Reversible vs. nonreversible fillers in facial aesthetics: concerns and considerations

Soft-tissue augmentation of the face is an increasingly popular cosmetic procedure. In recent years, the number of available filling agents has also increased dramatically, improving the range of options available to physicians and patients. Understanding the different characteristics, capabilities, risks, and limitations of the available dermal and subdermal fillers can help physicians improve patient outcomes and reduce the risk of complications. The most popular fillers are those made from cross-linked hyaluronic acid (HA). A major and unique advantage of HA fillers is that they can be quickly and easily reversed by the injection of hyaluronidase into areas in which elimination of the filler is desired, either because there is excess HA in the area or to accelerate the resolution of an adverse reaction to treatment or to the product. In general, a lower incidence of complications (especially late-occurring or long-lasting effects) has been reported with HA fillers compared with the semi-permanent and permanent fillers. The implantation of nonreversible fillers requires more and different expertise on the part of the physician than does injection of HA fillers, and may produce effects and complications that are more difficult or impossible to manage even by the use of corrective surgery. Most practitioners use HA fillers as the foundation of their filler practices because they have found that HA fillers produce excellent aesthetic outcomes with high patient satisfaction, and a low incidence and severity of complications. Only limited subsets of physicians and patients have been able to justify the higher complexity and risks associated with the use of nonreversible fillers.