaluronic acid fillers, which usually yield a fairly predictable result when injected by an experienced provider, hyaluronidase is “trickier to control,” says Dr. Biesman. There are different types of hyaluronic acid fillers, so one round of hyaluronidase injections won’t work the same way on all filler formulations, and the filler may dissolve unevenly.
Sometimes the deflation goes further than the patient wants, especially if a less experienced injector floods the area with too much hyaluronidase. New York City-based oculoplastic surgeon Dr. Joseph Eviatar cautions that if most of the filler is dissolved in an area that was “quite deflated prior to injection, especially around the eyes, there is often an initial wrinkling of the skin, much like deflating a balloon. This can appear like your own tissue was damaged, but the area will return to its pre-filler state over several days to weeks, depending on the thickness of the skin.” He strongly recommends having only a very experienced injector treat the delicate area around the eyes.

Question 3

How much does hyaluronidase cost?

Accepted Answer

Hyaluronidase cost can range considerably, depending on the amount of product needed (a low dose works for filler correction, but a high dose is required for vascular complications), your provider’s level of experience, and their practice location.

In many cases, the doctor who performed your filler injections will also provide hyaluronidase free of charge, if you experience complications or poor results. But expect to pay if you see a new provider or simply change your mind about your filler.

See our complete guide to hyaluronidase costs

Question 4

What does hyaluronidase do?

Accepted Answer

Typically, providers turn to hyaluronidase to reverse the results of filler injection results gone awry: overfilled lips or cheeks; the Tyndall effect (a blue cast in the tear troughs); lumps under the skin (aka granulomas or nodules); an uneven or asymmetrical result; or swelling around the eyes.

In very rare cases, it’s used to immediately reverse a serious complication of hyaluronic acid filler injections, such as an arterial blockage or blood clot behind the eye. If filler is accidentally injected into a blood vessel or presses against it, a complication called vascular occlusion, “this can cause pain and skin discoloration—either a bluish or pale-white tint—plus swelling and skin breakdown,” says Atlanta plastic surgeon Dr. Nelson Castillo. New York City oculoplastic surgeon Dr. James Gordon says, “Although very rare, there’s a small risk of a clot going to the back of the eye when filler is injected anywhere in the face. However, injecting hyaluronidase behind the eye can quickly dissolve the product."

The enzyme acts fast, beginning to break down hyaluronic acid fillers immediately. However, some filler formulations are more difficult to dissolve than others, so it takes several hyaluronidase injections—spaced over the course of a few days or even a few weeks—to fully break them down. Generally speaking, according to Dr. Biesman, the easiest hyaluronic fillers to break down are in the Restylane family, followed by Juvéderm products. The trickiest is Belotero.

If you aren’t initially thrilled with your results but your fillers don’t pose a health risk, don’t panic: consider waiting a week or two for the filler to settle, the swelling or bruising to subside, and your eye to adjust to change. The exception: If you’re experiencing considerable pain, the injection site feels hot, you have an extraordinary amount of swelling or changes in the color of your skin, or you have hives, contact your doctor right away. These may be signs of infection, a blockage, or an allergic reaction.

RealSelf Tip: To minimize the risk of filler gone awry, always choose a board-certified dermatologist or plastic surgeon to administer your cosmetic treatments. If things still don’t go as planned and you elect to get hyaluronidase injections, “make sure your doctor is very experienced using it,” says Dr. Biesman.

Related: Vascular Occlusion Is the Scary Filler Complication No One Talks About. Here’s What You Need to Know.

Question 5

What happens during a hyaluronidase treatment?

Accepted Answer

The treatment is very similar to getting filler injections. A round of injections typically takes less than 20 minutes. Most patients don’t opt for numbing cream, unless they’re dissolving filler around the lips (which can be quite sensitive). However, local anesthetics should be an option for any patient.

Your doctor will inject a small amount of hyaluronidase subcutaneously, into the areas you want to dissolve. It may burn slightly, though Dr. Biesman says that sensation subsides fairly quickly.

Knowing which filler you were injected with will make it easier for your provider to remove just the unwanted filler, says Dr. Eviatar. “The technology with some of the newer fillers, like Juvéderm Voluma, are more highly cross-linked to better ‘lift’ and hold together. They may last longer, and they are usually injected below the muscle, rather than just under the skin. The amount of hyaluronidase and method to dissolve each type of filler varies.”

It’s important to choose an experienced physician—ideally a surgeon—to perform your injections, since precision is key. “We have a keen understanding of facial anatomy and the effects of injecting fillers in different regions of the face,” says New Orleans plastic surgeon Dr. Parker Velargo. Dr. Eviatar underscores this, saying that “It's key to find a very experienced injector if you're looking to smooth out an irregular area without also dissolving all the filler, which would completely reverse the result. This is nuanced and not entirely predictable, even in the best hands.”

