Hi, Your description that the filler was injected on the cheek bone would make it difficult manually squeeze out since it is deep and close to the surface of the bone. My suspicion with the patients who have had a bad experience with hyaluronidase, is the following. A patient has had fillers for many years with upwards of 5-10 syringes of fillers injected over the years. Each year they get a syringe or 2 to maintain the result. They think that the filler is completely gone from their face after the year has passed. So they think that at any point in time they have at most 1-2 syringes of fillers in their face. The reality is that fillers last much longer than a year, and upwards of 2-5 years plus. The result may not persist for a year, but the filler is persisting, but just not giving the desired results. For example, fillers for smile lines don't seem to last more than a year, but I suspect the filler is shifting/migrating out of the smile line area, which makes the smile line improvement go away and the smile line returns. So the patient thinks the filler is gone. Another syringe is injected, and repeat for 5 years. The cheeks look a bit overly full, because much of the filler is still there. At some point the patient may think the last injection of filler looks bad and asks for dissolving with hyaluronidase. If the injector uses the full strength Hylanex (150 unit/ml) or Vitrase (200 units/ml) it has the possibility of dissolving all of the fillers injected in the past 5-10 years with that concentration. Usually it takes about 2-4 units to dissolve 0.1 cc of Restylane/Juvederm XC, but much more for the Voluma/Vollure with the Vycross Technology. So to dissolve the last syringe of filler you didn't like, may only require 20-40 units of dissolver. The more accurate the dissolver is placed to where the filler was placed, the less dissolver would be needed, so 20 units to dissolve 1 cc of Restylane would be a reasonable place to start, to dissolve the filler you don't like, while keeping the other fillers that you like. If 200 units were injected all over the place, and 10 or more syringes of fillers were still present in the face, it may appear to have dissolve away the person's facial fat. Unfortunately, hyaluronidase can't actually dissolve fat. If so, then Kybella would never have been invented. Hyaluronidase dissolves filler quickly and doesn't seem to dissolve fat. It doesn't cause the same massive swelling as Kybella as the Kybella dissolves the cell membranes of the fat cells causing the contents of the fat to spill out and get absorbed by the body over a period of 6-8 weeks. The horror stories of hyaluronidase appear to state that their face melted away quickly after the injection, but even for permanent fat removal by Kybella or even Coolsculpt, it takes weeks to months to see the fat eventually shrink away. When dissolving filler, the patient and I can immediately see a reduction in the firmness of the volume where the filler was located. Since the hyaluronidase is injected with some fluid, the actual result isn't immediately visible until 24-48 hours later. Since the horror stories also describe that the face melted away quickly and not over a 6-8 week period, I suspect the hyaluronidase simply worked as expected, but the story told may not reveal that they have been getting fillers for many years, and the injector injected the undiluted dissolver, possibly out of inexperience. This combination will appear to melt the fat off of the person's face, but really just the filler accumulated in their face over the years. I actually am wishing for an injectable fat dissolver which doesn't cause massive swelling like Kybella, since it would be great for non-surgical lower eyelid fat bag removal/reduction or even Buccal fat reduction. I have tried using Hyaluronidase to shrink eyebag fat or lumpy fat grafting from other surgeons, but it doesn't work even a tiny bit. Since injecting fillers is like sculpting, a sculptor doesn't always add more "clay" to their sculpture and sometimes removal or reduction of the "clay" will help to make the sculpture look better. This is how I use hyaluronidase as a tool to reduce/contour/shape, just as I used the filler to do the same thing. Occasionally, it can also be used to erase everything to start over, but this ends up being an expensive proposition for the patient, since they usually like most of the fillers they had in the past, and only regret the most recent injections. I hope this makes some sense and provided some value. Good Luck. Best, Dr. Yang
