Hyaluronidase (dissolver) is a crucial tool for correcting hyaluronic acid filler complications, but its use requires careful consideration due to potential risks, particularly in certain facial areas, and the possibility of permanent damage to natural hyaluronic acid.
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all right so just uh had a couple
minutes between cases and I've gotten
requests to do videos on certain things
so this one's just a quickie about dissolvers
dissolvers
um I think a lot of patients and doctors
have a poor understanding of what
dissolvers do and I'm talking about
hyaluronic acid dissolvers how you run a
base which is an enzyme that goes and
breaks up the
linkage of the sugar molecules within
hyaluronic acid fillers and it turns it
from a gel into a slimy slippery bit of
water and then your body reabsorbs it at
that point so uh
dissolvers are used to get rid of
fillers and it's a great thing to have
because injectables as you've probably
noticed are not fully predictable you
might place them in one little area and
it can move where it can draw in water
it can become superficial they can do a
lot of different things so it's nice to
have the option to reverse them or get
rid of them
the way it works is just with a simple
injection you place it wherever you see
the filler and it can disperse and
dissolve some of the filler the issue is
it dissolves hyaluronic acid and it's
not specific to hyaluronic acid injected
as a gel it can dissolve your own
hyaluronic acid so a lot of doctors
don't believe that for some reason they
think it would just dissolve the
hyaluronic acid gel for some reason but
that's not true and I know that as a
fact because I've seen the results
directly during the dissolution and
after dissolution of fillers during a
surgery and if you look at different
parts of the face different parts have
different amounts of hyaluronic acid
content so
if we look at an area like the under eye
where there's not much in terms of skin
thickness those areas have less
hyaluronic acid because the dermis is
thinner has less hyaluronic and there's
really no smash there the smash is a
very thin layer enveloping the facial
musculature at that point whereas if you
go down to the mid face the smash is
pretty thick all across here and the
dermis is thick as well so these areas
have the most hyaluronic acid which
means they have the most to lose so
hyaluronic acid naturally in your skin
exists and it's what hydrates your skin
what keeps it kind of fluffy not just
the fat the hyaluronic acid draws in
water and without that you'll look
shriveled and dry and old and gone so
it's very important to have the
hyaluronic acid so
um dissolvers they come in different
forms some of them come from like
testicles some of them are from Human
there's different ones the ones in the
US that use are usually either vitrace
or Highland X they're different forms of
high runidase and they have a a pulse
duration of about 30 minutes or so until
they stop working so when someone's
doing pulse treatments meaning they're
trying to dissolve something repeatedly
during a vascular event they would
inject it wait 30 minutes to three hours
depending on how much they wanted to
wait and then re-inject it again to get
it to work more again
and that's the case with all of them the
units that they come in are very
difficult for people to understand so I
try not to even measure things in units
for other doctors I just tell them
generally this is what I do and as long
as the hyaluronidase hits it it'll work
so it's not largely dose dependent but
you do have to have enough to to make a
difference so areas that don't cause
problems when you dissolve the most
common area that we dissolve is the
under eye and the upper lip the under
eye when you dissolve can deflate
dramatically you can lose a lot of water
volume immediately and the eye will look
like it collapsed and if you don't
prepare the patient for this which
happened to me before uh
they'll think that something terrible
happened even though you told them it's
going to get Hollow they think that
something excessive happened because all
this water that's been sitting there
forever goes even if you dissolve this
much Juvederm there's going to be that
much water on top of it so it really
dehydrates and collapses and they'll
look severely dehydrated gaunt and
crepey in this skin for a couple of days
until the body starts to rehydrate
itself now in that area it's unlikely
you're going to damage any or much of
your own hyaluronic acid so you can kind
of go to town on it with the only
downside being if you hit superficial
you're going to make the skin quality
worse so you have to really try to stay
deep if you can unless you have to go superficial
superficial
in those cases when I'm doing the under
eye dissolving I usually it's in the
case of Juvederm or voluma voluma should
never be placed in the under eye
Juvederm should never be placed in the
under eye but people do it I had a
patient today who had Juvederm placed in
