Hyaluronidase in Aesthetic Plastic Surgery: Clinical Uses, Safety, Ultrasound Guidance, And Current Controversies

Abstract

Hyaluronic acid fillers are widely used in aesthetic medicine because of their favorable safety profile, versatility, and relative reversibility. Hyaluronidase has therefore become an essential rescue agent for the management of hyaluronic acid filler-related complications, ranging from elective correction of overfilling, nodules, migration, persistent edema, and Tyndall effect to urgent treatment of vascular compromise. Despite its widespread use, important controversies remain regarding optimal dosing, timing, injection technique, ultrasound guidance, allergy testing, filler-specific responsiveness, and the management of vision-threatening complications. This narrative review summarizes the current evidence on hyaluronidase in aesthetic practice, with emphasis on mechanism of action, available formulations, clinical indications, dosing strategies, ultrasound-guided treatment, safety considerations, medicolegal implications, and unresolved controversies. Available evidence supports early and decisive hyaluronidase administration for suspected vascular occlusion caused by hyaluronic acid fillers, whereas elective indications require a more conservative and individualized approach. Ultrasound-guided hyaluronidase is emerging as a valuable tool for precise diagnosis and targeted treatment, particularly in complex or vascular cases. However, the lack of universally accepted protocols highlights the need for standardized training, prospective studies, and practical algorithms tailored to aesthetic clinicians and injectors.