I am an oculofacial surgeon with a very active, Beverly Hills based, aesthetic practice. A significant component of the practice is devoted to fillers including fixing bad filler services. I am a consumer advocate and have blown the whistle on iris color surgery, eye lash growth serum, and I fix botched surgery, fillers, among other services. I have carefully reviewed reports here and elsewhere claiming harm from enzyme. Many of these claims are amplified by just a few individuals who have posted hundreds if not thousands of times on these issues. The most active of these claim permanent facial volume loss following being enzymed to address a filler service that went bad with over fill. Almost uniformly the case details are incomplete as is the photographic documentation. Generally the most dramatic cases show an after face with profound loss of facial volume. These appear to be related to fat volume loss associated with dramatic weight loss and not enzyme treatment. One wonders. Another category of result I see is the completely inadequate enzyme result. I have seen many who have supposedly had several rounds of “enzymes.” Often there are no actual clinical records documenting the dose of enzyme injected. In some cases, an inadequate dose of enzyme mobilizes partially broken down filler high into the skin causing a patch of boggy swelling. This is instantly resolved with an adequate dose of hyaluronidase. In most other cases, a proper dose of enzyme was all that was needed to resolve the issue. More recently, I am seeing individuals with filler and enzyme issues who bring with them MRI and ultrasound studies. These imaging modalities are academically interesting but they lack sensitivity and specificity. They are no replacement for clinical judgement. The location of filler is really pretty obvious to the trained eye. The imaging studies are really not helpful. Finally, in some cases, more than one round of enzyme is needed. Also, the fillers were placed originally to help facial volume. When this volume is successfully removed, it should not be a surprise that most need some volume put back in the face and fillers are often the most logical product for this. There is no substitute for a detailed, in person assessment.
