Elizabeth, 26, had been waiting years to enhance her lips. “Pretty much the minute I could pay for it on my own, [I started getting filler],” she says. It was 2019 and “Instagram lips” were It. During her first appointment, she purchased one syringe of Juvéderm Volbella. When her thin lips would accept only half the syringe, her injector, a nurse practitioner (NP) at a med-spa, suggested she use the rest in her chin — an area that had never been an insecurity for Elizabeth. “I definitely had to be persuaded,” she says. “But the NP was like, ‘If you don’t like it, it’ll go away in six months.’”
Elizabeth booked a touch-up, as directed, and then continued to get hyaluronic acid filler injections around every six months for the next couple years. At each visit, she bought a syringe for her lips — and felt compelled to use any leftover gel elsewhere in her face (cheeks, undereyes), despite rarely having a desire for it.
Eventually, Elizabeth found herself overfilled, she says, her once heart-shaped face now decidedly round, with unpredictable lip swelling and persistent undereye puffiness. “The little bit I had placed under my eyes created what you might think of as an eye bag, but it was in the wrong spot, in the middle of my face.”
Meet the experts:
- Jonathan Cabin, MD, is a board-certified facial plastic surgeon in Arlington, Virginia.
- Lara Devgan, MD, is a board-certified plastic surgeon in New York City.
- Paul Jarrod Frank, MD, is a board-certified dermatologist in New York City.
- Elizabeth Houshmand, MD, is a board-certified dermatologist in Dallas.
- Flora Levin, MD, is a board-certified ophthalmologist and an oculoplastic surgeon in Westport, Connecticut.
- Ben Talei, MD, is a board-certified facial plastic surgeon in Beverly Hills.
- Jessica Weiser, MD, is a board-certified dermatologist in New York City.
While Elizabeth’s filler use was conservative compared with some (it’s not uncommon for patients to purchase multiple syringes in a single session), the doctors we interviewed for this series say her experience is typical of those who wind up fuller than intended. She got more filler than was ideal, at too-frequent intervals, based on bad intel — that hyaluronic acid “goes away” at a predictable time and that one shouldn’t waste a single cc of a syringe.
When Elizabeth’s lips unexpectedly ballooned during pregnancy a little over a year ago, she began researching how to dissolve filler with hyaluronidase, an injectable enzyme. “I even joined one of those hyaluronidase groups. Oh, my gosh, I was freaking out,” she says, referring to online support groups that now exist for patients alleging side effects from hyaluronidase. (More on that soon.)
Months after giving birth, Elizabeth met with a board-certified dermatologist in New York City, who removed about 90% of her filler (from her cheeks and lips) using hyaluronidase under ultrasound guidance (for $3,000). Ultrasound enables providers to see below the skin and dissolve filler particles more precisely. The doctor could see on the imaging that some of the gel had integrated into the soft tissue of Elizabeth’s cheeks. He said “it could swell up when I’m sick [or if] I eat certain things,” she recalls, but ultimately he suggested leaving it alone since it wasn’t obvious to the naked eye.
But Elizabeth wanted to remove more — “it makes me nervous having it there” — so she went to see a board-certified facial plastic surgeon in New York City for two additional rounds of dissolver ($1,250 total). Still unhappy with the appearance of her undereyes, Elizabeth is now exploring other options, including fresh filler, meticulously placed to camouflage her hollows; PRP injections to improve the tone and texture of her skin; and/or radiofrequency microneedling to thicken her skin and help with residual swelling that tends to come and go.
In this story:
- Is dissolver the new filler?
- Who’s dissolving their filler — and why?
- What exactly is hyaluronidase?
- Is hyaluronidase safe? What are the side effects?
- What is it like to dissolve your filler with hyaluronidase?
- How much does it cost to dissolve filler?
- The bottom line
Is dissolver the new filler?
If you read the first two installments of The Filler Files, you already know that hyaluronidase injections to dissolve filler are trending: Statistics show that despite the persistent popularity of injectables, filler reversals are on the rise, a sort of backlash to “Instagram face” and an era of extravagance in injectable use.
