Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, e416ee417
CORRESPONDENCE AND COMMUNICATION
Low dose of Hyaluronidase to treat
over correction by HA fillereA
Case Report.
Sir,
Hyaluronic acid (HA) is probably the most popular filler for
correction of deep facial lines as well as facial soft tissue
augmentation.
The peri orbital region is among the more delicate and
difficult areas to treat with filler injections on account of
the thin skin in the region.1 One of the possible complica-
tions with HA gel injection is over correction which is
particularly troublesome in the tear trough area.
Hyaluronidase injection is used to correct unevenness or
excess of HA gel.2e5
The dose of Hyaluronidase suggested and used as
reported in literature varies from 5 units to 75 units.2e4
We present a case report of over correction of lower lid
depression which was effectively treated with very low
dose of Hyaluronidase injection.
A 25 year old female patient requested to have
depressions in the lower lids to be filled non surgically.
Cross linked non animal source Hyaluronic acid (Juvederm
Ultra, Allergan, Pringy-France) 0.4 ml was injected on
either side in subcutaneous plane. Over correction and
Figure 1 Over correction with HA filler.
1748-6815/$ - see front matter ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2010.01.005
tyndall effect was evident from the 2nd day. Patient was asked
to wait for 3 weeks for adequate resolution of edema. At the
end of 3 weeks, there was visible over correction (Figure 1).
Hynidase  (Hyaluronidase ovine 1500 I.U/vial, Shreya
life sciences pvt.ltd, Aurangabad, India) was reconstituted
in 1 ml normal saline.
0.1 ml of this solution was added to 10 ml of normal saline;
in this dilution 0.1 ml would contain 1.5 I.U of Hyaluronic acid.
0.2 ml (3 units) of reconstituted dilute Hyaluronidase
was injected on either side. Patient was reassessed after 2
days; there was complete resolution on the left side and
about 60% improvement on the right side.
The right side was treated again with 1.5 I.U of Hyni-
dase and within 2 days there was complete correction on
the right side also. Patient was reviewed after 4 weeks and
showed stability of results (Figure 2).
It is well known that Hyaluronidase is effective in treating
lumps, bumps and over correction from HA injections. The
required dosage reported varies widely. A well structured
randomized control trial by Vartanian et al 4 showed the
efficacy if Hyaluronidase to remove injected HA. Their study
showed that smaller doses, 10 units of Hyaluronidase, were
effective in diminution of augmentation with HA. They
further recommended low doses 0f 5e10 units to decrease
allergic reactions which probably is dose dependent.
Although it is not possible to accept definite conclusions
from a case report, this case shows that even lower doses of
1.5e3 units are effective in treating over corrections.
Starting with very low doses would be preferable to prevent
complete removal of HA and to reduce allergic reactions.
Figure 2 4 weeks after hyaluronidase treatment.
Correspondence and communication e417

Conflict of interest 2. Rohrich Rod J, Ghavami Ashkan, MelissaCrosby A. The role of

Hyaluronic Acid Fillers (Restylane) in facial cosmetic surgery,
2007 in facial cosmetic surgery: review and technical consid-
None. erations. Plast Reconstr Surg 2007;120:98S.
3. Lambros V. The use of hyaluronidase to reverse the effects of
Funding hyaluronic acid filler. Plast Reconstr Surg 2004;114:277.
4. Vartanian AJohn, Frankel Andrew, Rubin Mark. Injected
None. hyaluronidase reduces restylane-mediated cutaneous augmen-
tation. Arch Facial Plast Surg 2005;7:231e7.
Ethical approval 5. Alam Murad, Dover Jeffrey S. Management of complications and
sequelae with temporary injectable fillers. Plast Reconstr Surg
2007;120:98S.
Not required.

Harikumar Menon
References Mohan Thomas
James D’silva
1. Goldberg Robert Alan. Nonsurgical filling of the periorbital The Cosmetic Surgery Institute Mumbai, India
hollows. Aesthetic Surg J 2006;26:69e71. E-mail address: Cosmodocl@yahoo.co.in