the under eye in most conferences
worldwide for years now everybody's been
in accordance that you don't put it in
the under eye it's not meant to go in
the under eye and the hyaluronic acid
pillars are very different so nobody
should think that they're all the same
or react the same so either way I would
dissolve it
have them I tell them they're going to
get bruised because it weakens the
vessel wall as well when you do the
solution of fillers the hyaluronidase
can actually weaken the vessel wall and
you bruise more easily so they typically
do bruise even for a regular injection
you might not so it goes down they come
back about four days later re-inject if
you need to four days later you check
again and then you can refill if you
want if you don't touch it it'll get
exaggerated and then it'll Rebound in
hydration over the course of about two
weeks just in case they don't want it
refilled which is fine so that's over
here the area in the face that causes
what I call filler dysmorphia or
dissolver dysmorphia is in the mid phase
so body dysmorphia or facial dysmorphia
is when a patient sees something wrong
with themselves that nobody else sees
that's called dysmorphia you have an
altered kind of version of yourself that
nobody else can see so
this area over here is filled with
natural hyaluronic acid filled with it
dermis is thick smash is thick and those
areas are what contain mostly hyaluronic
if you put dissolver in this area to get
rid of a filler you're going to shrink
your own tissue and it's going to become
deflated deflated is one of the worst
things that can happen to you deflation
in the mid face makes you look old makes
anesial labial folds look harsher it
makes your skin look like it has poor
quality so I advise strongly against
dissolving this area in the face unless
you have to or else your patient can end
up with dissolver dysmorphia dissolver
dysmorphia means they got dissolved and
usually not once whoever's going to
dissolve you here is going to do it
several times because it's not going to
work properly
once twice three times four times
multiple times usually and then they'll
mix in a radio frequency to shrink
things more so they develop dissolver
dysmorphia which means that they look at
their face and they feel like something
is so different they don't look like
themselves their photos all look
different and they do they lost the
brightness on their skin they look older
they look collapsed they look like they
lost 100 pounds it's a very strange look
however doctors generally don't identify
it because it's a very vague thing to
happen it's not something that you can
identify like there was a DOT there and
there's not a DOT there anymore it's a
vague change in the consistency and
health of the skin so it's very hard for
doctors to see it that disparity between
what the doctor sees and what the
patient sees is why we I call it filler
or dissolve or dysmorphia it's because
they end up obsessed with it they can
never fix it or they try to fix it for
years and the doctor can't see it and
work in their friends but if you show
them a picture
everybody sees that there's obviously
something wrong in the after photo so I
always advise please don't dissolve here
unless there's a discreet nodule you're
going after and instead if you're trying
to shrink that area from prior filler
try something like profound profound can
shrink the skin and tighten it at the
same time it'll increase the metabolism
of filler because your metabolism in the
face goes up when your immune system is
revved up like in it from an insult like
radio frequency so that's the way to
avoid that problem now let's say you go
and dissolve this area down in the mid face
face
some doctors say your hyaluronic acid
will come back I'll tell you for a fact
that that is not that is an uncertain
statement you cannot know if the
hyaluronic acid will ever come back
because I've operated on people who have
had dissolver and I know the natural
thickness of the smash in different
areas of the face because I'm always
staring at it always cutting it always
analyzing it and people who have had
dissolver before sometimes even four or
five years later I've gone and made
incisions for a lip lift or a facelift
and this mask is still thinner than it
used to be so some people never recover
they're hyaluronic that you dissolved
some people do you don't know who that's
going to be how long is it going to take
some people a year some people three
years some people 70 recovers and the
rest they'll never get so I advise
doctors not to take it for granted we
dissolve because we have to and always
dissolve because you have to it's not an
entirely safe thing to do although the
benefits usually outweigh the risks
that's why we do it and the upper lip
it's a very common area
to dissolve fillers because in the main
culprit as everyone's heard me say a
million times by now and if you haven't
gotten it please get it it's Juvederm
Juvederm is the devil of lip filler in
this area the devil of under eye filler