Over the past decade-plus, filler has too often been used to try to achieve unrealistic goals, whether it’s the ubiquitous megalips or a misguided “liquid facelift” with its hallmark overstuffing. Board-certified New York City dermatologist Jessica Weiser, MD, believes this is the main reason she and her peers are now confronting throngs of “overfilled, doughy, distorted faces,” she says.
Board-certified dermatologist Paul Jarrod Frank, MD, sees his fair share of filler fatigue in New York City. “At least two patients a day will come in specifically for reversal,” he says. “I go through bottles of Vitrase [hyaluronidase] a day in my office. It’s not a once-in-a-blue-moon, you’re-looking-for-it-in-the-back-of-the-fridge type of thing.”
He links the uptick in filler reversals and revisions to the growing “commoditization” of filler injections: A certain segment of “med-spa culture is about ‘how many syringes can I sell to patients?’” he says. “[Some of] these [injectors] have very little training and are incentivized by only one thing: money.”
Who’s dissolving their filler — and why?
As we reported earlier in this series, excess filler not only creates an odd aesthetic, it can lead to lymphatic channel obstruction and fluid accumulation, limited muscle function (which can cause strained expressions), and permanently stretch soft tissues over time, according to Ben Talei, MD, a board-certified facial plastic surgeon in Beverly Hills.
But dissolver isn’t the exclusive domain of the overdone. Doctors also use it to correct lesser offenses, like tear troughs left puffy by a misplaced gel and, even more prevalent, the issue of lip filler migration.
Olivia, 29, began getting her lips filled after graduating from college. “I always knew I had thin lips, but it wasn’t until my friends [and I] started getting into lip kits that I realized it was very difficult for me to fill in my lips with the product,” she says. “My friends had fuller lips, so I did feel left out and began questioning what was wrong with my lips.”
When Olivia moved from Florida to New York in 2019, she booked an appointment with Dr. Frank, expecting a routine top-off of lip filler. Instead, he recommended an all-out reversal. “While I was happy to have fuller lips, I never really noticed how they were looking until I spoke to Dr. Frank,” Olivia recalls. He pointed out areas where her filler had strayed out of bounds, distorting her lip line, and he suggested dissolving the filler to restore her natural shape and establish a clean slate. (Olivia had been getting her filler at a doctor’s office, not a med-spa, back in Florida.)
“The amount of filler in her lips was not only creating a bulge above her vermilion border [lip line], but the stretching of tissues was blurring her lip line,” Dr. Frank explains, “which we very commonly see in people with overfilled lips.”
After carefully reducing Olivia’s filler and assessing her facial anatomy, he noticed that when Olivia smiled, her top lip curled under and disappeared. To adjust this, he performed a lip flip — injecting a small dose of neuromodulator (like Botox) into the muscle above the lip to help turn it out a bit. He then refilled her lips with Belotero, a hyaluronic acid gel that, Dr. Franks says, is “almost more of a smoother than a real [volumizing] filler.” It’s the lightest and most forgiving of the bunch, he adds, and “it retains the least amount of water,” making it less apt to swell.
Knowing Olivia’s old filler had spread above her lip line and that “the route of migration had already been paved,” Dr. Frank took a slow and conservative approach when filling, so as not to “send it down that route again.”
Dissolving filler with hyaluronidase can also serve as a remedy for a different subset of the filler-fatigued: those who are simply sick of the syringe. “I see this a lot with the undereyes — [people] don’t want to keep doing filler,” says Flora Levin, MD, a board-certified ophthalmologist and an oculoplastic surgeon in Westport, Connecticut. “They’d rather get [lower eyelid] surgery and just live their lives.”
Other doctors share similar anecdotes about patients ditching filler for more permanent alternatives, be it rhinoplasty, a chin implant, a lip lift, or a facelift. For older patients who are considering surgery and want to dissolve their filler, “I often have them set up a couple of facelift consultations before we start,” Dr. Weiser says. “The plastic surgeon and I will then coordinate on dissolving the [patient’s filler] within a couple of months of their surgical procedure, so they don’t end up feeling terrible in the interim, because it is quite a drastic [change].”
