Patient: A 56-year-old woman presented 2 weeks post Restylane injection in the nasojugal folds by another practitioner. She complained of “a bluish blob” that “would not go away” under her right eye. Examination revealed a blue-grey infra-orbital nodule. The implant swelling was well-defined, firm, mobile and nontender. The depth of the implant was clearly palpable to be at a level in the subcutaneous fat, well above the orbicularis oculi muscle.
Treatment Issue: Effectively correcting the negative outcome that resulted from another practitioner’s incorrect placement of a hyaluronic acid dermal filler.
Introduction
The recent explosion in the number of dermal filler injections used to combat facial aging has been a boon to patients and practitioners alike.
However, increasing reports have surfaced of too superficial injections in the hands of novice injectors, which have resulted in the appearance of cosmetically undesirable superficial blebs or lumps.
In cases in which a hyaluronic acid filler substance was involved in the formation of these unsightly subcutaneous nodules of product, hyaluronidase (an enzyme that catabolizes the complex hyaluronan sugars) can prove quite helpful.
Studies Using Hyaluronidase
Hyaluronidase, an off-label use of a product approved by the U.S. Food and Drug Administration (FDA), offers an interesting therapy to improve poorly placed hyaluronic acid soft-tissue augmentation injections.
Lambros,1 reported on the successful use of hyaluronidase to reverse the effects of a hyaluronic acid filler given in excess.
He combined 75 units of hyaluronidase and 1.5 cc of 0.5% lidocaine with epinephrine. Within 24 hours, 90% of the lumpiness caused by the hyaluronic acid gel resolved, and the remainder took several more days to disappear.
Brody used hyaluronidase to remove a hyaluronic acid filler in an unhappy patient treated in the infra-orbital hollow.2 In addition, he used the formulation to remove hyaluronic acid product in a patient with a rare clinically apparent sensitivity to HA in the oral commissure.
Brody also referenced the two current formulations of hyaluronidase available (Amphadase and Vitrase) as well as a compounding source.
Hyaluronidase Backgrounder
Hyaluronidase is a soluble enzyme that acts locally at the site of placement via injection to break down and hydrolyze hyaluronic acid implants. Currently in the United States, several filler product lines contain hyaluronic acid, including Restylane, JuveDerm, Hylaform and Captique.
The hyaluronidase enzyme is thought to hydrolyze a hyaluronic acid implant by splitting the glucosaminidic bond between C1 of the glucosamine moiety and C4 of glucuronic acid.
Adverse reactions to hyaluronidase are uncommon, and when reported they are most frequently local injection-site reactions (such as mild erythema).
An immediate or delayed hypersensitivity reaction to hyaluronidase, such as angioedema, is believed to be very rare.
Treatment for Our Patient
We explained to our patient the options for dealing with this undesirable discolored lump including: letting the non-permanent filler resolve on its own over several months, needle incision to express some of the product, laser therapy with a 1064 nm Q-switched Nd:YAG, or an attempt to dissolve the product using hyaluronidase.
She indicated she wanted the lump “to be gone” and preferred the route of trying to dissolve it. She declined any history of sensitivity to any bovine products.
Skin testing was then performed pre-treatment by placing 5 units of hyaluronidase (Amphadase) into the dermis to raise a small wheel 1 cm above the antecubital fossa.
After the antecubital test site was read as negative for any erythema or induration at both 20 minutes as well as 12 hours later, the treatment of 75 units of Amphadase was immediately injected into and around the infra-orbital nodule using a fan-like distribution.
Within 72 hours, the patient reported by phone an almost complete resolution of the lump, and was quite pleased with the result.
At follow-up 9 days later, the right infra-orbital hollow skin had returned to apparent baseline, and there was no visual or palpable evidence of any remaining hyaluronic acid product.
Technique
Because of the small risk of a significant hypersensitivity reaction, we recommend skin testing be performed prior to hyaluronidase use (especially for this type of non-urgent circumstance). Hyaluronidase from bovine origins should theoretically not be used in patients with known sensitivity to bovine products. The test site of 5 units was performed by administering 0.1 cc of this reconstituted solution at the left antecubital fossa.
Hyaluronidase formulations are clear concentrated liquids that are stored in a refrigerated vial. To reconstitute these products for clinical use, physicians typically add either normal saline or lidocaine.
For Amphadase (as in this case) we have used 3 cc of lidocaine 1% with 1:100,000 epinephrine per 150-unit vial. In our opinion, epinephrine not only more precisely keeps the solution at the local site of injection but also potentially avoids significant bruising through vasoconstriction. Upon reconstitution, gently swirl the vial to facilitate mixing prior to drawing it for use.
