Filler Dissolving

What is filler dissolving?

Filler dissolving means injecting an enzyme called hyaluronidase to break down hyaluronic acid (HA) filler injected earlier. The enzyme breaks down hyaluronic acid molecules chemically, and it is used to manage complications of hyaluronic acid fillers. In many countries, using this enzyme for aesthetic purposes is considered off-label (that is, outside the uses covered by the medicine’s licence), and there is no single agreed treatment protocol.

Its use is not limited to one situation. Non-urgent situations (filler that does not stay in place, non-inflammatory nodules you can feel, a bluish tint under the skin, hypersensitivity reactions) are distinguished from emergencies such as vascular occlusion (a blocked blood vessel) and vision loss; the two groups are not managed in the same way.

The key point is this: hyaluronidase is not a beauty treatment chosen for its own sake. There has to be an earlier injection before it can be considered.

Details such as the dose, the dilution and the injection technique are decided by the doctor carrying out the treatment, based on their own assessment.

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What the word ‘dissolving’ does and does not mean

‘Dissolving’ is the word that has become established in everyday language and in online searches. Yet the word itself is being debated in scientific publications. A recent publication argues that the phrase ‘filler dissolving’ may be misleading, and that it would be more accurate to describe what hyaluronidase does as modifying the filler rather than removing it.

This is not just a debate about terms. The word ‘dissolving’ suggests a switch that can be turned on and off: put it in, then take it out. Laboratory findings do not support this idea. In a study that examined nine different commercial hyaluronic acid fillers in the laboratory, the fillers responded to the enzyme in significantly different ways; breakdown depended on both the dose and the time elapsed, and one filler did not break down to a significant degree even at the highest concentration tested. According to the results, what mattered most was not so much the filler’s hyaluronic acid concentration as its manufacturing technology and degree of cross-linking (how the hyaluronic acid chains are bonded to one another, which makes the filler longer-lasting).

In short, although ‘filler dissolving’ is a common phrase, you need to keep your expectations of the procedure realistic.

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When is it considered?

The situations in which hyaluronidase is considered fall into two groups.

Non-urgent: a bluish tint under the skin (Tyndall effect), non-inflammatory nodules, allergic and hypersensitivity reactions related to the filler, filler moving away from where it was placed, and unexpected aesthetic results. For inflammatory nodules, it is recommended that hyaluronidase be considered together with, or after, oral antibiotic treatment; for granulomas that have not responded to steroid injections, it has been reported that hyaluronidase may be tried.

Urgent: vascular occlusion caused by filler entering a blood vessel, and vision loss. These situations must be dealt with without delay.

Having one of these conditions does not mean the treatment is suitable for you; suitability is assessed separately at a consultation.

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The emergency: vascular occlusion

A serious complication of filler injections that has been described in detail is filler entering a blood vessel. Impaired blood supply to the tissue, skin tissue death (necrosis), vision loss and stroke have been reported as a result. According to a review of publications from 2000 to 2024, in cases that led to permanent damage, the deciding factors were not so much the amount injected as the injection site, the technique used and whether the filler was permanent.

A systematic review of vision loss cases examined 144 cases from 29 publications. In these cases, vision loss almost always affected one eye only and appeared immediately after the injection. Outcomes appeared to differ depending on how hyaluronidase was given; however, randomised controlled trials (trials in which participants are randomly assigned to groups) are needed to confirm this.

When vascular occlusion is suspected, hyaluronidase is not treated as one option among others but as a time-critical intervention. A 2015 consensus statement considers rapid diagnosis and starting treatment without delay to be decisive, and does not consider a skin test necessary in this situation.

If you have had filler and notice unusual pain at the injection site, a change in your vision, or white, grey or bluish discolouration of the skin, the US Food and Drug Administration (FDA) says you should get medical help straight away. The FDA also says the healthcare professional giving the injection should have planned in advance what to do in such a situation.

You can ask your doctor before the procedure how to reach the clinic in such a situation and what will be done.

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Dissolving lip filler

The lips are one of the most common areas for filler, and an area that prompts many questions about filler dissolving. The area has its own particular structure.

In an ultrasound study of 126 people, the layer under the skin in the upper and lower lip measured less than one millimetre on average; as a result, in most people who had had filler, the filler was found to sit within the muscle. A vertical injection technique was associated with deeper placement, increased vascularity and filler migration.

What this means for filler dissolving: in the lips, where the filler sits may not be as clear as it looks from the outside. The appearance people describe as ‘the filler has moved’ or ‘the area above my lip has thickened’ is often due to this difference in placement.

