March 3, 2022

aesthetics blank face

There are several Facebook groups dedicated to the discussion and support network around the use of hyaluronidase supposedly ‘ruining’ faces. Should aesthetic clinicians be worried about this, especially when considering performing procedures to electively reverse hyaluronic acid-based dermal fillers?

In this blog, Dr Tim Pearce reacts to a video posted by Dr Gavin Chan from the Victorian Cosmetic Institute in Australia entitled – filler dissolver (hyaluronidase) ‘destroyed my face’.  He discusses many of the points raised in the original video, his own opinions, and findings, and looks at how hyaluronidase works, the indications for its use in medical aesthetics, whether it is harmful, and reasons why you might avoid reversing dermal filler in some patients.

Dr Tim will be discussing more medical aesthetic training tips as part of his upcoming webinar series, so if you’re looking to increase your CPD-certified learning and want to learn more skills to make you a better clinician, then step one is to register for the free webinars by Dr Tim.

What is Hyaluronidase and how does it work?

hyaluronidaseHyaluronidase is one of over 75,000 enzymes that are known to exist in the human body. Enzymes are biological catalysts – complex, three-dimensional proteins that perform very specific chemical reactions at the molecular level – one enzyme will carry out only one chemical reaction that only it has the keys to unlock due to its protein shape. Hyaluronidase takes a water molecule and reacts it with hyaluronic acid (HA) to break it down into monosaccharides at one specific type of chemical bond called the beta14 bond.

Several versions of hyaluronidase are made regularly within our body system to manage our lymphatic drainage and clear fluids from the extracellular space within the tissue. It is also a key part of the process of conception as the sperm uses the enzyme to dissolve the HA which presents as the last boundary into an egg before fertilisation.

Animal versions of hyaluronidase (usually originating from the testicles of sheep, cows, and pigs) have been used in medicine for over 60 years to help absorption and dispersion of drugs in subcutaneous tissue, to break down haematomas, and to dissolve hyaluronic acid-based dermal filler products. Pharmaceutical companies have improved purification processes to reduce reaction rates due to subtle differences between the animal-based products and have developed a synthetic human-derived version that is much more compatible.

Why is there a dissatisfaction with filler reversal?

During his video, Dr Chan looked on RealSelf.com at their so-called ‘worth it’ rates for the elective use of hyaluronidase for dermal filler reversal. Analysing this data, we see figures around 40-50%, that is much lower than dermal filler treatment itself, which consistently rates at over 90% in terms of patient satisfaction.

Dr Tim notes that we need to delve deeper into this apparent dissatisfaction with the elective use of hyaluronidase to better guide our aesthetic patients. So, why might you and your patient even be discussing filler reversal?

5 indications for using hyaluronidase to dissolve dermal filler

There is a growing need (or demand), and several reasons why aesthetic clinicians are seeking to use hyaluronidase to dissolve soft tissue filler products.

  1. Emergency – to mitigate the effects of vascular occlusion or compromise leading to filler-induced blindness. This is the most extreme indication for hyaluronidase use.
  2. Over filling – it is agreed that this is on the rise due to the use of high volumes of filler, although the use of hyaluronidase as a correction for this indication has been widespread for 10-20 years.
  3. Migration – another growing problem within a subset of patients where fillers may last for many years and start to migrate and diffuse within the tissue, ultimately degrading their appearance. Similarly, Dr Tim notes a trend for solving loss of definition by adding more dermal filler (the worst thing you could do) that leads to migration away from the treatment zone, often seem with lips where filler is deposited beyond the vermillion border.
  4. Longevity of filler – waiting for filler to naturally metabolise does not always work, with published data noting that some products can last up to 12 years.
  5. Lymphatic obstruction – additional studies have shown that lymphatics may be blocked in some patients, most obviously in the tear trough.

Dr Tim concludes that whilst aesthetic clinicians use hyaluronic acid in cosmetic injectables, we will also require hyaluronidase.

Does hyaluronidase affect the SMAS?

hyalase decisionsDr Tim noted a very interesting discussion within Dr Chan’s original video that looks at the experiences of surgeon, Dr Ben Talei who presented his theory of how the SMAS (Superficial Musculo Aponeurotic System) could be affected by hyaluronidase. He reports on his perception in over 3,000 surgical lip lifts that for some reason the SMAS appears to shrink in size, losing its puffy nature, and its ability to hold moisture is reduced (noted by injecting saline) in a small number of his patients who had hyaluronidase treatment, compared to those who had not had such a reversal, concluding that the use of hyaluronidase can have a life-long effect in some patients.

However, Dr Tim does not believe that such a conclusion can be made with certainty, and states that we cannot draw a causal relationship between this experience and hyaluronidase, as there is a lack of a structured study and data, relying solely on personal experience, and with a specific patient cohort (lip lift surgery) that creates a selection bias, alongside confirmation bias that seeks to confirm a theory during clinical practice.

