Indentation on nose tip after dissolving filler – tissue loss?

The indentation (dent) on the nose tip after dissolving hyaluronic acid filler is most likely due to loss of volume—either from removal of the filler that was previously providing structural support, or, less commonly, from underlying tissue compromise such as fat or skin loss.

Key considerations:
1. Tissue loss after filler is rare but can occur if there was prior vascular compromise (even if not full necrosis), leading to subtle ischemic injury and atrophy over time.
2. Redness and bulging after filler, as you described, can be early signs of vascular compromise or local inflammation. Even if capillary refill appears normal, this does not rule out partial or intermittent vascular insufficiency.
3. Dissolving the filler with hyaluronidase (Hyalase) removes the volume, which can unmask pre-existing tissue atrophy or scarring that was previously camouflaged by the filler.
4. A single round of hyaluronidase is usually sufficient to dissolve hyaluronic acid filler, but repeated treatments can theoretically increase the risk of breaking down native hyaluronic acid in the skin, potentially worsening atrophy if overused.

Is this tissue or fat loss?
- If the area feels thin, indented, or atrophic, it could be due to:
- Volume loss from removal of filler
- Subtle fat or dermal atrophy from prior vascular compromise (even if not full necrosis)
- Scar tissue formation after inflammation or ischemia

Would a second round of Hyalase help or harm?
- If there is no palpable or visible residual filler, a second round is unlikely to help and could potentially worsen atrophy by degrading native hyaluronic acid.
- If there is still residual filler causing contour irregularity, a very conservative, targeted approach could be considered, but caution is warranted.

Options for correction:
- Small-volume hyaluronic acid filler (in expert hands) can be used to correct the indentation, but only after ensuring there is no ongoing inflammation or vascular compromise.
- Autologous fat transfer is another option for volume restoration, especially if there is significant- atrophy.
- Other options include observation (if mild), or surgical scar revision in rare, severe cases.

Key points:
- The dent is most likely due to volume loss (from filler removal or subtle tissue atrophy).
- Repeat hyaluronidase is not recommended unless residual filler is clearly present.
- Correction with a small amount of filler or fat transfer is reasonable if the area is stable and not inflamed.
- Vascular compromise can cause subtle tissue loss even without overt necrosis; this is a recognized complication of nasal filler injections.

If you need to confirm the presence of residual filler or assess tissue health, high-frequency ultrasound can be helpful, though this is not always available in all settings.

I have successfully been performing simple subcision for thirty years for elevating all kinds of skin Indentations from all causes, including Indentations secondary to the use of hyaluronidase for dissolving unwanted HA filler. You may wish to explore this safe, simple, nonsurgical, non-filler option for elevating and smoothing the nasal depression that is troubling you. You would be wise to consult with an experienced, board certified cosmetic dermatologist. Best of luck.