The second issue is the type of filler. In a study that examined six different commercial hyaluronic acid lip fillers in the laboratory, the rate at which the fillers broke down with hyaluronidase differed significantly; this difference is thought to come from differences in cross-linking and formulation. Other publications also note that different filler brands are not equally sensitive to the enzyme. These are laboratory findings and do not directly show what happens in people; but they explain why you are asked at your consultation which filler you had before.

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Dissolving under-eye (tear trough) filler

The under-eye area has a special place among filler treatment areas, for two reasons. First, the FDA lists the area around the eyes among unapproved uses of fillers. Second, filler problems in this area often appear late rather than early.

A systematic review of late complications of under-eye filler brought together 52 cases from 28 publications. The most commonly reported problems were swelling (22 of the 52 cases) and lumps or nodules you can feel (13 cases); xanthelasma-like reactions (an appearance resembling yellowish raised patches on the eyelids), filler migration and discolouration were also reported. The average time until symptoms appeared was 16.8 months. In other words, filler you had more than a year ago can be the cause of swelling you have today.

In a clinical study of 54 people who sought help for filler problems around the eyes, the average time from the first filler to seeking help was 25.8 months. The reasons for seeking help were persistent oedema (swelling), puffiness under the eyes, insufficient correction and nodules under the skin.

These figures are data from other centres; they do not relate to Türkiye or to this clinic. The area around the eyes is where the question ‘what happens after the filler is dissolved?’ matters most; you can read more about this in the ‘The result is not always complete’ section.

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Nose filler and filler dissolving

The nose is an area that needs particular care with filler treatments. The FDA lists the nose among unapproved uses of fillers. In the systematic review of vision loss cases, the nose is also the most frequently reported injection site.

A publication describing skin necrosis (tissue death) of the nose caused by hyaluronic acid filler reports that this process was reversed with high-dose hyaluronidase; however, it also notes that there is no single accepted standard treatment protocol for this situation.

The review of filler complications that led to permanent damage also lists the injection site among the deciding factors, and stresses the importance of knowing the high-risk areas.

The practical conclusion is not a ban but an order of priority: with a filler problem in the nose, time is weighed more heavily than in other areas.

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Limits of this treatment

Filler dissolving is an attempt to reverse a treatment that has already been done. It does not correct something that was never done, and it is not a rejuvenation treatment in itself.

In concrete terms, the limits are:

• Hyaluronidase acts only on fillers that contain hyaluronic acid; it offers no way to reverse permanent fillers.
• The FDA lists the glabella (the area between the eyebrows), nose, area around the eyes, forehead and neck among unapproved uses of fillers, and recommends that fillers are not used for body contouring or to increase volume.
• While targeting the filler, the enzyme also affects the natural hyaluronic acid in the area.
• Facial sinking and a feeling of hollowness have been reported after treatment; this was found to be linked to how long the filler had been in the tissue and to its total volume.
• Cases where the filler did not dissolve completely in one treatment and a further treatment was needed have been reported.
• There is no evidence at the level of randomised controlled trials on reversing filler in the face.
• If the appearance is caused not by filler but by age-related volume loss or skin laxity, dissolving the filler will not change it.

This information is not given to put you off, but so that you can compare your options. Which path makes sense for you (treatment, waiting or neither) is decided by your doctor’s assessment and your own decision. Having no treatment at all is also a valid outcome.

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Hyaluronidase does not dissolve every filler

Hyaluronidase targets hyaluronic acid. It does not dissolve other types of filler, such as calcium hydroxylapatite (CaHA), poly-L-lactic acid (PLLA) and polymethyl methacrylate (PMMA).

This is not a matter of preference. According to the review of filler complications that led to permanent damage, hyaluronic acid fillers stand out because they can be reversed, while permanent fillers increase the risk of long-term complications. The FDA also states that fillers not made from substances such as hyaluronic acid, and permanent fillers in particular, can be difficult or impossible to remove.

Hyaluronidase has also been reported to be used for blood vessel problems caused by fillers other than hyaluronic acid. In a multicentre case series of three cases, hyaluronidase was given under ultrasound guidance for blood vessel problems caused by calcium hydroxylapatite and poly-L-lactic acid, and the conditions resolved without necrosis or scarring. It is thought that the effect here may be linked more to the easing of vascular spasm (the blood vessel tightening) than to the filler dissolving. However, this is a hypothesis based on only three cases, not an established treatment.

In practice, this means that which filler you had before is the first question of all. If you do not know, you need to say so clearly.

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The result is not always complete

One less discussed aspect of filler dissolving is when the result is not what was expected.

In a retrospective study, 157 eye sockets (orbits) of 90 patients who were given hyaluronidase around the eyes over a four-year period were reviewed. The result was satisfactory in 59% of patients; 24% needed a further treatment because the filler had not dissolved enough, and 18% had changes such as facial sinking or a feeling of hollowness. The researchers call this last picture ‘post-hyaluronidase syndrome’.