Ultimately, Dr Tim believes that this is not a reflection on Dr Talei, but that we need more clinical studies and data to move this hypothesis forward. In fact, such studies may cause counter hypotheses which remove any blame from the elective use of the enzyme itself, such as – what if the regular deposition of hyaluronic acid within the skin causes a down-regulation in the natural production of HA, thus years of filler use, and natural dissolution could result in the same clinical presentation (damage to the SMAS due to the suppression of natural HA) without the elective use of hyaluronidase.

He was reassured to note some additional and reassuring data presented in the video from Dr Gabriella Casabona whose experiment observed the effect on the skin of hyaluronidase and showed a decrease in resistance to a pinch test (dose dependent) lasting only 48 hours before a complete return to baseline – this highlights that the enzyme breaks down the natural HA, but the body’s own manufacturing processes replace the loss within two days.

Why are a minority of patients unhappy after hyaluronidase treatment?

The reasons behind such dissatisfaction can be divided into issues of perceptual or real physical changes or a combination of both.

  1. Hyaluronidase is causing a real physical problem in a minority of patients.
  2. Hyaluronidase is used in conditions where it is very easy to create the perception of a long-term problem.
  3. Real changes that you would expect to occur in any reversal go on to cause an additional long-term shift in perception to create the problem.

The video from Dr Chan proposed some further explanations of the potential causes of patient unhappiness with hyaluronidase treatment and the potential reasons for perceived or actual physical changes.

  • Filler stretching the skin – The suggestion that the addition of filler to the face has stretched the skin, thus when it is dissolved, the patient believes it is worse. Dr Tim notes this as unlikely unless very large volumes are in use.
  • Acclimatisation to an over-filled state means that a reversal to normal simply feels worse because it is so shocking to lose so much volume so quickly. Even with a bounce back of endogenous HA, the trauma could still cause a shift in perception.
  • Hyaluronidase damaging the SMAS – the jury is still out as discussed above.
  • Dysmorphic tendency – Patients who seek reversal are more likely to be on the dysmorphic end of the spectrum, more easily traumatised by small changes that are expected and normal and will persist in an unhappy state for a long time.
  • The nocebo effect – The idea that if you go into a procedure expecting the worst or a bad outcome, you are more likely to take note of side effects, whilst ignoring the positives from the experience.

Dr Tim concludes that with growing online groups discussing the sides effects from the use of hyaluronidase, without moderation from medics or opposing views, he would warn any aesthetic clinician about treating patients who already believe that hyaluronidase dissolves normal tissue.

You might also like to read another recent blog where Dr Tim Pearce interviewed Dr Patrick Treacy and asked – Are we overdosing with hyaluronidase?

He also believes that dysmorphic patients will be over-represented in the patient cohort who report bad experiences with hyaluronidase because having an elective reversal usually implies that you were significantly unhappy with your appearance after having an initial treatment.

How to discuss elective filler reversal with your patients

It is a fundamental medical principle to intervene with discretion, clinicians are not omniscient, and it is possible that new evidence could emerge that there are cases where long-term effects are due to hyaluronidase use. Dr Tim confirms that he is yet to be convinced on this fact but urges practitioners to act as if it could be true, and avoid being gung-ho.

Dr Tim Pearce has also helpfully created a downloadable template for a hyaluronidase consent form which is useful to help you to explain the risks to your patients.

Be sure to explore your patient’s health beliefs during the consultation, never simply dismiss anything they verbalise, let them talk about everything they have read on the subject and then systematically share your own understanding. If they believe something that is not compatible with the treatment, then you should not offer it. An anxious patient with a self-loathing attitude towards their appearance, a belief that hyaluronidase can cause facial damage, and a history of treatment dissatisfaction should be handled very carefully, and cautiously, erring on the side of no treatment.

You can find Dr Gavin Chan on his You Tube channel for the Victorian Cosmetic Institute, and why not let Dr Tim know your thoughts on the use of hyaluronidase by dropping him a comment to Dr Tim Pearce on Instagram.

Aesthetics Mastery Show

Filler Dissolver Destroyed My Face

This blog accompanies a recent Aesthetics Mastery Show, where Dr Tim Pearce shared his take on: hyaluronidase indications; the science behind how hyaluronidase works; possible reasons patients are unsatisfied; and his top 3 tips for consulting before elective reversals.

Watch the full Aesthetic Mastery Show episode here:

 

Here’s what deantube said:

“I have to say this was a excellent video, not only is it by default a thorough look on how you critically analysed this argument, and how you formed a well articulated alternative hypotheses, but you did it in such a way the novice viewer could understand and possibly in the further themselves critically analyse pieces of research without bias.”

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Dr Tim Pearce eLearning

Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.

Our exclusive video-led courses are designed to build confidence, knowledge and technique at every stage, working from foundation level to advanced treatments and management of complications.

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