January 5, 2023

hyaluronidase

One of the biggest trends of 2022 and into 2023 is the number of lip filler reversals or elective dissolving procedures performed by aesthetic clinicians, confirms Dr Tim Pearce. He believes the growth in this practice is because patients and clinicians alike are realising that many of the dermal filler products last much longer than they first expected. Over time, and repeat treatment, there is a build-up of material and an increasing need to reverse previously performed procedures, even if they were done correctly at the time.

In this blog, Dr Tim will explain more about hyaluronidase, potential allergic responses, and how and when to use it for dissolving lip fillers.

If you are unsure where to start with elective filler reversal treatment – how to effectively discuss it with your patients, carry out the procedure, including how much hyaluronidase to use, and when you can re-treat the lips, or if you are worried about whether you can legally correct someone else’s work, then sign up for Dr Tim Pearce’s Elective Lip Reversal eLearning online course. It includes 15 in-depth learning modules and 5 bonus FAQ videos covering all the core knowledge and skills you will need to embark on elective lip filler reversal.

Also, introducing Dr Tim Pearce’s 8D Lip Design training course – the world’s first online lip training with interactive 3D anatomy and injection animation.

What is a lip filler dissolving procedure?

Dermal filler products in the lips can change position or volume over time. When a patient is treated with a hyaluronic acid (HA) based dermal filler, you can dissolve the treatment result using hyaluronidase, an enzyme that breaks down the HA into its monosaccharide units.

This a fantastic benefit to using hyaluronic acid-based products, however, dissolving with hyaluronidase should not be done willy-nilly, warns Dr Tim, because there are potential risks, the most common of which is the development of an allergic response to the enzyme.

The best way to avoid the development of an allergic response is to decrease the total exposure to hyaluronidase by achieving the dissolving result preferably in one session and not spread out over several, which could initiate an allergy. The aim is to place enough hyaluronidase into the lip to dissolve the remaining product and allow the patient to feel more confident to either continue without a further treatment or to retreat in a way that makes them happier with the result.

Sadly, Dr Tim notes that there is a cohort of patients who fit into a tennis match pattern – treat and reverse, treat and reverse – which never ends well and should be avoided by using hyaluronidase as little as possible to electively dissolve lip filler in patients who are consented and well informed about the aim of a good outcome and the risks associated with treatment.

It is vital that you gain consent from your patient before proceeding with an elective lip filler reversal treatment. Dr Tim has created a hyaluronidase consent form that you can download and use for free within your clinical practice.

How many people are allergic to hyaluronidase?

It is difficult to find data on the prevalence of allergy to hyaluronidase. Dr Tim discovered one clinical paper that suggested a rate of approximately one in two thousand people, which is quite low, but is probably a higher risk than anything else that we routinely use in medical aesthetics.

However, it can happen; Dr Tim has seen it a couple of times in his clinic, but very few cases get reported, although, hearsay suggests very small numbers end up seriously ill from hyaluronidase exposure. As aesthetic clinicians, particularly if you are a loan practitioner in a clinic without local support, you may wish to mitigate your risk and reduce the chance of finding yourself having to deal with anaphylaxis.

Aside from allergic reaction, there are no other serious, proven risks with hyaluronidase use, but it is worth knowing if you intend to offer this option to patients, that there are some who believe that hyaluronidase causes other tissue to dissolve, particularly collagen. Dr Tim does not believe there is any real evidence to back this up, although there are many people who will claim personal experience which is very hard to quantify from photographs. He maintains that he would be very reluctant to treat a patient with hyaluronidase who had a belief that it could dissolve collagen because you are already setting yourself up, as a practitioner, for a negative outcome. Ensure you consult your patients thoroughly to establish such red flags.

For more on this, read does hyaluronidase dissolve natural tissue and dissolve faces?

