What is the recommended dosing for elective hyaluronidase (hyaluronidase) dermal filler administration in a patient with no known allergies or medical history?

Hyaluronidase Dosing for Elective Dermal Filler Dissolution

For elective dissolution of hyaluronic acid dermal fillers in patients without allergies, inject 1.25 to 37.5 units of hyaluronidase per 0.1 mL of filler as a single injection, or use lower doses of 0.375 to 2.25 units per 0.1 mL when administering three consecutive weekly injections. 1

Dosing Strategy Based on Clinical Context

Standard Single-Injection Protocol

• Inject 12.5 to 37.5 units per 0.1 mL of filler when performing a single treatment session for uncomplicated filler nodules or aesthetic corrections 1
• The most commonly used concentration in clinical practice is 150 U/mL (66% of cases), followed by 75 U/mL (31% of cases) 2
• Research demonstrates a dose-dependent response for most HA fillers, with more dramatic dissolution occurring between 30 minutes and 3 hours post-injection 3

Multi-Session Protocol (When Applicable)

• Use 0.375 to 2.25 units per 0.1 mL of filler when planning three consecutive weekly injections 1
• This lower-dose serial approach may reduce the risk of over-dissolution while achieving adequate correction 1

Filler-Specific Considerations

High-Viscosity/Highly Cross-Linked Fillers (e.g., Voluma)

• Require higher doses exceeding 20 units per 0.2 mL of filler for adequate dissolution 3
• Voluma exhibits the clearest dose-response relationship, with 2.5 units showing minimal effect comparable to saline controls 3
• Start with at least 10 units per 0.1 mL for these products 3

Standard Cross-Linked Fillers (e.g., Juvéderm, Restylane)

• Restylane responds most readily to hyaluronidase, showing dissolution even at 2.5 units per 0.2 mL 3
• Juvéderm and Restylane demonstrate mild dose-response patterns across the 2.5 to 20 unit range 3
• These fillers can be effectively treated with the lower end of the dosing spectrum (12.5 units per 0.1 mL) 3, 1

Critical Pre-Treatment Safety Assessment

Absolute Contraindication: Bee Venom Allergy

• Never administer hyaluronidase to patients with bee sting allergy due to cross-reactivity between bee venom and hyaluronidase 4, 5
• When allergy history is uncertain, perform prick testing before administration 4
• Most allergic reactions are immediate hypersensitivity responses, though delayed reactions can occur that skin testing may not predict 6

Bleeding Disorders

• Available guideline evidence does not identify bleeding disorders as a contraindication to hyaluronidase use 4

Injection Technique for Optimal Results

Anatomic Placement

• Inject hyaluronidase directly into or immediately adjacent to the filler deposit for subcutaneous placements 6
• For intravascular filler (vascular occlusion emergencies), injection in the vicinity of the vessel is sufficient rather than into the filler itself 6
• Hyaluronidase is rapidly degraded and deactivated in the body, requiring sufficient quantity placed close to the target filler 6

Concentration Preparation

• The 75 U/mL and 150 U/mL concentrations show no statistical difference in clinical outcomes (P = 0.625) 2
• Choose concentration based on volume constraints and injection comfort rather than efficacy expectations 2

Common Pitfalls and Risk Mitigation

Post-Hyaluronidase Syndrome

• 18% of patients experience facial hollowing or unwanted changes after hyaluronidase treatment 2
• This syndrome correlates significantly with longer duration of filler in situ (P = 0.00019) and higher total filler volumes (P = 0.000017) 2
• The syndrome appears related to previous filler characteristics rather than hyaluronidase concentration or dose used 2

High-Risk Patient Counseling

• Patients with prolonged filler history (>1 year) and higher cumulative volumes face increased risk of post-hyaluronidase syndrome 2
• Warn these patients explicitly about potential hollowing and facial contour changes before proceeding 2
• Consider more conservative dosing or staged treatments in this population 2

Timing of Dissolution

• Most dramatic filler breakdown occurs from 30 minutes through 3 hours post-injection, with continued gradual degradation through week 2 3
• Some filler deposits (particularly Restylane) dissolve spontaneously over time without intervention 3
• One study documented Restylane controls lasting four years, indicating variable natural degradation rates 3

Inadequate Response Protocol

• 24% of patients require additional hyaluronidase treatment after initial injection 2
• When insufficient dissolution occurs, repeat injection using the same or slightly higher dose after waiting at least 48-72 hours to assess full effect 1, 7
• Avoid immediate re-injection, as hyaluronidase continues working for days after administration 3

Evidence Limitations

• All randomized controlled trials demonstrating hyaluronidase efficacy were conducted on forearm, upper arm, or back skin—no RCT evidence exists for facial applications 1
• Evidence for managing vascular occlusion, tissue necrosis, inflammatory nodules, or over-corrections consists only of case reports and expert consensus 1, 7
• Despite limited high-quality evidence, clinical experience with over 200 patients supports these dosing recommendations 7