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Face Fillers Gone Wrong: How to Treat it?

What can I do if the fillers in my face haven’t gone away?

Hyaluronic acid fillers such as in the
Restylane and Juvederm family of fillers have made a
radical shift in how fillers are used in aesthetics
since the mid-2000s in comparison to previous fillers
hyaluronic acid fillers are safer more convenient
and easily metabolized hyaluronic acid exists
naturally in the body in areas such as in the joint spaces the skin and even
the eye there are some instances where
hyaluronic acid filler remains longer in the body than would be
expected i’ll discuss the reasons why this can
happen and how i manage patients with this
problem in my practice I’m Dr Amiya Prasad
i’m a Board-certified cosmetic surgeon and Fellowship-trained
oculofacial plastic and reconstructive surgeon
i’ve been in practice in New York City and Long Island
for over 25 years i perform hyaluronic acid filler
placement for my patients every day in my practice i routinely
help people improve the appearance of the lips under
eye hollows and the smile lines or parentheses lines i also use thicker
hyaluronic acid fillers for the purposes of restoring the volume
at foundational level of the bone in areas such as the
cheeks chin jaw angle and jawline i’m also frequently consulted to reverse
hyaluronic acid filler and to even surgically remove permanent
and semi-permanent fillers originally
performed by other doctors generally the longevity of a hyaluronic
acid filler is related to its thickness and its
viscosity for example a thicker filler such as
Juvederm Voluma would be placed in areas where there is
less movement and there is a need for more projection
such as the cheek area a filler like Juvederm
Voluma can last up to two years i generally use softer
hyaluronic acid fillers in facial areas where there is a lot of movement
such as the lips and the under eye area i routinely use fillers such as
Restylane-L and Juvederm Vobella for these areas
it’s generally expected that these hyaluronic acid fillers
will be gradually metabolized by the body
although hyaluronic acid exists naturally in the body
there are times when there is a response by the body to treat the filler
like a foreign material it remains undetermined
whether this response is related to the material itself
or the presence of any surface bacteria that is transferred into the skin at the
time of placement nonetheless the response of the body is
to create a capsule around the material
when the filler material is surrounded by a capsule
the natural breakdown of the hyaluronic acid
is actually prevented although this may sound like
an added benefit a lot of times the appearance
is less than ideal this leads to patients
wanting to find a way to remove the hyaluronic acid filler
fortunately the treatment for encapsulated hyaluronic acid filler
involves a strategy to dissolve the filler
as opposed to needing surgical removal which would be necessary for
semi-permanent or permanent fillers in order to dissolve hyaluronic acid i
used the enzyme hyaluronidase hyaluronidase is sold
under brand names like Vitrase and Hylenex hyaluronidase exists
naturally in your body as part of the normal metabolic processes
in the production and turnover of your body’s
own hyaluronic acid the technical challenge is to be able to
place the hyaluronidase inside the encapsulated hyaluronic acid
once the hyaluronidase contacts the filler material
the material dissolves immediately i’ve had several patients who had been
getting hyaluronic acid fillers for many years
in areas such as the soft tissue of the cheeks and around their eyes
i found that as i dissolved the areas where the filler was more superficial
the patient and i came to realize that there was even more
filler present in the deeper tissues which needed
additional treatment this simply meant
that more sessions were needed until we reached the point
that the original normal anatomy was restored sometimes patients are
surprised to find that the filler they had placed in one area
had migrated to an adjacent area for example
filler placed in the temple to treat hollowing
can migrate to the brow making the brow appear
swollen a common location where filler migration occurs
is the nasolabial fold many practitioners try to soften the
nasolabial fold by trying to place the filler directly
under the line due to the anatomy of the nasolabial
fold the filler can be displaced upward toward the cheek and
downward toward the lip encapsulation of the filler can still
occur when the filler has migrated to an area that it was
not originally intended for as mentioned earlier bacteria that
typically is present naturally on the skin
surface can end up on the surface of the injected filler
resulting in a type of infection called biofilm
in addition to encapsulation biofilm infection is characterized by periodic
episodes of swelling and inflammation biofilm is known to occur in different
areas of medicine related to any kind of foreign material
that is placed past the skin barrier such as an iv
catheter or a breast implant the issue with biofilm is that your own
immune system is unable to respond to the bacteria
effectively due to the absence of blood supply within the foreign material
the standard approach to any infection like this is to remove the foreign
material such as would be the case in the removal
of a breast implant in the case of biofilm associated with
hyaluronic acid filler the strategy is to use
hyaluronidase to completely dissolve the hyaluronic
acid where the biofilm is residing
the challenge with biofilm is often making the diagnosis
biofilm is sometimes diagnosed as an immune mediated issue so that the
patient gets treated with anti-inflammatory medications as well as
antibiotics once again the absence of blood supply
makes these strategies challenging and often frustrating
a lot of my patients who come in for hyaluronidase
treatment will report that they had hyaluronidase injection performed
unsuccessfully by the doctor who had originally
performed their filler injection i find that many doctors and
non-physicians who perform injectables are not familiar with the tissue anatomy
of the area they’re treating at the level that a
surgeon who performs surgery in the same area would be
this is particularly relevant around the eyes
patients are often surprised to learn that an oculofacial
plastic surgeon such as myself who trained in the early 90s in
ophthalmology during that time i was using
hyaluronidase routinely as part of the anesthetic procedure
before cataract surgery i used hyaluronidase to
improve local anesthetic absorption when
injecting local anesthetic around and behind the
eye this was called a retro bulbar injection
as an oculoplastic surgeon i have extensive experience in performing
surgery around the eye including the bones and the anatomical
spaces around the eye this means that my knowledge and
familiarity in this area is very different
from someone who’s never done work like this
since hyaluronic acid can migrate or be injected into the space deeper
than the superficial skin layers my knowledge and experience
in this area has been helpful for people who have had
hyaluronic acid injected around their eyes
a common fear is that hyaluronidase injection
use will affect the native hyaluronic acid
that would be dissolved in addition to the filler
potentially resulting in hollow appearance
in my clinical experience of performing hyaluronidase injections for a wide
range of patients for many years i have not observed any
significant issue with hollowing after treatment
since the body’s natural hyaluronic acid is continuously replenished
there is really no issue in the long term
in summary if there is a long-standing hyaluronic acid filler present
which needs to be removed the treating physician
should have the knowledge and experience with both the anatomic spaces
and the precise application of hyaluronidase
to achieve the best outcome i hope you found this information
helpful thank you for your question