What is hyaluronidase?

fish lip fillers overdoneHyaluronidase, as mentioned is an enzyme that breaks down hyaluronic acid. It is a natural substance and all our lives started with hyaluronidase because the enzyme is found on the tip of the sperm which gives it the ability to break its way through the egg for fertilisation, dissolving the hyaluronic acid that coats part of the ovum, resulting in a baby.

Hyaluronidase is present throughout nature. As humans, we have it in our bodies to help with the natural turnover of hyaluronic acid. There are many hyaluronidase products used in medicine, including a genetic, recombinant version based on human hyaluronidase, but others come from purified animal proteins, e.g., bovine, or porcine testicles. This means that it is a very similar enzyme to our natural hyaluronidase but with some very small differences, hence the risk of allergic reaction.

Hyaluronidase adds water to the polysaccharide chain within the HA filler, splitting it in half through a process called hydrolysing. It does not dissolve it, per se, it adds water and splits these sugars into small monosaccharide components, so they float off, breaking up the hyaluronic acid.

How do you know when lip fillers need to be dissolved?

In medical aesthetics, Dr Tim believes that clinicians make three diagnoses for the use of hyaluronidase to dissolve lip filler.

  • Medical (emergency) – to dissolve dermal filler in an emergency due to a complication such as vascular occlusion.
  • Social (elective) – when other people are rejecting the patient because they do not like the lip filler, they appear over treated or unnatural. The patient may know this or can be advised by the clinician, sensitively.
  • Patient-led (elective) – this is the most common, when the patient’s experience is that they do not like how the filler is making them feel and they want to get rid of it.

When should you let dermal filler dissolve naturally over time?

For patients who are early in their treatment journey who have mild over treatment causing mild upset, Dr Tim suggests leaving it a couple of months to see if it settles. There are patients who break down dermal filler quite quickly, with it disappearing after six months, so it could all resolve naturally.

However, there are others where the material appears to persist for months, even years longer than claimed by the makers, and this is the cohort that could benefit from elective filler reversal. If they were treated one to two years ago, the product is still present, and the patient dislikes the look; in these cases, enough time has passed, and the filler is less likely to resolve naturally.

How long does it take for natural hyaluronic acid to restore and the skin to return to its previous state after dissolving?

Differing viewpoints on natural hyaluronic acid persist in answers to this question, notes Dr Tim. We know that HA is produced in a continuous production cycle by the body, being replaced approximately every 36 hours. If you dissolve all the HA in an area, it will probably take four or five days to fully replenish with natural HA.

Ideally, we should be telling patients that within a week, the natural hyaluronic acid levels should be resumed, however, they may not perceive this to be true because if you have dissolved several millilitres of dermal filler to resolve an over treated lip, plus their natural hyaluronic acid, it will be a bit of a shock to observe the change and you must council your patient accordingly.

For more on elective lip filler reversal, check out some more of Dr Tim’s blogs where he looks at how to effectively consult and consent a patient for elective lip filler reversal including the types of patients who seek reversal treatment, and how they feel about elective lip filler reversal. He also discusses the indications for elective lip filler reversal and asks can you perform a second elective lip filler reversal and who pays?

You can find Dr Tim Pearce on Instagram if you have any questions or comments about using hyaluronidase to reverse hyaluronic acid-based dermal fillers.

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Aesthetics Mastery Show

Dissolving lip filler

As patients increasingly want a ‘natural’ look, 2022 has seen an increase in lip filler reversal procedures. In this episode, Dr Tim discusses what you need to know when it comes to dissolving lip filler using hyaluronidase.

The show has had over 4,000 views and over 20 comments in the first week alone. Read more and join in the debate on our YouTube channel.

 

Lip Filler Reversal eLearning Course

If you want to increase your confidence by learning how to handle complications, Dr Tim Pearce offers a range of comprehensive courses that are highly rated by our delegates:

In addition, browse our FREE downloadable resources on complications.


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.

Thousands of delegates have benefited from the courses and we’re highly rated on Trustpilot. For more information or to discuss which course is right for you, please get in touch with our friendly team.

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