Not every case of filler burnout somersaults into getting surgery. Once free from filler, plenty of folks choose to embrace their natural proportions. Then there are those who, after a brief hiatus, ease back into injectables, adopting a new game plan the second time around. Lara Devgan, MD, a board-certified plastic surgeon in New York City, tells us that when she starts working with someone who was overfilled and then dissolved, step one tends to be “creating structure rather than just adding volume.” She does this by defining “the major support buttresses of the face” — the cheekbones, jawline, and chin.
What exactly is hyaluronidase?
No matter the accelerant, interest in dissolver has intensified over the past few years, says Dr. Talei. So has the confusion that surrounds it, he adds, fueled in part by the aforementioned hyaluronidase forums.
Hyaluronidase (which goes by the brand names Hylenex or Vitrase) is an injectable enzyme, a copy of a protein found in the body, that’s used to dissolve hyaluronic acid fillers. Beyond tempering an unwanted effect (like too-lavish cheeks) or righting a wrong (migrated, lumpy, or otherwise “bad” filler), the enzyme is essential for managing the rare filler emergency that is a vascular occlusion. If a hyaluronic acid filler is inadvertently injected into an artery, it can stall blood flow to the skin or eyes, potentially leading to skin loss, scarring, or even blindness. Flooding the treatment area with hyaluronidase promptly and repeatedly is the most surefire way to restore blood flow and avoid catastrophe.
While it is standard practice in aesthetics, melting filler is technically an off-label use for hyaluronidase, as the drug is not FDA-approved for this or any cosmetic indication. Classified as a “tissue permeability modifier,” hyaluronidase is meant to be injected in conjunction with other fluids or medications to increase their absorption and diffusion; it’s been used for this purpose for more than 80 years. Jonathan Cabin, MD, a board-certified facial plastic surgeon in Arlington, Virginia, says he sometimes adds hyaluronidase to his local anesthetic during surgery “because it helps the anesthetic spread — it moves really well.”
For this reason, hyaluronidase can be difficult to control when harnessed as a filler eraser. “This is not a spot treatment,” Dr. Cabin notes. Attempting to soften a discrete lump or a ridge along the lip line, for instance, can inadvertently wipe out the allover plumpness you’d hoped to preserve. That said, when targeting pinpoint blips, doctors usually inject the solution with a needle for precision. For more widespread coverage, they often opt for a cannula. In every case, “there's an art to sculpting things down just as much as there is to filling them up,” says Dr. Frank. “You don't always want to melt all the filler — you [may] just want to take away the bad part.”
And remember, both hyaluronic acid and hyaluronidase exist naturally in the body. A component of our skin, connective tissue, and blood vessel walls, hyaluronic acid lends structural support and hydration to soft tissues, but is constantly being degraded by our own hyaluronidase before being rebuilt — a kind of cellular housekeeping. Synthetic hyaluronidase, the injected kind, can similarly diminish our innate hyaluronic acid molecules — depleting the skin around the injection site and weakening blood vessels (hello, bruising) — but those effects are said to be short-lived.
Is hyaluronidase safe? What are the side effects?
When used judiciously, hyaluronidase is considered to be safe — and vital in cases of vascular occlusion. Still, you don’t have to dig deep to find hyaluronidase horror stories: allegations by patients that the dissolver irreparably damaged their tissues, caused volume loss, divots, and sagging.
Dr. Cabin, for one, doesn’t believe hyaluronidase can irreversibly destroy our soft tissues — and science seems to be on his side. A 2018 study on hyaluronidase’s effects on human tissue found dissolver-induced skin changes, like depressions, to be temporary, resolving within 48 hours of treatment. Another study estimates that it takes the body only 15 to 20 hours to restore lost hyaluronic acid.
Dr. Frank is equally unconvinced that hyaluronidase is deleterious to the skin in a forever sort of way. “There are no real studies to prove this; I’m not so concerned with what I think is a myth,” he says. “I've injected thousands of units at a time and I've never seen any detriment. It does destroy hyaluronic acid, both natural and injected, but your body makes hyaluronic acid back every 48 hours, in enormous amounts.”
