Hyaluronidase to Dissolve Unwanted Lip and Wrinkle Filler

 

 

If you are old enough to have filler injections you are probably old enough to remember the scene from the movie “The First Wives Club” where Goldie Hawn gets lip injections and ends up with wickedly gigantic lips.

No one can argue that injectable fillers have added immensely to minimally invasive cosmetic facial surgery, but sometimes you can get too much of a good thing!

The complications associated with injectable lip and wrinkle fillers are usually pretty benign with under treatment and over treatment being among the most common problems.  Frequently, overtreatment is associated with novice injectors or poor technique, but even the most experienced surgeons will occasionally have an overzealous result.  There is no doubt that a patient may be disappointed with an under treated area, but they will be livid with an asymmetric or over treated area.  Let’s face it, no patient wants to walk around with excess filler in the lip, smile line or under eye area.

There are numerous fillers available and each of them has various positive and negative aspects.  The most commonly injected fillers are the hyaluronic acid fillers which include Juvederm Ultra and Ultra Plus, Restylane, and Perlane being the most popular.  Hyaluronic acid is a naturally occurring sugar that is present in many human tissues, especially the skin.  These fillers have been shown to persist in the body for up to a year, which is a good thing if you have the correct amount in the right place.  One additional (and I feel a huge advantage) with the hyaluronic acid fillers is the fact that they can be dissolved or reversed with a very predictable, safe and simple treatment that happens almost overnight.

Sound too good to be true?  It’ a fact.  Hyaluronidase is an enzyme that will dissolve hyaluronic acid rapidly and safely.  This medication is marketed as Amphidase and is mixed with local anesthesia and injected into the area of excess filler.  Almost like magic and almost overnight, the excess filler will dissolve, leaving a happy patient and surgeon.  Hyaluronidase has been used by doctors for injections for years, most commonly to assist the spread of local anesthetic solutions.  It has an excellent safety record although it is good to perform an immediate skin test and wait 5-10 minutes before treatment.  A small bleb of the inner surface of the forearm can be injected to see if it causes any inflammation in the area.

Hyaluronidase is used to dissolve excess or unwanted filler by mixing it with local anesthesia and injecting into the area of excess filler.

I have personally injected one of my patients and a bunch of patients treated by other surgeons with Hyaluronidase with good results.  The excess filler (assuming it is a hyaluronic acid type) dissolves in one or two days and is impressive.  Occasionally it is necessary to re treat an area with additional Hyaluronidase if the first injection did not take care of the problem.  I have used it to dissolve bumps on the lip, lips that were too big and fat or tear trough areas (the groove under the eye and above the cheek) that were over treated with good results.

 

The above patient was over injected with a filler and was unhappy with the excessive result.  She is shown 48 hours after Dr. Niamtu injected hyaluronidase into the area of excess under the eye.

To find out more about injectable lip and wrinkle fillers or other cosmetic facial surgery procedures visit www.lovethatface.com

 

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

www.lovethatface.com

Tell Me About Injectable Lip and Wrinkle Fillers

If you asked a doctor about injectable fillers 20 years ago, the answer would have been easy…..collagen.  Bovine collagen (from cows) was about the only FDA choice for plumping lips and wrinkles.  It worked pretty well, didn’t last very long and required allergy testing a month before injection.  Hard to believe that surgeons and patients put up with it for so long!  Meanwhile, overseas, many filler options were popular.  In about 2002 Restylane was given FDA approval and started the filler revolution in the USA.

Restylane (a filler made by Medicis) is a sugar derivative that is called hyaluronic acid and is found naturally in many body tissues.  Since it is a non animal product, no allergy testing is necessary and this option ushered in the new age of fillers.  Medicis also has FDA approval for Perlane which is a thicker, longer lasting and more robust hyaluronic acid filler.  Restylane pretty much owned the filler market until Allergan obtained FDA approval for Juvederm.  Juvederm Ultra is another hyaluronic acid filler and is currently giving Restylane a run for its money.  Many people feel that Juvederm is easier to inject, hurts less, is softer feeling and lasts longer.  Others feel that it is very similar to Restylane, like Coke is to Pepsi.  Personally, I use both depending upon whom and where I am injecting the filler.  In some respects I am a filler “bartender” as I offer many brands of fillers for different applications and patients.  Allergan also sells Juvederm Ultra Plus, which like Perlane is a thicker (larger particle) filler.  These more robust fillers usually last longer and are more frequently used in deeper folds or wrinkles, but they can also be used in the lips.  The hyaluronic acid fillers constitute 90% of my filler practice.  These fillers generally last 6-12 months, depending upon on the patient’s metabolism and where they are injected.  Areas like the lips which are continually moving to not last as long when filled as less mobile areas such as the cheekbone regions.

