Hyaluronic Acid Fillers: Enhancing Facial Features and Addressing Unwanted Volume
Hyaluronic acid (HA) fillers are a popular choice for enhancing facial features, restoring volume, and smoothing out wrinkles. These fillers are known for their natural-looking results and minimal downtime. However, sometimes the desired outcome may not be achieved, or the filler may migrate, leading to retained or unwanted volume. Over time, aging fillers can retain more water than when initially placed, making changes noticeable years after the procedure. In such cases, hyaluronidase—an enzyme that breaks down HA—can be a game-changer. But is it necessary to have an MRI or ultrasound to locate the filler before using hyaluronidase? Let’s explore the role of hyaluronidase, the necessity of imaging, and the process of addressing retained and unwanted fillers.
Understanding Hyaluronic Acid Fillers
Hyaluronic acid is a naturally occurring substance found in the skin, connective tissues, and eyes. It has a unique ability to retain water, making it an excellent hydrating and volumizing agent. HA fillers, such as Juvederm and Restylane, are synthetically produced and are cross-linked to increase their longevity. Unlike natural hyaluronic acids, these fillers resist breakdown, lasting months or even years. They are injected under the skin to provide volume, reduce wrinkles, and enhance facial contours.
When first introduced into the market, manufacturers claimed these products last about 12 months, but clinical experience suggests a more realistic time frame of 6 to 12 months for optimal results. Over time, the fillers don’t disappear but rather spread out, diminishing their precise filling effect and leaving a more generalized volume. This gradual breakdown is slow, with unwanted volume sometimes persisting for years. Aging filler can retain more water, leading to fuller, older-looking faces as it migrates to unintended areas.
The Role of Hyaluronidase
Hyaluronidase is an enzyme that specifically targets and breaks down hyaluronic acid. While naturally present in the body, injectable forms are used in higher concentrations for medical and cosmetic procedures to rapidly dissolve HA fillers. The enzyme works quickly, breaking down filler within seconds, and continues to be active for about 24 hours. For recent treatments, small amounts can be used to make minor adjustments. However, older filler may require larger doses and possibly multiple sessions for complete removal.
When is Hyaluronidase Used?
1. Correction of Overfilling: If too much filler has been injected, leading to an unnatural appearance, hyaluronidase can help reduce the excess volume.
2. Migration of Filler: Fillers may migrate from the original injection site, causing lumps or unevenness. Hyaluronidase can dissolve the misplaced filler.
3. Adverse Reactions: In rare cases, allergic reactions or other complications may occur. Hyaluronidase can alleviate these issues by speeding up the breakdown and removal of the filler.
4. Unwanted Aesthetic Results: If the filler treatment doesn’t produce the desired outcome, hyaluronidase offers a way to reverse the effects.
5. Persistent Facial Volume: Over time, aging fillers can retain water and migrate, leading to unsatisfactory facial volume. Hyaluronidase provides a practical solution for removing this excess volume.
Is Imaging Necessary?
The necessity of using MRI or ultrasound to locate filler before using hyaluronidase is a topic of debate. Here are the arguments for and against imaging techniques:
Arguments for Imaging
1. Precise Localization: MRI and ultrasound can accurately locate filler, which is useful when the filler has migrated or is not visibly apparent. This precision helps in targeting the exact area for hyaluronidase injection.
2. Safety: Imaging can help avoid complications by ensuring that hyaluronidase is injected only where needed, especially in areas with critical structures like the eyes or lips. However, experienced clinicians can often discern the problem without imaging.
3. Assessment of Complications: Imaging can be valuable in assessing complications, such as vascular occlusion or granuloma formation, although these issues are rare and can often be managed without imaging.
Arguments Against Imaging
1. Clinical Expertise: Experienced practitioners often rely on clinical expertise, direct visualization, and patient history to identify filler location. This approach is usually sufficient to achieve excellent results with hyaluronidase.
2. Cost and Accessibility: MRI and ultrasound are expensive and may not be readily available. Relying on these technologies can increase the overall cost of treatment.
3. Time-Consuming: Scheduling and performing imaging can delay treatment, and in many cases, imaging does not contribute significantly to the outcome.
Practical Approach to Using Hyaluronidase
Initial Assessment
A thorough initial assessment is crucial for a successful outcome. This includes:
Patient History: Understanding previous filler treatments, the type and amount of filler used, and any complications experienced.
Physical Examination: Visual assessment, supported by old photographs, helps identify where volume has accumulated and whether migration has occurred.
In cases involving both hyaluronic acid and non-hyaluronic acid fillers, hyaluronidase will only remove HA fillers. Despite mixed fillers, enzyme treatment often provides significant improvement.
Decision-Making Process
Experienced practitioners like Dr. Steinsapir have found that MRI or ultrasound is unnecessary in most cases of old, retained fillers or unsatisfactory recent treatments. Filler is typically identifiable and accessible without imaging.
Administration of Hyaluronidase
1. Informed Consent: Patients should be informed about the procedure, potential risks, and expected outcomes, including the possibility of multiple sessions.
2. Test Patch: Although allergic reactions to hyaluronidase are rare (0.01% incidence), it’s essential to address any concerns, especially with patients who have known allergies.
3. Injection Technique: Hyaluronidase is injected into the area with retained or unwanted filler, with dosage and injections tailored to the amount of filler to be dissolved.
4. Monitoring and Follow-Up: Patients are monitored for immediate reactions and scheduled for follow-up visits to assess the effectiveness of the treatment. The goal is not to remove every bit of filler but to achieve a satisfactory reduction in volume.
Conclusion
Hyaluronidase is a valuable tool in aesthetic medicine for addressing retained and unwanted HA fillers. While MRI and ultrasound can identify retained filler, they add little to what an experienced clinician can discern through assessment and examination. Imaging is expensive, inconvenient, and often unnecessary.
Choosing a skilled clinician like Dr. Steinsapir, who has extensive experience in managing filler treatments, is the best way to achieve the desired aesthetic results. For a detailed in-person assessment, schedule a consultation with Dr. Steinsapir today.
About Dr. Steinsapir
Dr. Steinsapir is a world-renowned cosmetic surgeon specializing in eyelid and facial surgery, as well as cosmetic botulinum toxin and facial fillers. He is a board-certified eye surgeon, fellowship-trained in oculoplastic and cosmetic surgery. Based in Beverly Hills, his private practice includes an accredited surgery center. Dr. Steinsapir is sought after for his compassionate approach, sound judgment, and expertise in addressing challenging cases, including unsatisfactory filler treatments. Contact us today to schedule your consultation.