Vitrase Dissolved Cheek Tissue - Portland, OR

I was overfilled with Restylane under the eyes and went to another doctor -- Dr. Dailey -- to have it removed with Vitrase. I specifically asked him if there was any chance that the Vitrase would permanently dissolve my own tissue. He was emphatic in saying no. So I agreed to have him inject the Vitrase.
In the first month, some of the filler dissolved and some did not... More horribly, tissue in my cheek -- well below where the filler went, but where the Vitrase poured into -- began to dissolve! At two months, I went to see Dr. Dailey and showed him the outcome. There was a clear depression, surrounded by a less noticeable settling/depression of the tissue. At first, he feigned that he could see nothing, then conceded there was a depression but blamed the dissipated filler. When I reminded him that there was no filler in my cheek where the hole now stood, he said it was impossible for the Vitrase to be responsible, as he uses "gallons and gallons" of it in his eye surgery practice. He began to get up to leave the room, saying to come back in a few months. He added for good measure that I was "fine, look great... I have no idea why you're here."
For a sanity check, I went to a dermatologist who readily acknowledged the depression and increased redness of the area. She sent me to a new plastic surgeon, who saw me right away. He confirmed that Vitrase DOES in fact dissolve our body's natural HA along with the filler. In most people, the body quickly replaces it (matter of hours to days). However, in rare cases, the natural tissue never grows back or takes a very long time! Now I am left with an obvious indentation on my cheek with uncertain prospects that it'll ever fill back in. I'm mortified, and embarrassed, as this directly impacts my ability to earn income.
Dr. Dailey may well use "gallons and gallons" of Vitrase but he does his patients a profound disservice of 1) not warning them of the rare complication and 2) conducting some degree of testing on a patient's skin to make sure they are not one of the unlucky folks such as myself. Now that I am reading of other surgeons on RealSelf confirming this potential outcome, I am livid that Dr. Dailey was so dismissive of my initial question and subsequent follow up.

With temporary dermal fillers becoming more and more common, so too are poor outcomes -- from asymmetry to dangerous blood vessel compromise. Doctors using hyaluronic acid-based (HA) fillers (Restylane, Boltero, Perlane, Juvederm, etc) tell patients to rest easy, as they have a potent weapon to "erase" any of these bad outcomes: hyaluronidase (HYAL). The following gives an overview of this poorly understood HYAL drug, clarifying not just the benefits of using such but also the known and suspected devastating outcomes of using it. More importantly, my hope is that this overview will serve as a clearinghouse for patients who've had bad experiences with the drug and offer up ways to mitigate the damage it has caused.

Quick Backgrounder: When choosing a filler, you're also implicitly choosing a path to remove it. There are a multitude of reasons for having to remove filler, including benign (don't like the aesthetic look of the doctor's placement) to emergency (filler was accidentally injected into a blood vessel, resulting in near-term necrosis / death of tissue). There are other reasons too, like hypersensitivity reactions, development of nodules / granulomas, and biofilm infections. Lesson--> You should understand the risks of not only the HA dermal filler but HYAL too. Patients are rarely if ever told this by most doctors. Types of HYAL: Unfortunately, there's no clear standard for what you're likely to be injected with when it comes to HYAL. There are certainly three distinct groups from which HYAL is produced (mammalian, bacterial, and leeches/crustaceans/parasites), of which two well known brands have been mostly used (Vitrase and Hylenex). Lesson--> Ask your doctor which brand he/she plans to use and why. Dosage: Even with the well established drugs of Vitrase and Hylenex (both have been used for years in eye surgeries), there are no protocols for how much to use, whether to dilute it with other substances, etc when it comes to dermal fillers. Papers with NIH and PubMed show some HA compounds respond much faster to HYAL than others based on how they're chemically manufactured (degree of crosslink). Said differently, some HA fillers are designed to last longer by resisting degrading more than other fillers. Not surprisingly, they will thus take more HYAL to totally dissolve the product. For instance, studies show that Restylane dissolves the fastest and most complete when exposed to HYAL, while Boltero is one of the slowest and least complete. That would suggest, then, that Restylane would require less HYAL than Boltero, all things being equal. Yet most doctors have no idea that such medical study has been done on suggested dosing. Instead, most providers just inject HYAL at the same amounts regardless. Indeed, literature suggests that a "normal" dose is 150 IU of HYAL -- or 75 IU on each side of the face. Yet an injection of Restylane in the tear troughs, for instance, likely wouldn't need that amount; literature suggests no more than 75 IU total, or 37.5 IU on each side of the face. This has profound implications when considering the possible side effects related to HYAL injections... You want to inject as little of the drug as possible. --> Lesson: Ask your doctor if they are aware of the above and how much HYAL they'd inject if there were a problem. If you're not comfortable with their answer, go elsewhere. Complications - Allergic Reaction to HYAL: If you have an allergy to bee stings, you should never use HYAL, as you could have a death-enducing anaphylactic reaction. That also means you should never have HA fillers to begin with, as you must have a way to remove the filler before it's ever injected. Very few doctors ever tell patients this. Also, depending on the group of HYAL used (eg - mammalian, bacterial), you may also have an immune reaction and should thus never have HA fillers. Lesson--> Demand skin testing of both Vitrase and Hylenex before having filler placed to make sure you don't have allergic or immune reactions. Complications - Dissolving Native HA / Loss of Tissue: If you explore RealSelf, you'll see patients asking about whether HYAL can dissolve native HA. In other words, can HYAL melt away your healthy tissue and cause denting or skin damage? Many of the clinical answers on RealSelf will claim it cannot. Indeed, many well regarded doctors are both adamant and dismissive of any claims to the contrary. However, papers in NIH and PubMed make clear that they are wrong. In fact, HYAL absolutely does degrade your native HA (Pls search the internet for, "Complications of Injectable Fillers, Part I;" Aesthetic Surgery Journal, Volume 33, Issue 4, 1 May 2013, Pages 561-575; Dr. Claudio DeLorenzi). Indeed, the reason HYAL was manufactured in the first place was to assist in surgeries where doctors needed to separate skin / tissue to disperse other drugs more quickly. The question, then, is for how long HYAL will degrade natural HA, how much tissue is affected, and for what percentage of people who are injected with it? To answer these questions, a bit of background is helpful. Your body naturally makes HYAL enzymes every day, dissolving and rebuilding natural HA that's in your skin, joints, etc. Manufactured HYAL does much the same, but in superconcentrated formulas. In other words, HYALs -- both natural and manufactured -- degrade both natural HA and crosslinked HA dermal fillers. Obviously, that's why many people are attracted to HA dermal fillers... they're temporary, as the body (natural HYAL) will eventually break them down and new injections will be necessary after 6 - 18 months. NIH and PubMed papers make clear that Vitrase / Hylenex dissolve natural HA within seconds of exposure. Because of crosslinking, dermal fillers take longer than natural HA. In other words, whatever result you see within a few hours of injection is likely and almost exclusively your natural HA, not the dermal filler. Regardless, final results are seen within a day to two. The HA dermal filler obviously won't come back after a HYAL injection. But what about the natural HA that was dissolved along side the filler? What most doctors won't tell you is that medical science doesn't fully understand how the body creates its own HA and later remodels it with natural HYAL. (Pls see above source for further details. To quote from the text: "The biology of HA metabolism is far from being completely understood in animal models, let alone in humans.") Consequently, it stands to reason that manufactured HYAL could have unintentional damaging effects, depending on each body's unique process of naturally creating, destroying, and rebuilding HA. We know this to be true because Vitrase/Hylenex are both used off label for the dissolving of dermal fillers, meaning there are no known studies to clarify the risk these drugs pose for filler removal. Contrary to most doctors' advice, a lack of knowledge about risk does NOT equal no risk. This likely explains why, in so many reviews of Vitrase and Hylenex, you'll see some doctors use qualifying language when asked whether the HYAL drugs permanently destroy native HA. For example, "We don't believe..." or "It would be unusual," or "I've never heard of...". And it likely explains why a clear number of patients claim that they have, in fact, been damaged by the two drugs. In recent years, there is increasing concern in the medical community about the permanent impact of HYAL on native tissue. My private conversations with derms and PSs reveal carefully worded statements of, "I'm hearing more of this issue at conferences," or "I've not seen it at my practice but I'm frankly not surprised," or "Colleagues have claimed this but I don't think it's true." Their candid reactions are alarming as they are absent from feedback seen in places like RealSelf, leaving patients at some degree of risk. The Damage: Patients damaged by HYAL report 1) dents or hollowness (cavitation) even where no filler has been; 2) surrounding tissue that's soft or lacking firmness, with an ease of reaching bone underneath; 3) skin redness; 4) increased size of pores; 5) stratification of the epidermis (layers of the visible skin collapsing or peeling back); and 6) pain. Some of these effects may be caused by other things (eg - needle damage, scar tissue deep within the dermis, infection, etc), but a clear number of people are reporting these six complications to varying degrees. The Fix: This is where patients must help each other. Because medical science has rushed ahead with HA dermal fillers without fulling studying HYAL's effect on native HA, complications from using HYAL injections are usually dismissed by doctors. The result for patients is often frustration, anger, and despondency depending on the severity of HYAL's impact. In the comments section below, please offer your reflections on what might be helpful to address and fix the damage. Some solutions could include: --Supplements of hydrolyzed collagen, HA capsules, and anti-inflammatories (garlic, tumeric, etc). --Creams with human fibroblast conditioned media. --Anti-inflammatory doses of doxycyline (SDD 20mg 2xday; doxycycline monohydrate 40mg 1xday). --PRP injections. --Fat injections. Upshot: I would strongly encourage patients to avoid using fillers until the issues around HYAL is addressed. Instead, consider PRP injections or growing old with grace.

Over the past many years, I have tried more fixes than I can count. Mostly for volume loss, skin degradation (loose skin, wrinkling), redness, and pain. I've seen a wide swath of dermatologists, plastic surgeons, general docs, and neurologists. I've gotten an equally wide set of diagnosis, some admitting it was vitrase that caused the damage.
Treatments I've tried include:
1) Fat Grafting (for volume loss)
2) Excel V laser (for redness)
3) Peptide therapy (BPC-157 injections for pain and skin healing)
4) Multiple PRP / PRF injections (for volume and skin healing, esp subdermal)
5) Dermrollers with and without serums (for skin texture)
6) Assorted serums (w and w/out fibroblasts), incl copper-infused products to (for skin texture)
7) Hyperbaric treatments (for skin healing, esp subdermal)
8) Vitamin drips
9) Collagen powder and HA pills (general skin health)
10) Anti-inflammatory diet (general skin health)
11) Antibiotic treatments (for the possibility of rosacea)
12) Exercise with lots of sweat (for general skin health)
13) Resurfacing laser (for wrinkles and skin texture)
The result? The fat grafting helped for volume loss, though was not as effective in the areas badly damaged by hyaluronidase. Next, the Excel V helped for redness, though one treatment would have been better than the two I received. Finally, the general skin health stuff I suppose was marginally helpful. But the rest did absolutely nothing (#4-8, 11) while one (#13) made it temporarily worse and caused six months of effort to repair. The truth is that even the rest of it has returned me to normal. As you can see from the pictures, the skin is still damaged. Unfortunately, it's getting worse over time. And it just feels affected / damaged, especially the right cheek (which received the most hyaluronidase).
Bottom line: this damage is permanent. The best you can do is adjust your head to that fact and conceal as you can. The peptide therapy has helped with pain somewhat, so that's a blessing. But my upper cheeks are permanently damaged. For women, y'all might be able to conceal it with makeup. But not so for guys.
Such a foolish decision to trust my doc that vitrase wouldn't damage my native HA and dermis/sub-dermal tissue. It can and does, certainly for an undefined and unpredictable segment of people.
If I could turn back time, I would have left the filler alone and let it dissolve over time. Or used PRP to dissolve the filler, as smart doctors are now doing rather than using vitrase.
I wish everybody good luck and healing. This chemical is devastating. Until the medical community recognizing how dangerous hyaluronidase is and study different modalities to heal people, those of us who've been damaged are left to our own devices to suffer alone or in hope with others to find solutions.