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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5214_Библиотеки_им_академика_М_И_Перельмана.pdf
218
Fig. 6.11 Degradation of hyaluronic acid ller in blood
vessel by inltration of hyaluronidase
Table 6.4
Repeated hyaluronidase treatment is effective
The interval should be as short as 15–30min
It is effective to use high doses of hyaluronidase
Hyaluronidase usage recommendations
6 Side Eects andTreatment Methods ofFiller Procedures
injection using a rabbit model. Flaps were made
in rabbit ears to block blood vessel anastomosis,
and then llers were injected into the auricular
artery. Necrosis of the ear was induced after
which hyaluronidase was injected at various
intervals.
The results of the experiment were as follows
(Table6.4).
The hyaluronidase usage guidelines have
changed over time. In the past, it was recommended to repeat the procedure every day.
Recently, re-evaluation and re-administration at
1h intervals are recommended. This study found
that in emergency situations such as intravascular
injections, frequent administrations at 15 min
intervals are more desirable.
Based on these ndings, we expect that new
evidence-based guidelines will be coming soon.
To compare the difference between in vivo
and invitro experiments, the authors conducted
a similar experiment for the use of hyaluronidase in the laboratory. Unlike in vivo experi-
ments, the ller degradation effect of
hyaluronidase was related to the total amount of
hyaluronidase used. In summary, there was no
difference between the group administered
750 units at once and the group administered
250 units divided into 3 injections at 15 min
intervals. Repeated administration did not show
better results. This is thought to be associated
with the inactivation of hyaluronidase invivo
(Fig.6.12).
(6) Massage the area after injection.
Borders and Raftery (1968) reported that the
molecular weight of hyaluronidase is 61,000Da.
Khorlin et al. (1973) report four subunits of
14,000 each and a total molecular weight of
55,000Da. Hyaluronidase has a large molecular
weight; it dissolves on the outer surface of the
ller material when it encounters hyaluronic acid
ller. Naturally, the contact surface must be large
for effective enzymatic degradation. After hyaluronidase injection, the area of contact should be
widened through massage. As mentioned earlier,
because hyaluronidase activity decreases in the
body, it is recommended to massage after injection to effectively facilitate contact between the
ller and hyaluronidase.
The authors performed hyaluronic acid ller
degradation test and observed the difference of
solubility according to massage.
< Experimental condition>
(a) It was performed at 36.5 degrees Celsius to
match the enzyme activity.
(b) The authors performed a seal after hyaluroni-
dase mixing to prevent evaporation of water
during the experiment.
(c) A monophasic ller was used.
(d) The group without massage was compared
with the group which received the massage at
the same time.
(7) When injecting into a nodule or granuloma,
make sure to penetrate the capsule and inject
into the center of the mass.
Nodules or granulomas are caused by a vari-
ety of factors. Thick brous capsules form
6.3 Use ofHyaluronidase forDegeneration ofFillers
Fig. 6.12 Comparison of hyaluronidase usage invitro test
219
a
Fig. 6.13 Degradation difference between the non-massage and massage group after 24h of mixing 750units of
hyaluronidase
around the ller when it is due to the poor quality of the ller itself or by abnormal immune
responses (Fig.6.13).
Even when nodules or granulomas are present, hyaluronidase is recommended for primary
treatment. When the brous capsule around the
nodule or granuloma is not thick, it is adequate to
inject a sufcient amount of hyaluronidase into
b
the area around the lesion and massage it.
However, in cases where the capsule is very thick
and severely inamed with calcication, injection and massage of hyaluronidase around the
mass cannot effectively dissolve it. Only hyaluronic acid llers in connective tissues along the
periphery of normal tissues can be dissolved, but
the mass will not disappear.
220
6 Side Eects andTreatment Methods ofFiller Procedures
Although surgical removal may be considered, surgical removal often leaves scars on the
face. Therefore, efforts to dissolve using hyaluronidase should not be easily abandoned.
When treating a hard nodule or granuloma
with hyaluronidase, the hyaluronidase must be
injected into the center of the mass to dissolve it
from the inside (Figs.6.14 and 6.15).
It is important to know whether hyaluronidase
is properly injected into the center of the mass
during the procedure. If it is not injected in the
right place, not only does the mass not dissolve;
it can cause unwanted side effects.
There is a way to determine if the needle tip is
properly positioned in the center of mass.
It is one of the most important details in treating ller side effects (Table6.5).