Subcutaneous injections of the enzyme should be precisely delivered below the skin. While a 2019 study published in the Journal of Clinical and Aesthetic Dermatology identifies the technique of intravenous injection specifically for vision loss due to a filler complication, Dr. Eviatar says that isn’t strictly necessary. “Luckily for occlusion due to filler, recent studies suggest that hyaluronidase will sift through the vessel walls. In these cases we flood the area with this reversing agent and don't need to try to inject directly into the vessel or eye,” explains Dr. Eviatar. “The key is to recognize this rare complication right after injection and treat it immediately, before the patient leaves the office. Otherwise permanent tissue loss or function can result.”

Be aware that you can’t get new hyaluronic acid–based fillers in the same session as hyaluronidase injections unless the treatment areas are far apart: the hyaluronidase enzyme in your system would break down any hyaluronic acid–based product injected on the same day. Doctors on RealSelf recommend about two weeks between treatments, for the best results.

Similar to filler injections, there’s no downtime after a hyaluronidase injection. You may, however, have some lingering swelling or bruising, which could take up to a week to completely fade.

Question 6

How long does it take hyaluronidase to work?

Accepted Answer

It takes two the three days for hyaluronidase to break down filler, with most of the action happening within the first 24 hours. Over the next couple weeks, your body will continue to resorb the remaining hyaluronic acid molecules, after which you’ll see your final results.

For some patients, one round of injections is sufficient. For others, several rounds may be needed. A patient’s own body chemistry can impact the efficacy of or the speed at which the enzyme works.

“I like to wait several days between subsequent hyaluronidase injections, to give the swelling time to go down and so we can better see the result before deciding if we need more hyaluronidase,” says Dr. Biesman. “I tell my patients it’s a process that is hard to predict in advance.”

Other doctors may wait even longer between treatments. “I usually inject a patient, then have them return in a week for a follow-up and further injections, if needed,” Las Vegas dermatologist Dr. F. Victor Rueckl. “I've seen most hyaluronic acid fillers dissolved within two treatments, but sometimes it can take more.”

RealSelf Tip: If you’re having cosmetic facial surgery, ask your doctor about removing fillers beforehand. Most doctors on RealSelf say you don’t necessarily have to have fillers removed before surgery, but if your surgery includes “a volumizing procedure, such as fat grafting, it’s best that all filler is dissolved and gone prior to surgery,” says Salt Lake City plastic surgeon Dr. Scott Thompson.

Related: Here’s Why It’s Important to Tell Your Plastic Surgeon About All Your Past Nonsurgical Treatments

Question 7

What results can you expect from hyaluronidase?

Accepted Answer

The final result depends upon the kind of hyaluronic acid filler you had initially (and how difficult it is to break down) as well as the result you’re trying to achieve.

One RealSelf member who had the filler in her lips deflated said, “This is the first time I felt like the outcome was better than the best-case scenario in my head.” But other reviewers warn that the enzyme isn’t a miracle fix—it’s imprecise and may dissolve more filler than you want. When that happens, a doctor could inject more hyaluronic acid filler at a later date.

The breakdown of hyaluronic acid filler by hyaluronidase is permanent. To replump or smooth skin after a round of hyaluronidase injections, you’d have to inject new filler.

See hyaluronidase before and after photos

Question 8

What are the risks and potential side effects of hyaluronidase?

Accepted Answer

As with any injection, you do run the risk of bruising at the injection site. Most patients will also have some slight swelling. Some less common but still possible hyaluronidase side effects include redness, tenderness, or an itchy sensation at the injection site.

Before going forward with your treatment, talk to your doctor about any medications you’re taking, since reactions between hyaluronidase and certain medications (including antihistamines, anxiety medication, and aspirin) can result in dangerous side effects.

Question 9

Are there alternatives to hyaluronidase?

Accepted Answer

If quickly and significantly dissolving hyaluronic acid filler is your goal, there’s really no alternative to this enzyme. If, however, you’re willing to wait it out, your body will eventually break down the filler. Most HA fillers naturally dissipate within 6–18 months.

For faulty injections, there is hope: “If the filler was injected too superficially, it can sometimes be poked with a needle by your physician and extruded out,” says Dr. Ben Barankin, a dermatologic surgeon in Toronto.

Question 10

Sources & studies

Accepted Answer

“Hydase™.” FDA.

“HYLENEX.” FDA.

Landau, Marina. “Hyaluronidase Caveats in Treating Filler Complications.” Dermatologic Surgery, Dec. 2015.

McCann, Melissa. “Intravenous Hyaluronidase for Visual Loss Secondary to Filler Injection: A Novel Therapeutic Approach.” JCAD, 4 Feb. 2020.

Multum, Cerner. “Hyaluronidase (Injection) Uses, Side Effects & Warnings.” Drugs.com, 2019.“VITRASE® Prescribing Information.” FDA, 2004.

HYALURONIDASE

Joseph A. Eviatar, MD, FACS

Genevieve Monsma

Joseph A. Eviatar, MD, FACS

Genevieve Monsma

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Joseph A. Eviatar, MD, FACS

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Joseph A. Eviatar, MD, FACS

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HYALURONIDASE QUESTIONS

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