Therapeutic hyaluronidase to provide optimal aesthetic outcomes: A case report and call to action

Abstract

With hyaluronic acid injectable treatments becoming increasingly popular, more patients are presenting with pre-existing hyaluronic acid creating a poor cosmetic effect, requiring subsequent dissolving with hyaluronidase. We sought to characterize the clinical features and demographics of patients receiving therapeutic hyaluronidase electively and not in the context of an adverse event. We retrospectively reviewed the charts of patients receiving therapeutic hyaluronidase in two aesthetic dermatology practices from 2020 to 2024. There were 35 patients, ranging in age from 23 to 74 years. Fifty-seven percent of patients sought consultation for further injectable treatments and were unaware of the negative impact of their prior hyaluronic acid. Our data highlight the necessity of considering therapeutic hyaluronidase during an aesthetic consultation. Practitioners who seek to provide patients with the most optimal, natural, and balanced cosmetic outcomes must both recognize the signs of excess or poorly placed hyaluronic acid and be comfortable in administering treatment with hyaluronidase.

Introduction

In an aesthetic consultation, providers ideally complete a thorough facial assessment and determine a treatment plan that may include hyaluronic acid (HA) injectables if revolumization is indicated. Given the increasing popularity of HA injectable treatments, ¹ it is becoming more common for patients to present with preexisting HA, that is creating a poor cosmetic outcome due to inappropriate placement, excess product, or incorrect product rheology. As the scientific understanding of the durability of HA expands, it is now established that HA can last many years, even decades in some areas. ² In our experience, despite the popularized concept of “facial overfilled syndrome,” patients often fail to recognize areas where excess HA is negatively impacting their facial harmony. We sought to characterize the clinical features and demographics of patients receiving therapeutic hyaluronidase (TH) electively and not in the context of immediate management of an adverse event.

We retrospectively reviewed the charts of patients receiving TH in two aesthetic dermatology practices from 2020 to 2024. There were 35 patients (33 females and two males), ranging in age from 23 to 74 years (mean age 45). Fifty-seven percent of patients sought consultation for further injectable treatments and were unaware of the negative impact of their prior HA. The two most common areas requiring TH were the undereye/tear trough area (51%, 18/35 patients), followed by the perioral/lip area (34%, 12/35). A multi-area/full face hyaluronidase treatment was required in 14%, 5/35 (Figure 1). Eighty percent of patients were not aware of the product that was used in their previous HA treatments. Furthermore, 86% were unaware of the volume of product placed over time. Eighty percent of patients were successfully retreated with HA in some capacity after the TH.

Figure 1.

A 59-year-old female before (a) and after (b) three sessions of pan-facial therapeutic hyaluronidase. Patient consent for use of the photo was obtained.

Discussion

Our data highlight the necessity of systematically considering TH during an aesthetic consultation. The majority of patients reviewed consulted the authors seeking HA in a different area, or even more HA in the problem area. Thus, it becomes the responsibility of the aesthetic provider to recognize when previously placed HA may hinder the potential for an optimal aesthetic outcome, meriting removal. The aesthetic provider must be able to recognize the signs of excess or poorly placed HA ³ and be familiar with using hyaluronidase appropriately for this purpose.

While the use of hyaluronidase in acute emergencies (e.g., vascular adverse event) is well described in the scientific literature, there is very little data about ideal volumes, concentration, and subtype for therapeutic purposes. As the use of ultrasound in aesthetic medicine becomes more prevalent, there is also a potential role for ultrasound imaging of these patients to further delineate the presence, location, and volume of product. ⁴

Conclusion

It is our opinion that a comprehensive aesthetic evaluation must include considering the indication for TH. Practitioners who seek to provide patients with the most optimal, natural, and balanced cosmetic outcomes must both recognize the signs of excess or poorly placed HA and be comfortable in administering treatment with hyaluronidase.