Hyaluronidase is an enzyme that has garnered significant attention in the field of dermatology and aesthetic medicine. Its primary function is to break down hyaluronic acid, a naturally occurring substance in the human body that helps maintain skin hydration, volume, and provide joint lubrication. On Real Self, skin fillers are rated as worth it by 90%, but only 45% say that hyaluronidase treatment was “worth it.” Numerous individual reviews on RealSelf claim that hyaluronidase “wrecked” the person’s skin. Given its critical role in reversing hyaluronic acid dermal fillers, it is essential to answer the question: Does hyaluronidase wreck skin? What does that even mean? To comprehensively address this question, we need to explore the functions and applications of hyaluronidase and potential side effects.
Unwanted facial volume makes her look older. After her filler was removed and replaced with a correct service.
The Role of Hyaluronidase in Dermatology
Hyaluronidase enzymes are naturally present in the body and are involved in various physiological processes. The enzyme that is used to breakdown hyaluronic acid fillers has been used medically for years to help facilitate the diffusion of local anesthesia primarily in ophthalmology for cataract surgery. Increasingly, hyaluronidase has been used to break down hyaluronic acid fillers in several clinical situations.
Perhaps the most important of these applications is as a rescue drug when fillers occlude the circulation and cause tissue ischemia. Circulatory compromise after hyaluronic acid filler is estimated to occur in 5 cases per 10,000 treatments. The injection of larger volumes at a given time is a practice that is more commonly associated with circulatory compromise. Cannulas have been proposed as a method of preventing this issue but studies show that cannula injection also can cause circulatory compromise.
The most serious of these vascular complications is vision loss. A comprehensive literature review published in 2015 of reported cases of visual compromise causes by all types of fillers found 98 cases. A direct survey of retina specialists conducted the same year found only 4 reported cases in the United States. Last year there were approximately 2.6 million filler treatments in the United States. Clinical studies show that aggressive use of the enzyme hyaluronidase can reverse tissue ischemia in the face and prevent scaring. However, there are no studies that establish that the injection of hyaluronidase can reliably restore vision loss after the injection of fillers. Interestingly, a disproportionate number of cases of vision loss from fillers occur in South Korea. This is thought to be due to style of injection. The safest practice is to inject only very small volumes with each injection. This approach is safer but also time consuming so that this safer way of placing fillers is unfortunately not universally practiced. It is important to stress that these types of vascular complications are relatively rare.
A far more common use of hyaluronidase is the adjustment of unsatisfactory filler treatments. This can be lumps, bumps, and other types of immediate treatment over-fill—things that don’t look right after a service. Many of these types of concerns can actually be rolled out by a skilled injector within the first two weeks after a treatment. Beyond that time frame, hyaluronidase, the injectable enzyme, can be used to modify these unsatisfactory treatments. The enzyme can be used to feather a treatment or remove it altogether. In cosmetic practices, hyaluronidase is often used to correct or dissolve hyaluronic acid-based fillers. These fillers are commonly used to address wrinkles, add volume to facial structures, and enhance overall skin appearance. While hyaluronic acid fillers are generally regarded as safe and effective, there are instances where overcorrection, asymmetry, or adverse reactions occur, necessitating the use of hyaluronidase.
Medical hyaluronidase has two common sources. An animal-based product is derived from sheep testicle. The medical term for this source is ovine. Vitrase, a commonly used hyaluronidase, is ovine based. Allergic reactions to this particular product are reported in less than 0.1% of cases. Another source is a genetically engineered product of human hyaluronidase called Hylenex. The manufacturer of this product also reports a 0.1% incidence of allergic reaction. Patch testing for these products is not recommended as necessary by the manufacturers. Patch testing is helpful when there is a question of a prior allergic reaction to exposure to hyaluronidase.
Mechanism of Action
Hyaluronidase works by hydrolyzing hyaluronic acid, breaking down the molecular bonds that hold the actual chemical structures of the filler together. This action immediately decreases the viscosity of the fillers and facilitating its absorption from the tissues.
Potential Side Effects
While hyaluronidase is a powerful tool in aesthetic and medical interventions, its use is not without potential side effects. Commonly reported adverse effects include swelling, bruising, and redness at the injection site. These reactions are generally mild and temporary, resolving within a few days. Severe complications are extremely rare. These include allergic reactions, which may manifest as itching, hives, or even anaphylaxis. It is true and expected that use of hyaluronidase can lead to the degradation of natural hyaluronic acid in the skin however, there is no evidence anywhere that this leads to any type of permament skin change. It is generally believed that natural skin hyaluronic acid is rapidly replaced so that while it might be affected by the injection of man-made enzyme, this effect is short lived. The only hyaluronic acid material that is permanently removed by the injection of enzyme are the man-made products.
Dr. Steinsapir has seen many individuals with the complaint that “enzyme has wrecked the skin.” In all cases, the dose of hyaluronidase injected by the prior treating injectors was inappropriately small and insufficient to actually eliminate the problematic filler. The inadequate enzyme treatment can actually mobilize partially broken-down filler into the higher layers of the skin accounting for localized skin edema. The individuals with this effect mistake this for “enzyme wrecking the skin” based on limited Internet research. In each case, the issue was immediately resolved by Dr. Steinsapir with the injection of an appropriate dose of hyaluronidase. Usually, the dose Dr. Steinsapir injects can be as much as 10 times or more of the dose used by the prior injector. A squirt of enzyme does not fix these situations. Unfortunately, there are no formal studies to guide physicians on the amount of enzyme needed to address these situations. Dr. Steinsapir has been at the forefront of hyaluronic acid filler treatment and its management since these products were introduced to market.