The actual treatment of the superficial infra-orbital lump was performed the following day using a total of 75 units (through injecting 1.5 cc of the mixed Amphadase preparation).
When injecting the infra-orbital area, we recommend entering the skin laterally with fan-like injections leading medially and inferiorly. We always avoid angling the needle toward the globe, and make sure the back of the patient’s head is resting comfortably against the cushion of the exam table. The non-injecting hand can be used to pull the lower lid downward, and away from the orbit.
Patients can return to the clinic 1 week post-hyaluronidase injections to evaluate if additional enzyme is required to treat any remaining undesired HA product.
Tips
The nasojugal fold is an advanced injection site for soft-tissue augmentation. We recommend placing filler products below the level of the orbicularis oculi, and in a linear threading fashion (this is the subject of one of an upcoming column). We strongly feel that depot injections and/or placing substances above the orbicularis muscle increases the likelihood of lumping (as in this case) and significant bruising/swelling as well.
Points to Remember
When choosing a filler for the orbicularis area, hyalurons make a lot of sense due to their wonderful safety and efficacy profiles. The fact that inappropriate placement of product can be completely treated with hyaluronidase is another clear benefit, especially for injectors newer to this area of treatment.
However, we strongly emphasize that hyaluronidase should not be thought of lightly, as simply an “antidote” for novice injectors in any area. Proper training, knowledge of anatomy, an understanding of injection techniques and precise placement are critical factors with any injectable cosmetic product.
Patient: A 56-year-old woman presented 2 weeks post Restylane injection in the nasojugal folds by another practitioner. She complained of “a bluish blob” that “would not go away” under her right eye. Examination revealed a blue-grey infra-orbital nodule. The implant swelling was well-defined, firm, mobile and nontender. The depth of the implant was clearly palpable to be at a level in the subcutaneous fat, well above the orbicularis oculi muscle.
Treatment Issue: Effectively correcting the negative outcome that resulted from another practitioner’s incorrect placement of a hyaluronic acid dermal filler.
Introduction
The recent explosion in the number of dermal filler injections used to combat facial aging has been a boon to patients and practitioners alike.
However, increasing reports have surfaced of too superficial injections in the hands of novice injectors, which have resulted in the appearance of cosmetically undesirable superficial blebs or lumps.
In cases in which a hyaluronic acid filler substance was involved in the formation of these unsightly subcutaneous nodules of product, hyaluronidase (an enzyme that catabolizes the complex hyaluronan sugars) can prove quite helpful.
Studies Using Hyaluronidase
Hyaluronidase, an off-label use of a product approved by the U.S. Food and Drug Administration (FDA), offers an interesting therapy to improve poorly placed hyaluronic acid soft-tissue augmentation injections.
Lambros,1 reported on the successful use of hyaluronidase to reverse the effects of a hyaluronic acid filler given in excess.
He combined 75 units of hyaluronidase and 1.5 cc of 0.5% lidocaine with epinephrine. Within 24 hours, 90% of the lumpiness caused by the hyaluronic acid gel resolved, and the remainder took several more days to disappear.
Brody used hyaluronidase to remove a hyaluronic acid filler in an unhappy patient treated in the infra-orbital hollow.2 In addition, he used the formulation to remove hyaluronic acid product in a patient with a rare clinically apparent sensitivity to HA in the oral commissure.
Brody also referenced the two current formulations of hyaluronidase available (Amphadase and Vitrase) as well as a compounding source.
Hyaluronidase Backgrounder
Hyaluronidase is a soluble enzyme that acts locally at the site of placement via injection to break down and hydrolyze hyaluronic acid implants. Currently in the United States, several filler product lines contain hyaluronic acid, including Restylane, JuveDerm, Hylaform and Captique.
The hyaluronidase enzyme is thought to hydrolyze a hyaluronic acid implant by splitting the glucosaminidic bond between C1 of the glucosamine moiety and C4 of glucuronic acid.
Adverse reactions to hyaluronidase are uncommon, and when reported they are most frequently local injection-site reactions (such as mild erythema).
An immediate or delayed hypersensitivity reaction to hyaluronidase, such as angioedema, is believed to be very rare.
Treatment for Our Patient
We explained to our patient the options for dealing with this undesirable discolored lump including: letting the non-permanent filler resolve on its own over several months, needle incision to express some of the product, laser therapy with a 1064 nm Q-switched Nd:YAG, or an attempt to dissolve the product using hyaluronidase.