Hyaluronic acid fillers, such as those in the Restylane and Juvéderm families, revolutionized how fillers are used in aesthetics in the mid 2000s. Hyaluronic acid fillers are safer, more convenient, and easily metabolized as compared to previous filler materials. Hyaluronic acid is found naturally in the body in places like joint spaces, skin, and even the eye. However, there are some instances where hyaluronic acid filler remains in the body longer than expected. I’ll discuss the reasons why this can happen and how I manage patients with this problem in my practice.

Every day in my practice, I place hyaluronic acid fillers for my patients. With cosmetic fillers, I regularly help people improve the appearance of their lips, under eye hollows, smile lines, and parentheses lines. Thicker hyaluronic acid fillers are also used to restore volume at the bone’s foundational level in areas such as the cheeks, chin, jaw angle, and jawline. I’m also frequently consulted to reverse hyaluronic acid fillers, and to surgically remove permanent and semi-permanent fillers that were previously placed by other doctors.

restylane, juvederm, voluma, sculptra fillers

Generally, the thickness and viscosity of a hyaluronic acid filler affect its longevity. A thicker filler, such as Juvéderm Voluma, is used in areas where there is less movement, and more projection is required, such as the cheeks. The more viscous Juvederm Voluma can last up to two years. In areas where there is a lot of movement such as the lips and under the eyes, I generally use softer hyaluronic acid fillers such as Restylane-L and Juvederm Volbella. These hyaluronic acid fillers are expected to be metabolized by the body over time.

Can Facial Fillers Go Wrong?

Although hyaluronic acid occurs naturally in the body, there are times when the body reacts by treating the filler as a foreign material. It is unclear whether this reaction is caused by the material itself, or by any surface bacteria that is transferred into the skin during placement.

face fillers gone wrong treated with hyaluronidase

Nonetheless, the body’s response is to form a capsule around the material. The natural breakdown of hyaluronic acid is prevented when the filler material is surrounded by a capsule. Although this may appear to be a benefit, the appearance is frequently less than ideal. As a result, patients want to find a way to get rid of the hyaluronic acid filler.

What to Do When Facial Fillers Gone Wrong?

