Effect of Recombinant Human Hyaluronidase on Conventional Hyaluronic Acid Fillers: An In Vitro Analysis

March 2025 | Volume 24 | Issue 3 | 303 | Copyright © March 2025


Published online February 21, 2025

doi:10.36849/JDD.8428

Chelsea Handfield MDa, Deirdre Hooper MDb, Saranya P. Wyles MD PhDa,c

aMayo Clinic Department of Dermatology, Rochester, MN
bAudubon Dermatology, New Orleans, LA
cMayo Clinic Center for Aesthetic Medicine and Surgery, Rochester, MN

Abstract
Background: Hyaluronic acid (HA) fillers offer an advantage in being easily reversible with enzymatic hyaluronidase administration. Yet, there are no clear guidelines regarding the amount of hyaluronidase that should be administered given that commercially available fillers differ in constituent properties.
Methods: Six HA fillers were mixed with aliquots of human recombinant hyaluronidase (0 mL, 0.1 mL, 0.2 mL, and 0.3 mL). Filler dilution photography was obtained with the addition of various doses of hyaluronidase. Final filler and hyaluronidase mixture was then visualized on light microscopy at 40X magnification.
Results: None of the fillers responded to the direct addition of hyaluronidase alone. Active mixing was required to stimulate the enzymatic effect. Restylane® products which have equal concentrations at 20 mg/mL exhibited similar rates of dissolution. In contrast, JuvedermTM products, which differ in concentration, exhibited variable rates of dissolution. JuvedermTM Volbella (15 mg/mL) was the most easily dissolvable filler, in contrast, JuvedermTM Ultra (24 mg/mL) was the least easily dissolvable filler. Microscopically, JuvedermTM fillers appeared more refined whereas the Restylane® fillers appeared more globular following hyaluronidase.
Conclusion: This study demonstrates the in vitro response of different HA fillers to hyaluronidase. Each filler exhibited a variable dose effect. HA concentration (mg/mL) was the critical variable in determining the rate of hydrolysis. Therefore, HA concentration may be an important factor when calculating the dose of hyaluronidase needed to reverse HA fillers.

J Drugs Dermatol. 2025;24(3):303-306. doi:10.36849/JDD.8428

INTRODUCTION

Soft tissue augmentation is an increasingly popular aesthetic medical procedure. Hyaluronic acid (HA) fillers are commonly utilized for soft tissue augmentation.1 An advantage of HA fillers includes easy reversibility with enzymatic hyaluronidase administration.2 In clinical practice, HA degradation is utilized to manage adverse effects from HA filler including intra-vascular filler placement. Current guidelines for HA filler reversal recommend flooding the treatment area indiscreetly with hyaluronidase.3 Yet, there are no clear guidelines regarding the amount of hyaluronidase that should be administered, frequency of administration, or other dose adjustments based on filler type.4 Commercially available HA fillers differ in constituent properties such as crosslinking technology, concentration, and G' prime.5 Given this variability, it is reasonable to conclude that the HA fillers may have discordant responses to hyaluronidase-induced hydrolysis. This in vitro study demonstrates the dynamic response of 6 different commercially available HA fillers to hyaluronidase using gross and microscopic photography.

MATERIALS AND METHODS

Restylane® (manufactured by Q-Med and marketed by Medicis, Inc.) and JuvedermTM (manufactured by Lea Derm and marketed by Allergan, Inc.) received FDA approval in 2003 and 2006, respectively.6 HA fillers used were Restylane® Lyft (Lot# 20482, expiration date 02/28/2025), Restylane® Defyne (Lot# 19915, expiration date 10/31/2023), Restylane® Refyne (Lot# 20418, expiration date 02/28/2024), JuvedermTM Voluma XC (Lot# 1000552552, expiration date 03/30/2024 with 0.3% w/ lidocaine in physiologic buffer), JuvedermTM Ultra XC (Lot# 1000533484, expiration date 12/04/2023 with 0.3% w/ lidocaine in physiologic buffer), and JuvedermTM Volbella (Lot# V15LB10889, expiration date 10/13/2023).

For the HA fillers, 0.1 mL aliquots were placed on separate slides. Then 0.1 mL of Hylenex (human recombinant hyaluronidase, 150 USP units/mL, NDC 18657-117-02) was mixed into each filler sequentially at 3 different time points approximately 2 minutes apart. Filler dilution photography was obtained with the addition of various doses of hyaluronidase (total 0 mL, 0.1 mL, 0.2 mL,
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