6.3.2 SONO-Guided Techniques
forHyaluronidase Injections
6.3.2.1 Dissolving Hyaluronic Acid
Fillers
Hyaluronic acid llers can be dissolved using
hyaluronidase. In cases where the injected ller
causes nodules or granulomas, dissolution may
Table 6.5
injected into the center of mass
1. If the needle tip is located at the center of mass
2. When the injection is successful, you can feel that
3. You can feel the mass swell and burst while the
4. If it is properly injected and then promoted again
How to make sure hyaluronidase is correctly
correctly, it is difcult to inject hyaluronidase due
to the higher injection force than when the needle
tip is located at the surrounding normal tissue
the size of the mass has increased immediately
after the injection. If the central injection fails,
swelling simply occurs in the periphery
injection is successful. Fibrous capsules are inated
due to hyaluronidase injected into the body and
cannot withstand pressure and burst
after several minutes, it can be seen that the rigidity
of the mass is reduced and the size is reduced. If
you feel the capsule pops out, you can see that the
mass itself is gone
Fig. 6.14 When injected outside the mass: hyaluronidase
cannot pass through the thick brous capsule of the nodule and thus cannot remove the mass
Fig. 6.15 Hyaluronidase is injected and dissolved in the
center of the mass. Hyaluronidase is injected directly
through the brous capsule via a needle and then directly
inside
6.3 Use ofHyaluronidase forDegeneration ofFillers
221
be necessary. Typically, these injections are performed blindly by hand. However, the use of
ultrasound can enable a more effective dissolution process.
By employing ultrasound guidance, the exact
location of the ller can be identied, allowing
for precise administration of hyaluronidase. This
method improves the accuracy of the treatment
and increases the likelihood of successful resolution of nodules or granulomas caused by the
ller.
6.3.2.2 Sonographic Finding ofHA
Filler Nodule
On ultrasound, hyaluronic acid ller nodules typically present as homogenous, anechoic (black)
masses. The absence of internal echoes indicates
a uid-like consistency, which is characteristic of
HA llers. These ndings are generally welldened with smooth borders, making them distinguishable from other types of tissue
irregularities.
6.3.2.3 Sonographic Appearance
ofGranulomas
In contrast, granulomas induced by HA llers
present as heterogeneous and irregular masses on
ultrasound. These formations show mixed echogenicity, with both hypoechoic (dark) and hyperechoic (bright) areas. The irregular echo patterns
indicate a more complex internal structure, often
due to chronic inammation and brosis.
Granulomas may also exhibit poorly dened
borders and a “dirty” appearance, reecting the
disorganized nature of the inammatory response.
The presence of these irregularities makes granulomas distinct from the more uniform appearance
of HA ller nodules.
Hyaluronidase can be effectively used to dissolve
HA llers, and ultrasound guidance enhances the
precision of this intervention. For granulomas,
additional treatments such as intralesional steroids may be required to address the inammatory component.
6.3.2.5 Sonographic Findings inCases
ofSkin Impending Necrosis
Following Filler Injection
Sonographic andDoppler Finding
inIschemic Areas
In cases of ischemia following ller injection,
affected areas exhibit reduced blood ow on
Doppler ultrasound. This reduction in blood ow
is indicative of vascular compromise, which, if
not addressed, can lead to tissue necrosis. The
ischemic area may show altered echotexture
compared to healthy tissue, reecting underlying
tissue distress (Fig.6.16).
a
b
6.3.2.4 Clinical Implications
The ability to accurately differentiate between
HA ller nodules and granulomas using ultrasound is crucial for appropriate management.
Fig. 6.16 (a) Sonographic image of ischemic forehead
area (b) Sonographic image of the contralateral normal
forehead area
222
6 Side Eects andTreatment Methods ofFiller Procedures
a
b
Fig. 6.17 (a) Sonographic image of the treated ischemic
forehead area post-hyaluronidase (b) Sonographic image
of the contralateral normal forehead area
post-hyaluronidase
Sonographic Improvements Posthyaluronidase Treatment
Hyaluronidase is an enzyme that can dissolve
hyaluronic acid llers, thereby alleviating the
compression on blood vessels and restoring
blood ow. After hyaluronidase treatment,
Doppler ultrasound typically shows an improvement in blood ow to the previously ischemic
area. The echotexture of the tissue also returns to
a more normal appearance, reecting the recovery of the affected tissues (Fig.6.17).
Further Reading
1. Haddock NT, et al. The tear trough and lid/cheek junc-
tion: anatomy and implications for surgical correction.
Plast Reconstr Surg. 2009;123:1332–40. discussion
1341.