She indicated she wanted the lump “to be gone” and preferred the route of trying to dissolve it. She declined any history of sensitivity to any bovine products.
Skin testing was then performed pre-treatment by placing 5 units of hyaluronidase (Amphadase) into the dermis to raise a small wheel 1 cm above the antecubital fossa.
After the antecubital test site was read as negative for any erythema or induration at both 20 minutes as well as 12 hours later, the treatment of 75 units of Amphadase was immediately injected into and around the infra-orbital nodule using a fan-like distribution.
Within 72 hours, the patient reported by phone an almost complete resolution of the lump, and was quite pleased with the result.
At follow-up 9 days later, the right infra-orbital hollow skin had returned to apparent baseline, and there was no visual or palpable evidence of any remaining hyaluronic acid product.
Technique
Because of the small risk of a significant hypersensitivity reaction, we recommend skin testing be performed prior to hyaluronidase use (especially for this type of non-urgent circumstance). Hyaluronidase from bovine origins should theoretically not be used in patients with known sensitivity to bovine products. The test site of 5 units was performed by administering 0.1 cc of this reconstituted solution at the left antecubital fossa.
Hyaluronidase formulations are clear concentrated liquids that are stored in a refrigerated vial. To reconstitute these products for clinical use, physicians typically add either normal saline or lidocaine.
For Amphadase (as in this case) we have used 3 cc of lidocaine 1% with 1:100,000 epinephrine per 150-unit vial. In our opinion, epinephrine not only more precisely keeps the solution at the local site of injection but also potentially avoids significant bruising through vasoconstriction. Upon reconstitution, gently swirl the vial to facilitate mixing prior to drawing it for use.
The actual treatment of the superficial infra-orbital lump was performed the following day using a total of 75 units (through injecting 1.5 cc of the mixed Amphadase preparation).
When injecting the infra-orbital area, we recommend entering the skin laterally with fan-like injections leading medially and inferiorly. We always avoid angling the needle toward the globe, and make sure the back of the patient’s head is resting comfortably against the cushion of the exam table. The non-injecting hand can be used to pull the lower lid downward, and away from the orbit.
Patients can return to the clinic 1 week post-hyaluronidase injections to evaluate if additional enzyme is required to treat any remaining undesired HA product.
Tips
The nasojugal fold is an advanced injection site for soft-tissue augmentation. We recommend placing filler products below the level of the orbicularis oculi, and in a linear threading fashion (this is the subject of one of an upcoming column). We strongly feel that depot injections and/or placing substances above the orbicularis muscle increases the likelihood of lumping (as in this case) and significant bruising/swelling as well.
Points to Remember
When choosing a filler for the orbicularis area, hyalurons make a lot of sense due to their wonderful safety and efficacy profiles. The fact that inappropriate placement of product can be completely treated with hyaluronidase is another clear benefit, especially for injectors newer to this area of treatment.
However, we strongly emphasize that hyaluronidase should not be thought of lightly, as simply an “antidote” for novice injectors in any area. Proper training, knowledge of anatomy, an understanding of injection techniques and precise placement are critical factors with any injectable cosmetic product.
Patient: A 56-year-old woman presented 2 weeks post Restylane injection in the nasojugal folds by another practitioner. She complained of “a bluish blob” that “would not go away” under her right eye. Examination revealed a blue-grey infra-orbital nodule. The implant swelling was well-defined, firm, mobile and nontender. The depth of the implant was clearly palpable to be at a level in the subcutaneous fat, well above the orbicularis oculi muscle.
Treatment Issue: Effectively correcting the negative outcome that resulted from another practitioner’s incorrect placement of a hyaluronic acid dermal filler.
Introduction
The recent explosion in the number of dermal filler injections used to combat facial aging has been a boon to patients and practitioners alike.
However, increasing reports have surfaced of too superficial injections in the hands of novice injectors, which have resulted in the appearance of cosmetically undesirable superficial blebs or lumps.
In cases in which a hyaluronic acid filler substance was involved in the formation of these unsightly subcutaneous nodules of product, hyaluronidase (an enzyme that catabolizes the complex hyaluronan sugars) can prove quite helpful.
Studies Using Hyaluronidase
Hyaluronidase, an off-label use of a product approved by the U.S. Food and Drug Administration (FDA), offers an interesting therapy to improve poorly placed hyaluronic acid soft-tissue augmentation injections.
Lambros,1 reported on the successful use of hyaluronidase to reverse the effects of a hyaluronic acid filler given in excess.
He combined 75 units of hyaluronidase and 1.5 cc of 0.5% lidocaine with epinephrine. Within 24 hours, 90% of the lumpiness caused by the hyaluronic acid gel resolved, and the remainder took several more days to disappear.
