Filler Dissolving with Ultrasound Guidance and Hyaluronidase
Filler has recently become less popular with more and more people starting to realize the long term risks. Filler lasts much longer than 1-2 years, gets stiffer, and naturally degrades unevenly resulting in a lumpy appearance. Filler builds up over time and can migrate from its original intended location. Because filler attracts water, an over-filled, puffy appearance may occur. Consequently, many people are now interested in having their filler dissolved and opting for other treatment options instead.
What types of filler can be dissolved?
Hyaluronic acid (HA) filler can be dissolved with Hyaluronidase. Whereas other types of filler (Bellafil - silicone) and Sculptra or Radiesse (biostimulators) cannot be dissolved with Hyaluronidase. Some types of filler such as Juvederm is more difficult to dissolve due to it’s extensive chemical crosslinking.
A study published in Jan 2023 in the Journal Molecule describes how different brands of Hyaluronidase such as Hylenex is superior to Hyalase in dissolving filler. Luckily, Hylenex is readily available in the United States. Read the full article: article link
How many sessions of Filler Dissolving will I need?
People are most often surprised by how difficult it is to dissolve filler and by the number of sessions it requires. For 1 syringe of filler, it is not uncommon to require 2-4 sessions of filler dissolving and several vials of Hyaluronidase to achieve the desired outcome. It’s much easier to dissolve filler when there is a large collection in one spot. However, most of the time filler is dispersed in tiny amounts diffusely. For those who have had many syringes of filler over many years, it could require 10 - 15+ sessions of filler dissolving, and yet not all the filler will be entirely dissolved.
How does Ultrasound help to dissolve filler?
Ultrasound increases accuracy and efficiency by allowing direct visualization of filler location and depth as well as proper cannula or needle placement. An ultrasound with doppler capability can help distinguish the difference between vessels and pockets of filler as both will appear dark. Silicone filler such as Bellafil will look different than HA filler. Ultrasound can also help to reduce the risk of bruising or hematoma formation by allowing visualization of the vessels to avoid.
It’s important to remain up to date on the most current clinical data for best outcomes with a commitment to safety. It’s also important to have the best equipment with proper features to allow for visualization of superficial anatomical landmarks. Dr. Kaplan at Rejuve Medspa in Newcastle, WA has over 25 years experience using ultrasound and has expertise in dissolving filler.
What are the common reasons to dissolve Filler?
Changing Trends: Sometimes we change our minds about following trends such as big lips, big cheeks, or pointy chins. Nothing wrong with wanting to revert back to your original or more natural appearance.
Filler Migration: Over time, filler can migrate from its intended location. Lip filler injected into the vermilion border can migrate outside of the lips. While lip filler injected too close to the wet/dry border can cause a lumpy or uneven smile along the inside border of the lips. Gravity and muscle contractions can eventually cause mid cheek filler to migrate downwards, causing an accentuated fullness to the lower cheeks and worsening the appearance of the nasolabial folds. Chin filler can migrate below the jawline causing an unusual contour.
Unnatural appearance: We often lose sight of how we look. Slowly adding more filler over the years can eventually lead to an over-filled look.
Lumps and bumps: Lip filler injected too superficially can cause a bumpy appearance. Under eye filler can frequently cause a lumpy appearance.
Bad outcome: Sometimes, filler can lead to delayed nodules or even infections (recurrent abscesses) in which case, the filler should be removed entirely.
Vascular occlusion: Filler inadvertently injected into an artery can cut off the blood supply to the surrounding normal tissue, leading to necrosis. If this happens, the filler should immediately be dissolved. In rare cases, even blindness or stroke symptoms can occur.
Do I need to remove all of my filler or can I keep some of it?
Not everyone wants all of their filler dissolved. Sometimes removing a small amount of filler can help achieve the desired outcome. If there is a nodule or complication related to old filler, it’s probably best to dissolve everything and start over with a clean slate.
How soon after getting filler dissolving will I know the results?
Filler dissolving usually works fairly quickly. However, on the day of dissolving you can expect to have swelling from the injection and fluid associated with injection of Hyaluronidase. Typically it can take 1-3 days for the swelling from the injection to reduce and for the effects of Hyaluronidase to become apparent.