Although bovine collagen (Zyplast and Zyderm) have largely fallen out of popularity, Allergan offers human collagen fillers called Cosmoplast and Cosmoderm.  These fillers are not quite as popular as the hyaluronic acid fillers and do not last as long.  They are very forgiving and work well for fine lines and lipstick lines.  I only use these fillers when a patient requests them.

Radiesse is popular filler that is made from synthetic calcium which is similar to a ground up bone paste with the consistency of tooth paste.  This filler is more for deeper folds or wrinkles and I do not use it in the lips.  Radiesse is popular for smile lines (nasolabial folds) or cheek plumping.  The advantage of Radiesse is that it lasts for up to 18 months.

Sculptra is synthetic filler that is FDA accepted for facial filling in HIV patients.  It is also used for cosmetic applications.  This filler is injected and stimulates the body’s collagen to increase, which contributes to the filling.  I have used Sculptra and see no significant advantage over the hyaluronic acid fillers such as Juvederm Ultra or Restylane, although some of my colleagues favor it.

Permanent fillers exist and this can be good or bad.  If the treatment result is positive and if the patient likes it, being permanent is a positive thing, but if there is a treatment problem or the patient does not like it, there can be big problems.

Liquid Silicone (Silikon 1000) is permanent filler.  In the past silicone has gotten a bad rap because surgeons were injecting non medical grade silicone into the body and it caused many problems.  In addition they were injecting large amounts of silicone at a single treatment.  Silicone is actually a very naturally feeling and safe filler and I use it for lips, wrinkles folds and acne scars on patients with whom I am well acquainted and have experienced resorbable fillers (those that go away) in the past.  Silicone has been safely used for 50 years, and when using medical grade silicone (which is FDA approved) with the proper technique, it is safe, natural feeling and predictable.  The key to successful silicone injection is called the micro drop technique.  In this technique, extremely tiny drops of silicone (smaller than a pin head) are injected.  The volume may be so small that it is not very noticeable on the first treatment.  When the small droplets of silicone are injected, the body will surround them with the patient’s natural collagen.  This causes an increase in the tissue and produces bigger lips or fills wrinkles.  Silicone is generally injected on a monthly basis until the desired effect is almost reached (since the silicone will grow after the last injection).  After this, touch up injections may be done once a year.  The results of silicone injection last for many years and should only be given by experienced injectors. 

Artefill is the newest permanent filler to obtain FDA approval.  In February of 2008, I injected the first Artefill patient in Richmond, Virginia.  This filler contains microscopic plastic beads that fill the wrinkles and like silicone, stimulate the body’s collagen to increase the filling.  Since the beads are permanent, the result can last for many years, which is a good thing if it is done correctly.  I use Artefill on the smile lines for patients that request it or desire a permanent option.  Since this filler also contains animal collagen, the patient must be allergy tested a month before treatment.  This is a bit of a drawback.

Human fat is also a filler option and although I used to perform a lot of fat transfer, I do it much less since the availability of new fillers.  In fat transfer, I harvest fat from around the belly button and inject it in the lips and face.  Fat is nice because it is the patient’s own tissue but in my experience, most of it gets dissolved with time and it requires several injection sessions to achieve a lasting result.  Another drawback of fat injection is that the area must be over corrected since much of the injected fat will go away.  Due to this, patients will have an extended recovery until the over correction adjusts.

 

The above descriptions don’t cover every single filler but is a synopsis of the most common available FDA fillers in this country.  Each year new fillers will be introduced.  I recently went to the Cayman Islands to become certified as a trainer and inject a new filler called Evolance (made by Johnson & Johnson).  This will also be promising filler once the FDA approves it for use in this country, which will be soon.

Since every patient is different and every area is also different, many options occur for plumping the lips and filling out wrinkles and scars.  Experienced injectors should be able to guide the patient to the best filler for their particular needs.  To find out more about injectable click the link below.

http://www.lovethatface.com/cosmetic_facial_surgery_richmond_va/injectable_fillers.html

Lip implants are also an option for permanent lip filling and will be discussed in a future blog entry. To learn more about lip fillers select the following link.

http://www.lovethatface.com/cosmetic_facial_surgery_richmond_va/lip_implants.html