Brody used hyaluronidase to remove a hyaluronic acid filler in an unhappy patient treated in the infra-orbital hollow.2 In addition, he used the formulation to remove hyaluronic acid product in a patient with a rare clinically apparent sensitivity to HA in the oral commissure.
Brody also referenced the two current formulations of hyaluronidase available (Amphadase and Vitrase) as well as a compounding source.
Hyaluronidase Backgrounder
Hyaluronidase is a soluble enzyme that acts locally at the site of placement via injection to break down and hydrolyze hyaluronic acid implants. Currently in the United States, several filler product lines contain hyaluronic acid, including Restylane, JuveDerm, Hylaform and Captique.
The hyaluronidase enzyme is thought to hydrolyze a hyaluronic acid implant by splitting the glucosaminidic bond between C1 of the glucosamine moiety and C4 of glucuronic acid.
Adverse reactions to hyaluronidase are uncommon, and when reported they are most frequently local injection-site reactions (such as mild erythema).
An immediate or delayed hypersensitivity reaction to hyaluronidase, such as angioedema, is believed to be very rare.
Treatment for Our Patient
We explained to our patient the options for dealing with this undesirable discolored lump including: letting the non-permanent filler resolve on its own over several months, needle incision to express some of the product, laser therapy with a 1064 nm Q-switched Nd:YAG, or an attempt to dissolve the product using hyaluronidase.
She indicated she wanted the lump “to be gone” and preferred the route of trying to dissolve it. She declined any history of sensitivity to any bovine products.
Skin testing was then performed pre-treatment by placing 5 units of hyaluronidase (Amphadase) into the dermis to raise a small wheel 1 cm above the antecubital fossa.
After the antecubital test site was read as negative for any erythema or induration at both 20 minutes as well as 12 hours later, the treatment of 75 units of Amphadase was immediately injected into and around the infra-orbital nodule using a fan-like distribution.
Within 72 hours, the patient reported by phone an almost complete resolution of the lump, and was quite pleased with the result.
At follow-up 9 days later, the right infra-orbital hollow skin had returned to apparent baseline, and there was no visual or palpable evidence of any remaining hyaluronic acid product.
Technique
Because of the small risk of a significant hypersensitivity reaction, we recommend skin testing be performed prior to hyaluronidase use (especially for this type of non-urgent circumstance). Hyaluronidase from bovine origins should theoretically not be used in patients with known sensitivity to bovine products. The test site of 5 units was performed by administering 0.1 cc of this reconstituted solution at the left antecubital fossa.
Hyaluronidase formulations are clear concentrated liquids that are stored in a refrigerated vial. To reconstitute these products for clinical use, physicians typically add either normal saline or lidocaine.
For Amphadase (as in this case) we have used 3 cc of lidocaine 1% with 1:100,000 epinephrine per 150-unit vial. In our opinion, epinephrine not only more precisely keeps the solution at the local site of injection but also potentially avoids significant bruising through vasoconstriction. Upon reconstitution, gently swirl the vial to facilitate mixing prior to drawing it for use.
The actual treatment of the superficial infra-orbital lump was performed the following day using a total of 75 units (through injecting 1.5 cc of the mixed Amphadase preparation).
When injecting the infra-orbital area, we recommend entering the skin laterally with fan-like injections leading medially and inferiorly. We always avoid angling the needle toward the globe, and make sure the back of the patient’s head is resting comfortably against the cushion of the exam table. The non-injecting hand can be used to pull the lower lid downward, and away from the orbit.
Patients can return to the clinic 1 week post-hyaluronidase injections to evaluate if additional enzyme is required to treat any remaining undesired HA product.
Tips
The nasojugal fold is an advanced injection site for soft-tissue augmentation. We recommend placing filler products below the level of the orbicularis oculi, and in a linear threading fashion (this is the subject of one of an upcoming column). We strongly feel that depot injections and/or placing substances above the orbicularis muscle increases the likelihood of lumping (as in this case) and significant bruising/swelling as well.
Points to Remember
When choosing a filler for the orbicularis area, hyalurons make a lot of sense due to their wonderful safety and efficacy profiles. The fact that inappropriate placement of product can be completely treated with hyaluronidase is another clear benefit, especially for injectors newer to this area of treatment.
However, we strongly emphasize that hyaluronidase should not be thought of lightly, as simply an “antidote” for novice injectors in any area. Proper training, knowledge of anatomy, an understanding of injection techniques and precise placement are critical factors with any injectable cosmetic product.