It is important to recognize that someone seeking the removal of a filler service fundamentally is not happy with some aspect of their treatment. It is important to understand that if you got fillers to address some concern, and then felt compelled to removes a treatment, it is highly likely that you will still be happy with the appearance of the face after the removal of the offending filler service. Most patients Dr. Steinsapir sees for enzyme treatment of a prior filler service benefit from the placement of a correct filler treatment or a surgical service when appropriate.
It has been claimed that enzyme causes chronic SMAS damage. The SMAS is the superficial musculoaponeurotic system. It is the fibrous and muscle network of the face. However, this report is merely an opinion. Without a formal clinical study, having an opinion about the basis for an observation tends to be a self-fulfilling, also known as observation bias. It is human nature to see what we want to see. Dr. Steinsapir has not seen evidence of such damage and advises that it is always important to assess the quality of evidence presented to support these types of claims.
Concerns about Long-Term Effects
Increasingly Dr. Steinsapir is seeing individuals who have been receiving hyaluronic acid filler for years. Often, they have a consistent history of getting 1 or 2 milliliters (syringes) of filler two or more times every year for 10 or 15 years. Sadly, this material does not really go away. We have learned that hyaluronic acid filler products can persist for this long or even longer. The runniest of these fillers also spread out in the face. They may have originally been injected in the lips or at the top of the cheek but over time, these products spread out to drift as low as the jawline and drift into the back edge of the cheeks and temple. Lip edge treatment drifts into the upper lip to cause the so-called lip shelf. In some cases, injectors place filler behind the lower eyelid septum resulting in the development of fullness that is often mistaken for herniating lower eyelid fat. Fixing this only requires injection with enzyme, and not lower eyelid surgery.
Patients are often inappropriately offered surgery to address this fullness with surgeons explaining the change represents aging. However, they are mistaken. One or two rounds of hyaluronidase enzyme of a sufficient dose can and will dramatically remove this ancient filler. The effect starts instantaneously with treatment. The effect is so dramatic that many clients are in tears seeing the more youthful face revealed withing minutes of the enzyme service. The fear that the skin and soft tissue will hang when this happens is unfounded. For many, it is like having an enzyme facelift. Literally, they can look 10 or 15 years younger at the conclusion of the enzyme treatment. And, yes for many, it helps to have a bit of filler put where needed about 10 to 15 days after the enzyme service. For travelers coming to see Dr. Steinsapir, he may offer a filler service as early as 4 days after the enzyme service.
Clinical Considerations
From a clinical perspective, the administration of hyaluronidase should not be regarded as a high-risk procedure. It is not. These is simply no evidence that the use of this enzyme does anything but remove unwanted man-made hyaluronic acid filler. There is no evidence that it harms skin texture or integrity. There is a small risk of allergic reaction to the enzyme but the risk is so small (0.1%) that patch testing is not indicated. Obviously, it you have a known allergy to hyaluronidase, you should share this information with your doctor.
The Balance Between Benefits and Risks
The decision to use hyaluronidase involves balancing its significant benefits against its potential risks. For patients experiencing adverse effects from dermal fillers, hyaluronidase offers a reliable solution, often restoring normal appearance and function swiftly. In cases of vascular occlusion, hyaluronidase can prevent severe complications, including tissue death and scarring. Thus, its utility in emergency and corrective scenarios is undeniable.
There is simply no evidence that hyaluronidase damages skin. To the contrary, there is ample evidence that hyaluronidase is an essential service that complements the use of hyaluronic acid filler. Under eye filler treatments are fussy and many injectors lack the skill and aesthetic judgement to reliably provide periocular filler treatment. Please understand that if you had an issue that prompted you to get a filler service and then need an enzyme service to fix that, it is likely that you will need both a properly performed enzyme service and the judicious placement of filler as needed to accomplish your goals. Dr. Steinspir finds that properly done, hyaluronic acid filler performed with the right filler, is one of our most powerful treatment options. Getting the right service the first time is ideal but knowing that there is a reliable way to fix a treatment is an undeniably powerful option.
Conclusion
In conclusion, while hyaluronidase is an invaluable tool in dermatology and aesthetic medicine, its use does carry some potential risks. The service is fussy. Find the right injector can be challenging. It is precisely for this reason that individuals travel from around the United States and the World for Dr. Steinsapir’s expertise. So, If you are living with an unsatisfactory hyaluronic treatment or an unsatisfactory enzyme treatment, please know that help is available with Dr. Steinsapir. No, hyaluronidase did not wreck your skin. Rather than being “gaslit” by injectors with little to offer, know that Dr. Steinsapir can assess you and has the experience and skill to offer you a way forward.
Dr. Steinsapir is a world-renowned cosmetic surgeon specializing in eyelid and facial surgery and services like cosmetic botulinum toxin and facial fillers. He is a board-certified eye surgeon and fellowship-trained in oculoplastic surgery and cosmetic surgery. His private practice is based in Beverly Hills and his office includes an accredited surgery center. He specializes in balanced facial cosmetic surgery for natural results, with an emphasis on minimally invasive techniques. He is sought for his compassion, judgement, and skill in addressing the most challenging issues including the management of prior unsatisfactory filler treatments. Contact us today to schedule your consultation.