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Hyaluronic acid excesses can occur after superficial injections (mesotherapy-like injections) of cross-linked hyaluronic acid.


Hyaluronidase can quickly resolve the problem, no matter what the delay is between hyaluronic and hyaluronidase injections.


Figure 4 Puffy eyes as a result of hyaluronic acid excess


Figure 5 Result following correction with hyaluronidase


to dissolve the excess only, without dissolving every


hyaluronic acid molecule outside the injection area. There is no known consensus on this point, but it is known that some hyaluronic acids are more resisting to hyaluronidase than others. Hyaluronic acid excesses can occur after superficial


injections (mesotherapy-like injections) of cross-linked hyaluronic acid (Figure 1). In such cases, one injection of one drop of hyaluronidase (1500 UI diluted in 4 ml saline solution), directly inside the tumefaction induced by the hyaluronic acid, can quickly resolve the problem, no matter what the delay is between hyaluronic and hyaluronidase injections. Hyaluronic excesses usually occur after injections to periorbital wrinkles or correction to under-eye circles, giving the puffy eye appearance seen in Figures 2 and 3. In the case of Figure 4, a cross-linked hyaluronic acid had been injected into the under-eye circles 2 years previously. The patient was informed that the hyaluronic acid had no tendency to


Key points


■ Hyaluronidase is an enzyme used specifically to treat hyaluronic acid and filler excesses


■ All patients should be allergy tested prior to the use of hyaluronidase


■ Hyaluronidase has been used for many years and can provide very fast and definitive results


36 ❚ April/May 2012 | prime-journal.com


disappear and of any surgical possibility of erasing the puffiness to the lower eyelids. Injection of hyaluronidase was therefore decided on, using an ovine lyophilised hyaluronidase, with a dilution of 4 ml saline solution for 1500 IU. After an allergy test showing a lack of immediate reactivity in the patient, three injections points of 0.1 ml each were carried out on each side. As the product is presented in a 1 ml syringe, with a 32 G needle, retro-injections should be performed directly inside the area showing the excess of hyaluronic acid. Injections here should be quite deep, as hyaluronic injections to this area are usually performed close to the bone. No side-effects, except transitory ecchymoses and local oedema, should be expected in normal conditions. The result of the injection began to be visible after 1 hour, when the patient was allowed to leave the clinic. Figure 5 shows the definitive result after day 3 ® a complete disappearance of injected hyaluronic acid and a return to the original state with wrinkles and under-eye circles. A new injection of hyaluronic acid was carried out 2 weeks after the hyaluronidase treatment in order to fill this area without excess. No problems were experienced as a result of the corrective injection. Many cases of cross-linked hyaluronic acid excesses have also been witnessed in lip augmentation. The authors have only had one experience of general hyaluronic acid excess in this area, which was sent to the clinic by a colleague. The injection of hyaluronidase allowed for the correction of the problem over a few days, and without side-effects.


Tyndall effect Superficial injections of hyaluronic acid can give the skin a different colour around the entire injection area compared with normal colouring. The skin may appear blueish, but in this case the resulting colour was different (Figure 6). Cross-linked hyaluronic acid had been injected a few months previously and the patient, even if happy to see the disappearance of circles


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