In case you haven’t noticed, the tides seem to be turning—trends in aesthetics are pivoting toward a more natural look. BBLs have gone from bodacious to barely there; extreme fox eyes are fading away; and perhaps most noticeably, people are turning to hyaluronidase to dissolve hyaluronic acid (HA) filler—including celebrities like Amy Schumer, Blac Chyna, and Courteney Cox. But is this the right move for you? Communities on social media are sharing their experiences with this solution, with many speaking out about scary side effects including inflammatory issues, nerve damage, and even permanently malformed faces after being treated with hyaluronidase. And while it can be effective, it’s actually being used off label to dissolve filler—so what do we know about hyaluronidase, and what are the ramifications of using it?
What does hyaluronidase do, and when do providers use it?
According to Dr. Catherine Chang, board-certified plastic surgeon in Beverly Hills, California, hyaluronidase is approved by the U.S. Food and Drug Administration (FDA) to help improve the absorption of injected drugs and support studying the urinary tract during radiography sessions. It’s an enzyme that breaks down hyaluronic acid, so when used on areas that have been treated with HA fillers, it can dissolve them. (It can also be extremely painful—most patients report a powerful stinging sensation during treatment.)
In most cases, providers use hyaluronidase in emergency scenarios. “Hyaluronidase is commonly used to rescue tissue that has had vascular occlusion,” says Dr. Amir Karam, a board-certified facial plastic surgeon in San Diego. In these cases, hyaluronidase can be a lifesaving tool—the risks from vascular occlusion include tissue necrosis, blindness, and even death in very rare situations. Hyaluronidase is also used to reverse filler treatment in soon-to-be plastic surgery patients. It’s best to do this many weeks, if not months, before any plastic surgery in order to achieve the best result. “In our practice, we commonly use it to remove the fillers underneath the eyes when somebody is overfilled and we are planning on performing fat transfer on them,” said Dr. Karam. “I never advise patients to remove it throughout their face—I have never done this before.”
There’s a reason that providers like Dr. Karam won’t do this: frequent and long-term filler use can result in irreparable irregularities within the facial tissues. “Those who have had really large amounts of filler tend to have a more exaggerated response to hyaluronidase because they have completely damaged soft tissue,” warns Dr. Ben Talei, a board-certified facial plastic surgeon in Beverly Hills, California. “Not only does this reveal all the stretching that’s happened when you deflate it, but the skin doesn’t rebound and rehydrate so well—it doesn’t have the resiliency that it used to have.”
These are patients that Dr. Talei refer to as “filler dependent.” Once the filler is dissolved, you see all the damage caused by it—and natural aging—over the years. What was once rosy, healthy tissue appears shadowed and sallow. This can be exacerbated by the “reach” of hyaluronidase. “The consistency of hyaluronidase is like water, so it’s possible that it can spread outside the zone of injection,” says Dr. Chang. This makes it hard to control and its outcome somewhat unpredictable, even when diluted, says Dr. Talei. And the more filler you have, the more hyaluronidase you’ll need. “In general, around five units of hyaluronidase are necessary to dissolve 0.1cc of hyaluronic acid,” says Dr. Chang.
The move away from filler
The first hyaluronic acid fillers were FDA approved nearly 20 years ago, so if you’ve been getting filled regularly since then, you probably have no idea how much has actually accumulated in your face,” says Dr. Talei. “Patients are led to believe that filler only lasts for six months [to two years], because the representatives from the companies tell you that,” he says. “[But providers] know that it can last longer—it can last forever.” So when patients come in for their regular top-up of filler, they don’t have just a few cc in there already. They could have anywhere from 15cc to even 40cc, depending on how often and how long they’ve been treated. “People have been really irresponsible about the amount of filler that they’ve been placing in their faces—and through no fault of their own,” says Dr. Karam. “As an industry, we’ve created this paradigm that somehow, using fillers can slow down the aging process or redirect laxity.” Really, the only resolution for laxity is plastic surgery, and you need only a small amount of filler to restore the volume that’s lost over time.
Dissolving filler isn’t as simple as it seems
So what happens when you’ve long had a face full of filler and are ready to get it dissolved? Your options may be limited. “Because of the large amount of expansion over the years from the filler, the soft tissues just aren’t healthy anymore,” says Dr. Talei. “They’ve been stretched out in every possible direction because the filler soaks in there like a sponge.” Adds Dr. Karam, “because fillers are placed over years and often in multiple planes of injection, trying to remove it causes irregular loss of the fillers, creating an unusual appearance on the surface of the skin.”
When patients have been significantly overfilled, Dr. Talei will not touch their faces, because it becomes impossible to restore them to a delicate appearance or even lift the tissues. If the patient’s goal is a facelift and to be free of filler, it may not be possible. “Even if we don’t dissolve the filler, we end up having to replace it—because when they’re under that much pressure within the skin, they escape as soon as you open up the face for the facelift,” he says. In minutes, 10cc of filler could escape from one side of your face while you’re under the knife, resulting in a decidedly “unlifted” appearance. In those cases, your provider will then have to put filler back in, because your facial tissues rely on it for structure. In short, when you’ve gotten that much filler, you can’t just get rid of it all, and you may be filler dependent for the rest of your life.
However, it’s not all bad news. Those who have been moderately or minorly overfilled or have gotten filler for only a few years, especially if their skin is in good condition, should be able to rebound after treatment with hyaluronidase and see their skin return to its original state or close to it.
Hyaluronidase side effects
Side effects from hyaluronidase are very rare. Most people are treated with no issue, but “complications to be aware of include anaphylaxis, pruritus [itchy skin], urticaria [rashes/welts], and angioedema [swelling] as well as minor complications from the imprecise nature of hyaluronidase,” says Dr. Chang.
You can also experience temporary nerve issues and irritation from hyaluronidase, though it’s not impossible for there to be long-term discomfort. But usually those nerve problems are caused by the significant inflammation in the face caused by the filler. “The nerves have been kind of numb for a long time, because they’re pretty much soaked in water—if you have a puffy face, you don’t feel things as well,” says Dr. Talei. When you go to dissolve the filler, it will trigger a major inflammatory response in your body as the enzyme gets to work, which can occasionally set off bigger issues in the body, though these complications are not well understood. “Out of a few hundred thousand people, you have one person who has an inflammatory issue,” says Dr. Talei. “When you’re weighing the risks, the risk of keeping that stuff in their face is probably worse.”
Ultimately, providers and patients need more education about how to approach tissues that have been damaged by long-term accumulation of filler. According to Dr. Talei, the majority of sessions at injectable conferences are spent teaching how to inject, while a very limited amount of time is dedicated to treating vascular occlusion complications. Slowly but surely, as we gain a better understanding of filler longevity, more interest has been turning to hyaluronidase. As more mature, overfilled patients come to swap their injectables for surgery, more MDs will learn in the OR that some of their patients’ HA filler simply cannot be dissolved, regardless of the claims that filler manufacturers have perpetuated.