So, how to explain the lasting deflation and defects that some claim to experience post-dissolver? Dr. Cabin theorizes that these so-called side effects are likely unrelated to the enzyme itself and more a matter of perspective: Longtime filler users grow accustomed to their voluptuous appearance; it becomes their norm. They’re also unaware of age-related changes that have occurred while their filler has been in place. Dissolver, by merely doing its job, can unmask a new reality. And for overfilled patients especially, returning to an unaugmented baseline — or baseline plus never-seen-before eye bags, hollows, and jowling — can be jarring.
Once dissolved, filler-induced tissue damage can also come to light. “For a lot of people who’ve abused fillers and have filler fatigue, what happens when you melt all that filler? They realize they now have loose, saggy skin,” says Dr. Frank. “But that ain’t from the hyaluronidase — it’s from you overfill[ing] your face for years.”
This is not to say that hyaluronidase operates without leaving a trace. Some of the doctors we interview have witnessed certain dissolver drawbacks. “We definitely see crepey, deflated skin from too much hyaluronidase,” says Dr. Weiser. “The skin may become deflated with even small doses of hyaluronidase, as nearly 50% of the body’s innately produced hyaluronic acid exists in the skin. But we typically see it rebound within a few days of hyaluronidase injection.”
To minimize side effects, Dr. Weiser dilutes her dissolver with saline and often combines the injections with a same-day collagen-spurring treatment, such as the ultrasound-based Sofwave or a superficial radiofrequency microneedling, like Secret RF. In her experience, this helps to maintain the integrity of the skin while boosting the healing process.
Dr. Talei has found that when patients have been grossly overfilled for more than a year and are then aggressively dissolved, their SMAS layer — the superficial musculoaponeurotic system, or fibrous tissue binding skin to muscle — can suffer lasting damage. It’s like a one-two punch: Too much filler injected repeatedly stretches the SMAS over time, stealing its elasticity. Then the dissolver robs its ability to retain water, causing the tissue to shrink and collapse in the absence of filler. The overlying skin often appears dark as a result, Dr. Talei explains, because the dry, flattened SMAS no longer reflects light well.
“If an overfilled face is dissolved within, say, six months, there is unlikely to be any sequela [or negative consequence],” he adds. But “if a massive amount of filler stays there for over a year, it is very likely to cause permanent issues.”
Dr. Talei insists, however, that “dissolver is not dangerous.” When handled properly, “it’s a fantastic tool to have when we need to get rid of filler.” Barring the rare allergic reaction (which can include anaphylaxis in less than 0.1% of patients), it can generally be used without issue, particularly in those who aren’t already overfilled. Healthy tissues begin to rehydrate within a week, he says, and ultimately “snap back, no problem.”
What is it like to dissolve your filler with hyaluronidase?
If you choose to dissolve your hyaluronic acid filler, partially or mostly, choose a doctor who is well-versed in hyaluronidase. There’s very little published data on this cosmetic use — meaning there is no clear consensus nor are there guidelines on strategy or dosing — so it’s crucial to see someone who dissolves frequently (weekly, if not daily) with a tried-and-true protocol.
Dr. Weiser, for instance, has her reversal routine down pat. In addition to diluting her hyaluronidase to dampen its concentration and treating the skin with some type of collagen-stimulating energy just before dissolving, she typically “picks an area that looks the most distorted, whether it’s a temple or a tear trough, and goes slowly,” she says. For reference, on a very overfilled face, she injects 100 to 200 units, max. When tweaking smaller areas or less extreme scenarios, she’ll use closer to 20 to 40 units, selectively. If she is finessing filler rather than fully removing it, a patient may require less.
Since “no one wants to go from looking one way to looking a completely different way overnight,” says Dr. Weiser, most doctors dissolve only one or two areas at a time, with small doses, and then see patients again in two to four weeks to determine next steps.
Says Dr. Cabin, “I bring them back for two reasons: to assess and see if they need more dissolving or want to inject new filler in a more targeted way.” Hyaluronidase tends to do most of its work within 48 hours, but the body quickly responds with swelling, which can linger for days. For this reason, adds Dr. Cabin, “I never try to refill or assess right after dissolving because all bets are off with the swelling.” You can’t really see what’s what.