How much does filler dissolving cost?
Dissolving filler is expensive. There are multiple factors that contribute to the cost. Primarily, Hylenex is an expensive product. Other supplies such as lidocaine solution, sterilizing products and other medical supplies are additional expenses. Dissolving filler with Ultrasound guidance takes more time and adds more cost than blindly dissolving filler because it requires more precision, more clinical expertise, and specialized equipment. On the other hand, dissolving filler without ultrasound guidance will likely result in missed areas and/or uneven results.
What are the potential side effects of Hyaluronidase?
There is a less than 1% chance of allergic reaction which is more likely if you have a bee sting allergy. Other potential complications include risk for local swelling, bruising, discomfort, itching. Injecting lidocaine can help with discomfort. Using ultrasound and/or Accuvein can help identify vessels to avoid, and will reduce the risk for bruising.
Before and After Photos of Filler Dissolving
Ultrasound in Aesthetics
When Dr. Kaplan transitioned from Emergency Medicine into Aesthetics in 2019, ultrasound was something she naturally wanted to incorporate into her practice. After working as an Emergency physician for 20 years, she found that ultrasound was a crucial diagnostic tool which helped her manage patients with pregnancy, cardiac, trauma, and surgical related complications. With the help of ultrasound, Dr. Kaplan was able to safely and accurately place central intravenous lines and perform various critical life-saving procedures.
Ultrasound for the placement of Dermal Filler:
Knowing the proper depth to inject dermal filler is crucial in providing a good aesthetic outcome as well as avoiding potentially devastating complications. Vascular occlusion is the dreaded complication of dermal filler which can lead to skin necrosis, stroke or even blindness. Vascular occlusion occurs when dermal filler is inadvertently injected into an artery, causing the blockage of blood flow to the surrounding tissue/skin. Intra-arterial filler injection can also embolize (float to the brain or retinal artery) to cause a stroke or blindness. While all injectors should know the facial anatomy and where arteries are most likely located, there are anatomical variations and not all humans are identical. Ultrasound adds a layer of safety by allowing for precision and accuracy. For someone who is meticulous in attention to detail and safety, Ultrasound is a vital tool which cannot be compromised.
Ultrasound for Filler Dissolving:
Knowing the precise location and depth of where dermal filler was placed allows for accuracy in proper dissolving technique. As a result, Filler dissolving product is less likely to be wasted in areas where no filler is located.
Ultrasound for PDO Thread Lift:
Dr. Kaplan once saw a patient who complained of uneven results after PDO threads placed by a plastic surgeon. Upon investigation with ultrasound, she saw that the PDO thread traversed the layer superficially under the skin but also deeper into the muscle layer in some areas. After realizing how easy it is to incorrectly assume that you are in the proper layer of the skin, Dr. Kaplan decided to use ultrasound to verify suitable placement of her PDO threads.
PDO threads if placed too deep into the muscle can cause suboptimal lifting effects. PDO placed improperly can also lead to injury to vital structures such as nerves, parotid gland, etc.
Ultrasound for Botox and Dysport injections:
When Neuromodulators such as Botox or Dysport are injected, the precise location and depth of the muscles are important in achieving the best outcome. Some areas such as masseters (jaw muscles) can have large variations in depth given everyone’s facial structures are slightly different. The muscles that control the forehead frown lines are closely aligned with nerve bundles that can result in migration of product down to the eyelid muscles, causing eyelid drop (ptosis). Knowing the precise anatomy allows for greater accuracy and improved effectiveness of the neuromodulator treatment as well as reducing any potential complications.
The Type of Ultrasound and experience Matters:
Ultrasound technology has evolved over the years. Using high quality equipment provides superior resolution. Using an ultrasound probe with the proper frequency will allow for visualization of detail in the superficial layers of the skin. If the wrong frequency probe is used without doppler, than arteries, veins and nerves will not be seen even if they are present.
At Rejuve Medspa, Dr. Kaplan prioritizes safety and is meticulous in her attention to detail. She chooses the highest quality equipment, and is well experienced and trained in the proper use of ultrasound in her practice. Dr. Kaplan is one of the first aesthetic providers in the Puget Sound area to incorporate the routine use of ultrasound in a Medical Spa setting.