I do use Juvederm and the lip if it's a
patient with Scleroderma or fails all
other hyaluronic acid fillers because
Juvederm does have that benefit of
drawing in water and Lasting a little
bit longer especially on resistant lips
however it can migrate so let's say you
inject over here it can crawl up and go
about a centimeter North silicon can go
two three centimeters Juvederm goes
about one centimeter Restylane and velor
volbella all the others go about two
millimeters three millimeters something small
small
the other thing to know is that
hyaluronic acid here once it's there can
last about 10 years plus so it's a
mistake to think that you had one place
two years ago and it's gone when it's
placed here it can migrate up it
migrates even more if a doctor injects
from here down so that's something I
never understood there are doctors who
take their needle and they inject it
from here down with
I'm not sure why I think it might be
because they think they'll bruise less
they might be because they think it
hurts less I I don't know why either way
the vector of injection is completely
wrong uh you're gonna end up getting
more lumps and bumps when you go that
way you're going to end up with more
Super Vermilion filler because you have
to from the way it's injected and your
you're going to get more uh migration to
filler because of direct backtracking
along the needle line pretty fast so
um I don't think it's a smart idea to
ever inject from up here unless you have
a really really good reason on one
patient out of like a thousand that
you've done otherwise injections should
always be done from down here either
cannula or needle that's all technique
dependent the only thing that I'd say is
uh unanimously or often wrong is going
from top down
so let's say you inject it over here
uh the filler can migrate North about a
centimeter and it typically infiltrates
into the smash layer which sits on top
of the muscle and it draws in water so
when this happens the lip gets thicker
you look more like a monkey and your lip
gets floppier because the muscle can't
Flex anymore
when muscle has water in it it kind of
lays out and it can't Flex anywhere and
the lip is a very sensitive muscle as
you know it talks and so it's the one
that moves and does this and kisses and
it's a very Dynamic very sensitive
muscle you don't want to tamper with it
in any way that's why I tell people
don't do threads around the lip that's
why I tell people don't do fat around
this area because it can go inhibit
muscle movements you have to be super
super careful with that so either way it
deposits itself mainly onto the smash
layer which is the thick cushy tissue
layer that's under the dermis and above
the muscle it's in that area
all you have to do is put small amounts
of dissolver what I do is I use vitres I
use 10 units of vitres and a 0.3 cc
syringe so I use 10 units of bitrace and
I use 20 units of Lidocaine one percent
because it buffers it it's a painful
burning sensation when you uh put in
dissolvers so 10 and 20 is usually
adequate so you have 0.3 CC's which will
dissolve this either entire half of the
lip or lateral to the field trim and 0.3
for this side so 10 units plus 20 of
Lidocaine that's your mix I have them
come back four days later we take a look
at it I tell them listen I might
dissolve your own hyaluronic and you
might end up with a little indentation
or wrinkling there that you didn't have
before or you didn't know it was there
before because you've been expanded for
so long with unnatural filler not a big
deal when they come back in if they have
that little red Ridge of indentation
right along the Vermilion which is
usually where it is you grab your needle
of Restylane wrestling is the easiest
one you can use other ones too but
wrestling's the most predictable for
this you put your needle in and as you
draw it out you put a scant amount and I
say scant because all it needs to do is
put the tiniest little micro droplets
back into the smash and you'll see how
rapidly water comes in and hydrates it
you don't want to fill it back up you
just want a little stimulation for
hydration so that's why I use the rest
insulin after that the tiniest tiniest bit
bit
I usually dissolve wait about four days
check it again to see if I need to
dissolve again wait about four days and
refill you do not want to do repeat
dissolution repeat dissolving can damage
your own Smash and your own dermis and
it may never recover you have to know
that another area people get the
dissolver dysmorphia is down over here
in this area this is also a common area
to see migration where the doctor will
go and they have a deepened marionette
or pre-gel sulcus in this area and
they'll try to fill it to camouflage the
indentation however it can migrate back
into this fold and if it does then all
of a sudden this weighs down and this
can happen here on the corner of the lip
right over there where it hoods down
it's very common so they get a bulge
here above the modiolis or it can happen