This picture was found to be linked not to the dose or concentration of the hyaluronidase used, but to how long the filler had been in the tissue and to the total filler volume. The publication’s recommendation is clear: everyone who is to be given hyaluronidase should be told about this risk, and people who have had filler for a long time or who have a high total filler volume should be reminded of it specifically.

These figures come from a single centre, were collected retrospectively and relate only to the area around the eyes; they do not relate to Türkiye, to any other area or to this clinic. They do not give a rate that applies to you; but they show that the expectation ‘it is dissolved and everything goes back to how it was’ is not always that simple.

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Risk of allergy and anaphylaxis

Hyaluronidase is an enzyme and, like any injected substance, can cause an allergic reaction. This is a point that should not be overlooked.

According to a review of allergic reactions to hyaluronidase injections, such cases have been reported since 1984 but are often misdiagnosed. The review includes 106 patients from 37 publications; their average age was 54.2. In these patients, a history of allergy to other substances (bee venom, penicillin, insect stings, egg white, nickel and others) and a history of allergic conditions (asthma, dermatitis, atopy — that is, a tendency to develop allergies — and rhinitis) were reported. The review concluded that becoming sensitised through earlier injections or bee venom may be a leading factor in developing the allergy. It also reports that symptoms improved quickly and largely with steroid (corticosteroid) and antihistamine treatment.

Whether a skin test should be done before treatment is debated; there is no single agreed approach. In an emergency such as suspected vascular occlusion, however, the 2015 consensus statement does not consider a skin test necessary, because time is what matters there.

Whether an allergy test is done, how you are prepared before the procedure and what is done if a reaction occurs depend on the doctor’s own protocol; you can ask about these at your consultation. Your allergy history, especially if you have ever reacted to a bee sting, is information you should mention at your consultation.

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Regulation

The question of reversing filler often comes up after a treatment that falls outside the regulatory limits set for fillers; this is why it is important to know these limits. For products used at the clinic, the deciding points are the product’s CE marking, its registration and conformity status in Türkiye, and the manufacturer’s intended purpose and indications. FDA approval on its own is not an assessment criterion; the FDA is the regulatory authority of the United States.

The FDA’s information page lists the following as unapproved uses of fillers:

• Breast enlargement.
• Increasing the volume of the buttocks.
• Increasing fullness in the feet.
• Injection into bone, tendon, ligament or muscle.
• Injection into the glabella (the area between the eyebrows), nose, area around the eyes, forehead and neck.

This is information about the scope of approval only; it does not mean that an area cannot be treated, or that treating it is unsafe.

In a systematic review that brought together cases of vision loss linked to hyaluronic acid filler, the most common injection sites were reported as the nose, the forehead and the glabella. This finding also explains why the question of reversal is handled with more care in these areas.

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Where the evidence is strong, and where it is thin

Although hyaluronidase is widely used, the scientific evidence supporting this use is not equally strong.

A review of hyaluronidase use for complications of aesthetic treatments found 5 randomised controlled trials, out of 395 studies, that met its criteria, with 53 people in total. All of these trials were carried out on the skin of the forearm, upper arm or back. There is no evidence at this level on reversing filler in the face, correcting overcorrection, inflammatory nodules or impaired blood supply to tissue.

Laboratory findings point in the same direction. In a study of twenty-two commercial hyaluronic acid fillers, the lowest single dose needed to dissolve each filler was determined separately, and the fillers differed several-fold; the range between the most resistant and least resistant groups is wide. This shows that reversal cannot be described by a single number.

None of this means that hyaluronidase does not work in the face; there is established clinical experience. What it means is this: there is no body of studies that offers numerical certainty about what will happen in the face. This is why information such as ‘this much will dissolve in this much time’ cannot be given.

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The question of dissolving filler at home

One frequently asked question is whether filler can be dissolved at home. Hyaluronidase is a medicine given by injection; injecting it is not a procedure that can be done at home.

There are two reasons for this: the possibility of an allergic reaction and anaphylaxis (a severe allergic reaction that develops suddenly and can be life-threatening), and the fact that the dose, the area and the timing need a separate decision every time. Treating an allergic reaction depends on the medical resources available on the spot at that moment.

The FDA defines filler injection not as a beauty treatment but as a medical procedure, and says the person giving the injection should have planned in advance what to do if a complication occurs.

The sources used here do not include any study showing that a product rubbed onto the skin or applied by massage dissolves hyaluronic acid filler; this does not mean that no such study exists. If you are unhappy with a filler, the first step is a consultation.

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