Ultrasound to Guide Dermal Filler Dissolving

Using UltraSound to Guide Hyalase Treatments

There are various reasons why someone might want to use ultrasound to dissolve previous fillers and they fall under two subcategories. Non-emergency/aesthetic dissolving and emergency dissolving. The Manse Clinic has been heavily involved in managing both types of cases.

The most likely place that people will want non-emergency dissolving is most commonly, tear trough and lips. The reason for tear troughs is either the tyndall effect (bluish discoloration) or it being placed wrong/migrating into an undesired space or lumpiness. Lips may be because of migration, unaesthetic placement or lumpiness and sometimes aesthetically the patient may not like the look of the lip filler anymore.

Less commonly but a lot more serious is when we have to dissolve for emergency reasons. Which is a vascular occlusion, this is serious because it means the blood flow supplying the skin is blocked off. Leading to the death of the skin above the blockage if left untreated or managed poorly. It is important to note that when using ultrasound in a potential emergency situation that this is done by an experienced injector who also uses ultrasound. The ultrasound done at either an imaging place or a non-injector clinician can give a false impression that there is no serious issue. 

So why ultrasound? And how is it helpful?

Ultrasound is a very handy tool when it comes to aesthetics, it does not take away from the clinical skills of the injector but enhances them. It can help the clinician to identify where potentially the filler could be and also where a blockage of blood flow might be. This will mean that less hyalase may be needed during the treatment and we can target the area of concern. Once treated the clinician will be able to use the ultrasound to make sure that it has been successful and identify if more treatment is needed. 

This is helpful because we can improve on reducing risk, and improve on outcomes. Also it makes it the most comfortable for the patient. Using less hyalase will mean less pain,  leading to an overall better experience. 

How does the ultrasound work?

It works by using ultrasound waves, the head of the machine receives what has bounced back. Creating a picture of what is under the skin as each type of tissue will look slightly different . We can use it to see past bones but we can still see an image of it. 

The best thing about ultrasound is the clinician can learn and understand anatomy better and what variations people might have. Putting our knowledge into practice for improving safety  is something that every clinician appreciates.

Who is suitable for dissolving?

Most people are suitable for dissolving, there are some exceptions. If you have had anaphylaxis (severe allergic reaction) to bee or wasp stings, or a previous reaction to hyalase. If it is known before filler has been done then you are ineligible for filler due to the risks of not being able to hyalase. 

Is it common for people to request hyalasing?

Short answer is no, most of the time it is a discussion with the injector that has previously done the treatment and what the concern is. 

For non-emergency hyalase do people often request this?

Yes due to in recent years the change of people wanting to look effortlessly natural rather than over done, people are opting in to hyalasing. This shows with the increase in treatments that stimulate our own collagen, elastin and hydration to reduce fine lines and wrinkles. 

What is the procedure for ultrasound assessment and hyalase?

First the clinician will have a discussion with you in regards to your concern. And suggest what might be the cause of this. It is helpful if the patient has been somewhere else previously to be aware of their cosmetic injectable history. This will inform the clinicians assessment better. 

After this the ultrasound can be utilized, this involves using a clear gel that helps the transducer part send and receive the ultrasound waves. Then the surrounding area of concern and the area of concern will be assessed by the clinician. The ultrasound will give an indication of what could potentially be filler and where it is. This may help diagnose what the reason for the concern is. If it is during an emergency procedure then we may also look at how other things are reacting, including if there is hyperactivity of the surrounding arteries and veins. This is important as it helps diagnose where the blockage that needs to be dissolved might be. 

Once this has been established and if agreed on by the injector and patient, we can go ahead with dissolving the filler. If it is the lips typically topical numbing can be applied prior, if not the hyalase is usually mixed with a local anesthetic to make it as comfortable as it can be. This is then injected directly into the filler of concern. Immediately the area will swell, this is a normal and expected reaction and usually by the end of the day the swelling will have subsided. 

How many treatments for hyalase are typically required?

Especially with ultrasound we are able to check as we are treating that most or all of the filler has been dissolved. Sometimes we may have to be more careful if there is surrounding filler that we don’t want to dissolve, if this is the case a staged approach may be taken. Otherwise, typically after 4 weeks we can review the results aesthetically and if need be with the ultrasound again to check the result. If at this point not all of the filler is gone we can repeat the process. Generally most people will need 1-3 treatments

What is the satisfaction rate with dissolving?

Most of the time people are satisfied with the result and usually depends on why in the first place they decided to dissolve. Usually the only time someone might be dissatisfied would be if they do not like an area without filler. I.e lips, people may not aesthetically like their lips due to them being over filled but once taken away they may also not like the loss of volume. This can also happen with the tear troughs. The patient may forget how hollow they were previously

When is the safest time to retreat an area?

The earliest time we recommend retreating is 4 weeks after dissolving. At 4 weeks the result will be there and the swelling associated with the injections will be resolved. Your clinician can assess you accurately aesthetically and recommend the best course of action for treating these areas. It is unwise to assess aesthetically until the swelling has resolved.

What are the risks with dissolving?

The biggest concern when using hyalase is that there is a risk for a patient to be anaphylactic (severe allergy) to the hyalase. We also know that if someone is anaphylactic to bee or wasp sting then there is a higher chance of anaphylaxis . For people who have no history of anaphylaxis, then we can do a patch test on the arm 10 minutes prior to injecting. Please note that all clinics and clinicians  need to have access to adrenaline or an epipen. Staff need training in the management of anaphylaxis. If anaphylaxis occurs and ambulance will be called as an emergency

Are there any options for patients who are unhappy with their results?

There are various options. Manual extraction is a superior option to hyalase due to it being lower risk and also very accurate. Another  option is to wait for the filler to dissolve naturally. This will depend on the severity of concern about the area. If the issue is lumpiness, then massage is an important option.

How do we prevent patients from needing hyalase in the first place?

The best way to prevent a patient needing hyalase (for non emergency use) is for a staged approach to treating volume loss or contouring of the face. This is best achieved by a collaborative approach from the injector and clinician. Things that should be discussed in a consultation is; time frame as people are usually getting ready for an event, the aesthetic goal of the patient, how achievable the goal is and risks and side effects of each treatment. 

Is there any downtime/aftercare?

Due to the risk of anaphylaxis, we prefer the patient to remain in the clinic for some extra time after the treatment.. Although we are able to visualize the major arteries with ultrasound and use minimal amounts of hyalase. There is still some downtime. Things to consider is that bruising could still happen, swelling will definitely happen but usually subsides very quickly and lastly a chance of infection due to breaking the skin to deliver the hyalase to the correct area. Like any cosmetic injectables we have to break the skin so the same risks and post care apply to when you would have had the filler. These include, no make up after the treatment, no touching the area, no exercise and no alcohol.