here and it gets deeper and usually
there it's not a first time injection
it's somebody who's had injections
multiple times and they're already
masculinized and looking boxy and kind
of full down here and then you do one
more and then it migrates up and it
starts making it heavier
when you dissolve those areas you also
can end up with the filler dissolver
dysmorphia because it's a very sensitive
area to dissolving for the same exact
reasons as here is thick dermis fixed
Mass lots of hyaluronic acid so you'll
see a bigger difference in deflation it
can also it's an area where you see more
indentations the last reason why this is
worse is because you have a very strong
muscle contraction in this area from the
depressor angulia Oris mentalis is here
at the presser labia inferioris is here
and they pull down pretty hard and those
are strong muscles now let's say you're
somebody who has these areas forming
prematurely it's usually because you're
also using your depressors prematurely
and hyperactively so if you have
prominent teeth then you can't close
your mouth so well
depressors get stronger over time so in
that person when you go do a dissolver
their muscles already stronger now
you've deflated it where you can see the
muscle contracture Under the Skin and it
gets even deeper so that's something I
always caution against
dissolving this area again that's
something I like using profound radio
frequency for it can shrink the area
instead so those are the main areas that
you're going to be using dissolver the
other areas in the nose or for little
balls of the Vermilion I would say in
the nose and in the Vermilion these are
areas where you don't need to dissolve
so doctors forget that the dissolver is
a gel and sometimes it congeals and when
it congeals it congeals into balls into
capsules or just into little tiny uh
spheres so you get little spheres of
filler along the edge here rather than
dissolving it and bruising the person
really badly why don't you just grab the
same needle you injected with which is a
27 gauge for the most part you poke it
in there and you push it and you'll see
the little bead of filler come out in
the nose in the nail nasal tip that's
another area that congeals from too much
filler it's also pushing the nasal
cartilages apart which is a bad thing so
instead of dissolving here I I usually
go and I grab a needle I poke it and I
squeeze it out and you can do anything
up to even a 20 gauge if you really had
to but you don't need to usually like a
nine a 22 gauge is huge and that'll
allow all the filler to come out so you
do it with a poke alternatively I've had
strips of filler that are superficial
and I want to get them gone and I know
that some fillers here can cause nodular
hypertrophy which means thickening of
the mucosa and what I do is I grab a
little dissolver I poke it into the
areas that have those little nodules
even here I could put a little dissolver
in there tiniest bit I use that to
liquefy it now I can put in my needle
and squeeze it out put in my needle and
squeeze it out the benefit of doing that
in the nasal tip is that most patients
don't want you to get rid of all the
filler so how can you control that
dissolver is not controllable dissolver
will go dissolve whatever it wants to
dissolve if you want to control it
naturally just aspirate it yourself put
in a needle squeeze out take a look at
it squeeze it out take a look at it and
say you know what I can leave the rest
of the filler now not a big deal the way
you know that's happening in the nasal
tip is usually because it looks like a
ball or it becomes translucent you put
up a light to it and the whole thing
glows it glows like a bright little
light bulb that means that you've
congealed filler on the nasal tip
this area in the glabella is another
area that's notorious for drawing in
water and getting heavier over time the
worst filler for that I mean obviously
radius you don't use in the nose never
use radius on the nose uh this is I mean
I always say this is a joke but unless
you really hate somebody and if you
really hate somebody and you don't care
about the repercussions so you don't use
radius in the nose because what if you
hit a vessel you can't get rid of that
you've blinded them otherwise the other
problem is that it can draw on water
over time and calcify the area it's not
good so out of hyaluronic acid the worst
you could put in there is Juvederm
Juvederm can draw in water and all of a
sudden you get this really heavy
glabella that thickens and widens over
time and patients don't know they had it
because it's been years it takes years
and when things happen over years
patients don't realize it so it's up to
the doctor to feel it and see oh my God
that's not natural it doesn't feel like
my nose it feels doughy and thick that's
filler that's filler accumulation so
that's another area where I really like
to put dissolver you're at very minimal
risk dissolving in this area do not let
it hit the writing on if you get over
