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Dissolving Fillers

As it becomes easier and easier to access anti wrinkle injections and dermal fillers in chain clinics and via mobile setups in hair and beauty salons, it is also becoming more common to see adverse outcomes due to some of these treatments, in part due to inexperienced and new injectors often left on their own after brief training stints, and equally, injectors being guided by the latest trends on social media, be it big lips, tear trough fillers, highly structured faces by way of "snatched" jawlines and cheeks and more.

As a result, it is becoming more common now than it was 5+ years ago, to see more patients coming in to clinic wishing to discuss more filler, sometimes to hide "bad filler" elsewhere or to even dissolve filler gone rogue.

In almost every case, the reason cited is either that the injector kept telling them it was normal and to wait it out without offering the option to dissolve, or occasionally, that they were told there was nothing wrong.

Equally, we are beginning to see filler that has been in place for years at a time, when we were told by companies that it only lasted 6-12 months, and would need topups to stay viable every 6-12 months.

Over time, some of this filler accumulates by being added to every 6 months, or in very mobile areas such as lips and around the eyes, moves ie migrates.

Think of how mobile these areas are - the way the muscles around the eyes move when we blink, smile, close our eyes; or the way our lips move when we smile, talk, sip through a straw, kiss. Or even in cheeks, how filler might move when we laugh, smile and regularly animate our faces. Over time, in some of us, for reasons we do not fully understand, the filler does not integrate as we are told it is meant to, but instead is pushed by small, repetitive muscle actions, to areas it does not belong.

When this happens, we may see it as a shelf or moustache above the lips. Or as lumps or waterlogged areas under the eyes or even around the cheeks.

Occasionally, if the wrong type of filler is used in an area of the face, it can lead to a puffy appearance, or conversely, a highly structured look in an area that does not need it eg in the cheeks, leading to a "peanut head" appearance in the temples which look hollow by comparision. Think of Molly-Mae Hague as an example when, by her own admission, she went overboard with the jaw filler and cheek filler such that it ended up distorting her face.

When I see patients like this to discuss dissolving fillers (not all of them want to start over), there are some key commonalities I notice among all of them:

- they dislike the way they look
- AND they are afraid nonetheless to dissolve the filler because they are afraid of what they will look like post dissolution. Will they have a giant gaping hole where their overfilled lips were? A sunken hollow where their overshaped cheeks are? Will their own hyaluronic acid be dissolved in the process leaving them with even less to work with?
- there is almost a psychological toll on people at the idea of dissolving filler, even filler they are unhappy with; it is almost like they are grieving the loss of money they spent to look a way they are unhappy with, only to spend more money to dissolve it and then potentially more money again to refill the area.

As such, I have found, giving them time and space is vital, as is having an open and frank discussion and setting realistic expectations.

As with so much of aesthetics, we are working with living anatomy and physiology and what worked for your friend may not work for you. You may need as much as she did, or more or less and we will not know until we begin.

Additionally, I like to touch on some other important information:

- the enzyme used in Australia is derived of animal origin. As such, barring an emergency, it is important to do a test patch, in anyone we are contemplating dissolution in as long as they do not have a history of bee or wasp allergy due to a small risk of allergic reaction including anaphylaxis. For this reason, I always advise using a dedicated clinic rather than a mobile setup in a salon.
- the enzyme is acidic and stings/ burns but can be made more comfortable by the use of a numbing agent to minimise the side effects.
- depending on the amount of filler to be dissolved and how quickly it responds, more than one session may be needed to dissolve the filler
- I usually do a test patch and if safe to proceed, we will begin slowly to minimise dissolving too much filler/ filler they do not want to dissolve in surrounding areas
- I observe them in clinic for 15-20 minutes more before they head home and we touch base with them over a day or two till everything has settled
- we review them at 2-3 weeks post dissolution to see if we need more, or if they are happy with results and/or want to refill

Occasionally, despite multiple conversations, some patients are simply not ready to dissolve even though they do not like what they see in the mirror and they want more filler to disguise the area they dislike. In such cases, if it is possible, I may add filler elsewhere to hide the disliked area, but if it not possible to do so, it is essential in the interest of ethical practice to say no and to save the patient their money till they are ready to dissolve and possibly start again.

In areas such as lips and often under eyes, depending on what the problem is, dissolving is almost always needed to begin again.

As the use of hyaluronic acid based fillers becomes more and more common, dissolving clinics are going to rise to provide a need to begin again, so it is vital, as always, to be informed about your choices and options before committing to fillers in the first place, and choosing wisely to minimise the need to dissolve.

As with every other medical aesthetic procedure, communication is key, as is setting realistic expectations and having a clinician you feel is a good fit for you and who will listen without judgement and help you to achieve your desired goal, or say no if they do not feel they can realistically help you.

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