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Purpose: Several injectable hyaluronic acid dermal fillers exist in the market, each with different rheologic and cross-linking properties. Their reversibility is useful for managing complications. We sought to determine the response of three different hyaluronic acid gels to varying doses of hyaluronidase., Methods: Each of 18 arms of nine subjects were prospectively randomized to receive intradermal injections of hyaluronic acid gel (Restylane-L, Juvéderm Ultra, Juvéderm Voluma). Seven sites on each arm were randomized to receive 0.2 mL of hyaluronic acid gel in anticipation of dissolution 1 week later with varying doses of hyaluronidase (Hylenex), 2.5, 5, 10, or 20 units or to be a control site. The outcome measures of diameter, elevation, and firmness were measured pre-injection and at varying time points to beyond 4 years. Subjects, graders, and injectors were masked., Results: The most dramatic changes for all fillers occurred starting at the 30-min time point through 3 h time point, with continued gradual degradation through week 2. A mild dose response was found for Juvéderm and Restylane; however, a clear dose response was seen from 2.5 to 10 units for Voluma, with 2.5 units showing features more like those of saline only or no hyaluronidase control. One Restylane arm had controls lasting four years., Conclusions: All fillers had a dose response, with Voluma exhibiting it most clearly. Voluma required higher doses of hyaluronidase for dissolution, i.e., more than 20 units per 0.2 mL of filler. Restylane appeared to respond most readily to hyaluronidase, at the dose of even 2.5 units, but it also was fastest to dissolve on its own., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Purpose: Hyaluronic acid (HA) fillers can be reversed with hyaluronidase, but their dose responses are not well-characterized. We evaluated 12 fillers' in vitro responses to varying doses of recombinant human hyaluronidase (RHH)., Methods: For the 12 HA gels, 0.2 mL aliquots were placed on six slides. Samples received no injection, saline injection, or RHH (2.5, 5, 10, or 20 units). The most resistant gels received 40 units of RHH on a seventh slide. Photos of gels were taken from bird's-eye and lateral views with a ruler at multiple time points., Results: Restylane-L and Restylane Lyft were the most easily dissolvable HA fillers. Both demonstrated a significant response to 2.5 units RHH/0.2 mL. Juvéderm Ultra, Belotero, Restylane Silk, and Restylane Defyne had moderate resistance to RHH. Restylane Refyne, Juvéderm Ultra Plus, Vollure, Versa, and Voluma were most resistant, requiring more than 20 units RHH/0.2 mL for complete dissolution. Volbella was moderately resistant up to 20 units RHH but demonstrated pronounced dissolution with 40 units RHH., Conclusions: This study visually and objectively demonstrates the in vitro response of HA to dissolution by hyaluronidase. Fillers were categorized into least, moderate, and most resistant to RHH. Interesting findings include markedly different degrees of liquefaction for products used for similar indications (such as Restylane Lyft being more liquefied than Voluma), and Belotero easily flattening but retaining texture. Combined with in vivo data, this may help calculate hyaluronidase doses needed for controlled, partial reversal of commercially available HA gels., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)