this thin skin area all of a sudden you
can kind of see through to any bumps or
anything that are underneath so make
sure never to hit here this is safe but
put your finger around it and do it responsibly
responsibly so
so
I think that's it never dissolve someone
too much
never tell someone you can get rid of
all their filler it's not possible even
here when I dissolve it gets rid of like
70 percent dissolve again 70 of that
dissolve again 70 of that filler residue
will remain filler residue will rain in
the whole face once it's injected you
have it and it could be for life even
though these things are supposed to last
a couple years I think it's very rare
for the body to reabsorb all of it
little microscopic portions can always
stay and they can draw on water make
your under eyes tired do a lot of
different things so I'd never tell a
patient that this stuff is temporary I
would say the effect can be temporary
can be temporary just like threads you
don't say it's a temporary thread
um you know and that's like calms the
patient down to think okay well I don't
if I don't like it it goes away no it
sat there for six months nothing sits in
your face for six months and doesn't do
something it's not fully inert so that's
why if it were fully inert the threats
wouldn't get eaten back up they get
eaten back up which means they're not in
there your body hydrolyzes them when
it's hydrolyzing that means it's drawing
in cells to do it and it's going to draw
in immune cells too and fibroblasts and
it deposits collagen or fibrotic type of
scar tissue so
hyaluronics fortunately do not really
form Scar Tissue they're pretty benign
it's a gelatinous material but it can
hypertrophy or thicken tissue or expand
it over time by drawing in water
staying in the mucosa it can cause
nodular changes to the point where you
can't even dissolve it you say oh my God
I had to dissolve 20 times it's still
there well it's now a nodule it's no
longer just filler you have to cut it
out so those things happen too but never
jump to cutting it out never jump to you
know doing anything if you don't have to
don't dissolve people if you don't have
to only dissolve if you need to and if
you're going to dissolve somebody make
sure you do it delicately and you're
ready to take on this show that you
just started because it's going to be
two weeks where they don't feel good
about themselves
and if you don't know how to do it very
predictably and tell them how it's going
to happen which has happened to me I've
done it on patients and I knew exactly
what I was doing and I knew exactly what
was going to happen but I'm not the most
eloquent person sometimes I come in the
room I kind of like okay I'll fix this
I'm a mechanic I'll go boom boom boom I
do the injections I'll see you in four
days I'll take care of it don't stress
they come back crying because I didn't
explain it well enough and it's
completely my fault I've learned since
then I don't do that anymore now I'm
very very clear about what's going to
happen and I tell patients over and over
again I hate doing this on people if I'm
doing this to you it's because you want
me to please don't ruin my life after I
inject you it's this is exactly is going
to happen and so you really want to
dissolve uh candidates that are already
emotionally to go through it candidates
that have the time to go through it
because they'll Brews they'll Hollow
they'll sink skin gets crepey it's
dehydrated it takes a while to come back
you can fix most of it but uh it's a
it's a process so all that means is
don't take it for granted dissolver
although it's a lovely thing it is uh by
no means risk-free by no means is
dissolver risk-free so
um if you have patients that need to be
dissolved feel free not to send them to
me you can send them uh to plenty of
other people I do deal with like the
worst cases when nobody else can take
care of it but Jen my nurse practitioner
loves doing that stuff now
it's a bit of an emotional toll
sometimes although patients once we do
it the people who love it the most it's
for the under eyes and the lip those are
pretty straightforward areas their
parents love me their parents come back
like oh my God you give me my kid back
oh my God she looks like she used to
uh or I don't look tired anymore uh
so it's there's huge benefits to it and
patients are very confused sometimes
with under eye filler because they have
no wrinkles since it's all blown up and
they think okay well wrinkles hollowing
it's the same thing they're very
different it's another you know fillers
in the under eye are just one more thing
that can give you bogginess and a tired
appearance under the eye although it's
not hollowing anymore it's a different
tired appearance it's bogginess uh water
it looks allergic it looks blue it's
nasty so either way if you have any
questions you can always ask me about
this stuff
um I will try to do some videos maybe on
dissolver it's not that exciting but
happy to uh and hope everybody is loving
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