Beyond allowing time for swelling to subside, delaying further treatment for “at least four to six weeks from the date of dissolving” gives patients a chance to adjust to their new face and prevents knee-jerk refilling, says Elizabeth Houshmand, MD, a board-certified dermatologist in Dallas. “Once they get used to what they look like [without filler], they may opt for not refilling in that area we dissolved.”
Ordinarily, Dr. Frank has patients wait at least two weeks to refill after dissolving — unless the unwanted filler was just placed and hasn’t had time to alter the tissues. “If someone comes to me and says, ‘Oh, God, I went to this med-spa. I had my eyes done for the first time. I look like I have pillows under my eyes,’ I can melt it down, and four days later they can come back [for fresh filler].”
The dissolving process can be unpleasant, Dr. Cabin warns: “People are sometimes surprised that it’s more painful than getting filler.” The shots tend to burn, due to the solution’s pH, and bruising is common, since the enzyme leaves vessel walls weak. “You may look more beat up after the dissolving than you did after the filling,” Dr. Cabin points out. “But if you don’t bruise and you get past the discomfort of the injections themselves, it’s a pretty benign recovery.” (Every patient is different, of course. Olivia says she felt only mild stinging and experienced zero bruising. “After dissolving, my mouth wasn’t as heavy,” she says. “I didn’t realize how much weight was there.”)
While some patients (like Olivia) are satisfied after a single round of dissolver, others (like Elizabeth) require multiple sessions for best results. Says Dr. Talei, “The more [filler] you have in the face — and the longer you’ve had it — the harder it’s going to be to manage.”
Moreover, people are sometimes surprised to learn that they can’t refill on the heels of dissolving. “If someone’s had puffy eyes for four years and that tissue’s been stretched, they may no longer be a candidate for filler,” says Dr. Frank. “I may have to send them for a blepharoplasty [upper and/or lower eyelid surgery]. I may have to do CO2 laser resurfacing [to tighten the skin]. Or I may have to do a bit of both.”
How much does it cost to dissolve filler?
Dissolving generally starts around $400, but can climb into the thousands. The specific cost of a hyaluronidase treatment can vary tremendously based on several factors, including the dose of hyaluronidase needed to reduce or remove the offending gel, the number of sessions required to get the job done, and, in some cases, whether or not ultrasound is used to locate the filler.
Dosing is largely determined by the amount of filler in play and the areas being treated. Says Dr. Houshmand, “The lips may require one session, depending on how much product is present, while the mid-face generally [requires] multiple sessions.” The technique originally used to place the filler can also influence the ease with which it dissolves. Hyaluronic acid gels that were deposited in tiny droplets are easier for the enzyme to digest than those that were injected in large blobs.
Also worth noting: Certain types of filler degrade faster than others. Juvéderm Vycross fillers — Voluma, Volbella, Vollure, Volux — are famously resilient and often take more time (and hyaluronidase) to dissolve than other hyaluronic acids, says Dr. Houshmand. For this reason, it helps a doctor to know the brand of filler they’re going after (always ask your injector!). Says Dr. Frank, “That makes a big difference in the number of units [of hyaluronidase] that I use.”
In his experience, he adds, some brands of filler are much easier to melt than others. Classic Restylane and Restylane Lyft, for example, were shown to dissolve more readily than other fillers in a 2021 study published in the Journal of Plastic, Reconstructive, and Aesthetic Surgery.
The bottom line
Reversing filler demands at least as much skill and artistry as injecting it — and the procedure does come with risks and repercussions. “Every intervention is going to cause a butterfly effect in the face,” Dr. Devgan says. “There’s no way to leave the universe unperturbed.” So the word "reversal" in this context is really a misnomer. Think about it, says Dr. Weiser: “If you had allowed a face to age by itself with no filler, the outcome would be very different from a dissolved-filler outcome.” Indeed, removing your filler, to whatever extent possible, will not restore your face to its pre-injectable state — know this from the outset — but dissolving can serve as a springboard, moving you closer to a place of ease and authenticity.
Read more on injectables:
Watch as a dermatologist explains how fillers work:
