Hyaluronic acid fillers such as Juvéderm and Restylane can produce beautiful results—and when they don’t, hyaluronidase can often correct the problem remarkably well.
But somewhere along the way, “dissolving unwanted filler” has evolved into something quite different: a quest to hunt down and eradicate every detectable trace of filler from the face.
And I think we need to talk about it.
Unless you have been living in a hermetically sealed cave for the past 20 years, you have probably heard of hyaluronic acid (HA) fillers such as Juvéderm and Restylane.
Hyaluronic acid itself is hardly an exotic substance. It is a naturally occurring sugar found throughout the human body—in our skin, connective tissues, joints and even our eyes. Its ability to attract and retain water is one reason HA fillers are so useful for restoring volume, softening contours and reshaping certain areas of the face.
Most of the time, when properly selected and properly injected, they work very well.
But not always.
When Good Filler Goes Bad
Hyaluronic acid is hydrophilic—it attracts water. That is generally useful, but in certain areas, particularly around the eyes, too much filler or filler placed at the wrong depth can create persistent puffiness or edema.
HA filler can also sometimes produce a characteristic bluish-gray discoloration, particularly when placed too superficially. This is commonly referred to as the Tyndall effect.
And frustratingly, these problems don’t necessarily announce themselves while you’re still sitting in the injector’s chair. Swelling, contour irregularities and unwanted fullness can become apparent days or even a week or two later.
Fortunately, HA fillers have one enormous advantage over many other injectable materials:
We have an eraser.
Under-eye Tyndall effect / bag from hyaluronic acid filler (before hyaluronidase).
After hyaluronidase with careful massage and molding.
Before and after treatment of the Tyndall effect. Improvement followed targeted hyaluronidase with careful massage and molding.
Hyaluronidase: The Filler Eraser
Hyaluronidase is an enzyme that breaks down hyaluronic acid. Commercial preparations include products such as Hylenex and Vitrase, among others.
I often describe hyaluronidase to my patients as a pencil eraser.
If I’ve performed a filler treatment and several days later notice a little excess fullness or an area that needs refinement, a carefully placed amount of hyaluronidase can often correct it quickly and effectively.
I also use hyaluronidase before certain facial surgical procedures when previously placed filler is obscuring the anatomy I actually need to evaluate or treat.
Used thoughtfully, it is an extraordinarily useful tool.
The trouble starts when the pencil eraser becomes a belt sander.
The New Obsession With Dissolving Everything
Increasingly, I see patients who don’t simply want an unattractive area of filler corrected.
They want every molecule of filler removed from their face.
Some arrive after months of repeated dissolving sessions. They have undergone ultrasounds, MRIs or other imaging studies searching for residual pockets of filler.
A scan identifies another tiny area.
That area gets injected with more hyaluronidase.
Another scan is obtained.
Something else is found.
And down the rabbit hole we go.
More appointments. More scans. More dissolving. More swelling. More anxiety. More money.
Yet when I actually look at the patient, there may be very little—or sometimes nothing—visibly wrong.
At some point, the pursuit itself becomes the problem.
Hyaluronic Acid Is Not a Metastatic Disease
This is where some perspective is desperately needed.
Residual hyaluronic acid filler is not cancer. It is not a metastatic disease that must be hunted down and banished from every corner of the face.
The objective of aesthetic medicine is not to produce an MRI demonstrating absolute molecular purity.
The objective is to make the patient look better.
That distinction sounds ridiculously obvious.
Apparently, it isn’t.
Imaging can unquestionably be useful. Ultrasound, for example, can help identify the location and depth of previously injected material in selected situations. MRI may reveal material or tissue changes that aren’t obvious on examination.
But the existence of something on an image does not automatically mean that it is producing an aesthetic problem—or that treating it will improve the patient’s appearance.
Which brings me to the sophisticated diagnostic technology I use most frequently.
My Favorite Imaging Device: My Eyes
Patients sometimes ask:
“What makes you successful at dissolving difficult filler? Are you using MRI? Ultrasound? Some special imaging technology?”
Those technologies certainly have their place.
But my primary diagnostic instrument remains decidedly low-tech:
My eyes.
If I see abnormal puffiness, a blue-gray Tyndall effect, contour distortion or meaningful asymmetry that appears related to filler, I treat it.
If I don’t see a problem, I generally leave it alone.
And, perhaps more importantly, I encourage the patient to leave it alone too.
Because I’m treating a face, not an MRI.
An imaging study should help answer a clinical question. It should not automatically create a new clinical problem simply because it detected something.
Hyaluronidase Dissolves. Massage Sculpts.
There is another element of successful filler correction that receives surprisingly little attention: massage and molding.
Hyaluronidase is not magic water.
You don’t simply inject a few drops, walk away and wait for perfection to occur.
When appropriate, careful manipulation of the treated area—from deeper tissues toward the surface—can be an important part of achieving a smooth, controlled correction.
In my experience, thoughtful massage and molding can sometimes be every bit as important as where the enzyme itself is placed.
The goal isn’t indiscriminate destruction of filler.
It is controlled correction.
That requires anatomy, judgment, examination and, yes, occasionally knowing when to stop.
Dissolve the Problem—Not the Patient’s Peace of Mind
There is nothing wrong with wanting poorly placed filler corrected. I do it regularly.
There is nothing wrong with using imaging when the clinical situation genuinely warrants it.
And there is certainly nothing wrong with hyaluronidase. It remains one of the great advantages of HA fillers precisely because it gives us a degree of reversibility that many aesthetic treatments simply don’t have.
But there is an enormous difference between correcting a visible problem and embarking upon an endless search for microscopic remnants of something simply because modern imaging technology is capable of finding them.
More information does not always mean more treatment.
Sometimes the most sophisticated decision a physician can make is to look at the patient and say:
“That looks good. Leave it alone.”
In aesthetic medicine, as in much of medicine, the simplest solution is often the best one.
And occasionally, the hardest procedure to perform is no procedure at all.
Randal D. Haworth, M.D., F.A.C.S.
Board-certified plastic surgeon
Beverly Hills, California
Haworth Institute
