28 Reversers
Summary and Key Features
• Increasing popularity of soft tissue augmentation requires knowledge of reversal techniques
• Complications associated with fillers include nodules and contour irregularities, skin necrosis, allergic reaction, foreign-body response, and infection
• Biodegradable fillers are much more forgiving and more easily corrected
• Hyaluronidase can be considered a treatment ‘eraser’ for many complications arising from the injection of hyaluronic acid
• Non-inflammatory nodules can be managed conservatively
• Delayed inflammatory reactions may require more invasive techniques, particularly after complications due to non-biodegradable filling agents
Filler complications
Adverse effects following soft tissue augmentation are generally classified as early (up to 1 year) or delayed (appearing over 1 year after treatment) complications (Box 28.1). Delayed-onset reactions are almost always associated with non-biodegradable filling agents.
Hyaluronidase
Pearl 1
Hyaluronic acid fillers are the only truly reversible fillers with the use of hyaluronidase.
Hyaluronidase in cosmetic dermatology
In 2004, different reports by Soparkar and colleagues and Lambros detailed the use of hyaluronidase to dissolve unwanted side effects after augmentation with HA in the periocular region up to 5 years after initial HA injection. Since then, hyaluronidase has gained enormous popularity among cosmetic practitioners as an off-label ‘eraser’ for HA filling agents, with a reported ability to reverse bluish Tyndall discoloration, lumps and nodules due to overfilling or improper placement, foreign-body reactions, and injection necrosis (Box 28.2).
Several reports have documented the use of hyaluronidase to resolve the slightly bluish effect secondary to the Tyndall effect, caused by too-superficial injections of HA. Brody treated a 64-year-old woman who presented with visible, slightly blue masses beneath each eye 6 weeks after superficial HA injections in the periorbital area. Most of the material disappeared within 24 hours after 75 U of intradermal hyaluronidase; reinjection of the remaining small nodules dissolved the rest of the material within 5 days. In 2006, Hirsch and colleagues reported the case of a woman who developed a large blue ‘egg’ in the subdermal space at the right nasojugal fold 4 days after HA injection. Two injections of 75 U of hyaluronidase a few days apart led to complete resolution. Similar results were reported a year later by Hirsch and colleagues in a 48-year-old woman who received an overabundance of HA for the bilateral treatment of nasojugal folds and subsequently presented with two large, blue-tinted bulbous nodules under each eye. Hyaluronidase dissolved most of the material within 72 hours (Fig. 28.1)