Fortunately, unlike semi-permanent or permanent fillers, encapsulated hyaluronic acid filler treatment involves a strategy to dissolve the filler rather than surgical removal. I use the enzyme called hyaluronidase to dissolve hyaluronic acid. Vitrase and Hylanex are two brand names for hyaluronidase.

fillers gone wrong treated with hyaluronidase before and after
dissolving filler under eyes before and after
restylane gone wrong treated with hyaluronidase before and after
under eye fillers gone wrong treated with hyaluronidase before and after
dissolving filler under eyes before and after
dermal fillers gone wrong treated with hyaluronidase before and after

Hyaluronidase is found naturally in your body as part of the normal metabolic processes that produce and metabolize hyaluronic acid. The technical challenge is to be able to place the hyaluronidase inside the encapsulated hyaluronic acid. Once the hyaluronidase contacts the filler material, the material dissolves immediately.

I’ve had several patients who had hyaluronic acid fillers for many years in areas such as the soft tissue of the cheeks, and around the eyes. As I dissolved the filler in the more superficial areas, the patient and I realized that there was more filler in the deeper tissues, which required additional treatment. This simply meant that more sessions would be required until normal anatomy was restored.

Sometimes, patients are surprised to find that the filler they had placed in one area had migrated to an adjacent area. For example, filler placed in the temple to treat hollowing can migrate to the brow, making the brow area appear swollen. A common location where filler migration occurs is the nasolabial fold. Many practitioners try to soften the nasolabial fold by trying to place filler directly under the line. Due to the anatomy of the nasolabial fold, the filler can be displaced upward toward the cheek, and downward toward the lip. Encapsulation of the filler can still occur when the filler has migrated to an area where it was not originally intended.

What is a Biofilm Infection?

As mentioned earlier, bacteria that typically is present naturally on the skin surface can end up on the surface of the injected filler, resulting in an infection called biofilm. In addition to encapsulation, biofilm infection is characterized by periodic episodes of swelling and inflammation. Biofilm is known to occur in different areas of medicine related to any kind of foreign material that is placed past the skin barrier, such as an IV catheter, or a breast implant.

bacterial infection illustration - biofilm

The issue with biofilm is that your immune system is unable to respond to the bacteria effectively due to the absence of blood supply within this foreign material. The standard approach to any infection like this is to remove the foreign material, such as would be the case in the removal of a breast implant. In the case of biofilm associated with hyaluronic acid filler, the strategy is to use hyaluronidase to completely dissolve the hyaluronic acid where the biofilm is residing. The challenge with biofilm infection is often making the diagnosis.

Biofilm is sometimes diagnosed as an immune-mediated problem, in which case the patient is treated with anti-inflammatory medications, in addition to antibiotics. Again, the lack of blood supply makes these strategies difficult and often frustrating. A lot of my patients who come in for hyaluronidase treatment report that they had a hyaluronidase injection performed unsuccessfully by the doctor who had originally performed their filler injection.

I find that many doctors and non-physicians who perform injectables are not as familiar with the tissue anatomy of the areas they’re treating, compared to the level of a surgeon who performs surgery in the same area. Knowledge of the anatomy of the treatment area is particularly relevant around the eyes. Patients are often surprised to learn that an oculofacial plastic surgeon such as myself who trained in the early 90s in ophthalmology, was using hyaluronidase routinely as part of the anesthetic application before cataract surgery. I used hyaluronidase to improve local anesthetic absorption when injecting the local anesthetic behind the eye called a retrobulbar injection.

Dr Prasad performing Surgery

As an oculoplastic surgeon, I have extensive experience performing surgery around the eye, including the bones and the anatomical spaces around the eye. This means that my knowledge and familiarity in this area are very different from someone who’s never done work like this. Since hyaluronic acid can migrate or be injected into the space deeper than the superficial skin layers, my knowledge and experience in this area have been helpful for people who have had hyaluronic acid injected around their eyes. A common fear is that after hyaluronidase injection, the native natural hyaluronic acid would be dissolved in addition to the filler, potentially resulting in a hollow appearance. In my clinical experience of performing hyaluronidase injections for a wide range of patients for many years, I have not observed any significant issue with hollowing after treatment. Since the body‘s natural hyaluronic acid is continuously replenished, there is no issue in the long-term.

How to Avoid Dermal Filler Complications?

If there is a long-standing hyaluronic acid filler which needs to be removed, the treating physician should have knowledge and experience with both the anatomic spaces, and the precise application of hyaluronidase to achieve the best results.

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