Dermal Filler Dissolving & Hyaluronidase Use Protocol

Off‑label notice: Hyaluronidase use for dissolving dermal fillers is off‑label in Australia. This protocol aligns with Australian governance and current consensus. Do not delay vision‑threat management for testing or consent formalities. ¹ ² ⁹

1. Purpose

Outline safe, effective, evidence‑based protocols for dissolving hyaluronic acid (HA) dermal fillers with hyaluronidase, embedding Australian regulatory and patient‑safety requirements. ¹ ² ³ ⁴ ⁶

2. Scope

Applies to authorised injectors (doctors and nurses within scope) at Newcastle Cosmetic Doctor performing elective filler correction or managing complications (cutaneous or ocular). Includes dosing, reconstitution, allergy precautions, administration, escalation, documentation and reporting. ¹ ³ ⁴ ⁶

3. Indications for Dissolution

Aesthetic correction: unwanted/excess filler, asymmetry, migration. ¹⁰
Suspected or confirmed vascular occlusion/impending ischaemia after HA injection. ¹¹ ¹² ⁹
Inflammatory nodules/delayed swelling unresponsive to conservative care (consider antibiotics ± steroids as indicated). ¹³ ¹⁵

4. Contraindications & Cautions

Absolute: known hypersensitivity to hyaluronidase or excipients; avoid use directly into infected or malignant tissue. ² ³
Relative: pregnancy/breastfeeding (insufficient data—risk/benefit); history of anaphylaxis to hymenoptera (bee/wasp) may indicate higher risk of hyaluronidase allergy—proceed with caution and have anaphylaxis kit ready. ⁸ ¹⁴ ¹⁵

5. Preparation & Reconstitution

Use TGA-listed hyaluronidase (Hyalase® 1500 IU vial). Prepare working solutions below in sterile conditions; label syringes with concentration and time. ²

Working Solution	How to Mix (from 1500 IU vial)	Typical Use
1500 IU/mL	Add 1 mL 0.9% NaCl → 1500 IU/mL	Small test dose; targeted dense depots; NOT routine for aesthetics
300 IU/mL	Add 5 mL 0.9% NaCl → 300 IU/mL	Medium-strength correction
150 IU/mL	Add 9 mL 0.9% NaCl → 150 IU/mL	Common clinic default; widely used concentrations 150–75 IU/mL
75 IU/mL	Add 19 mL 0.9% NaCl → 75 IU/mL	Fine control for lips/tear trough

Notes: Concentrations commonly used in clinical practice include 150 and 75 IU/mL; select strength to match depth/volume and risk of over-dissolving. ¹² ¹³ ¹⁰

6. Allergy Precautions & Testing (elective cases only)

Check history of hymenoptera anaphylaxis and prior hyaluronidase exposure. Have anaphylaxis kit open. ¹⁴ ⁸
Optional intradermal test (IDT) for elective aesthetic corrections only: tiny dose (≈3—5 IU) intradermally; observe 30 minutes. Do NOT delay urgent VO or ocular management to test. ¹⁰ ¹⁵
Caveat: skin testing lacks validated concentrations and may itself provoke reactions in venom‑allergic patients; use clinical judgement and consider referral to allergy specialist. ¹⁶ ¹⁴

7. Administration Technique

Target the filler plane; inject slowly with low pressure. Use 30G needle for superficial work or 25G cannula for broader fields. Ultrasound guidance improves accuracy for localisation and to track response. ¹³ ¹⁶ ¹⁷

7.1 Dosing by Indication (guide — tailor to anatomy, product, and response)

Indication	Suggested Conc.	Typical Dose / Site	Reassess / Repeat
Tyndall (superficial blue hue)	75–150 IU/mL	5–10 IU micro‑deposits	24–72 h; repeat small doses
Small nodules/overfill	75–150 IU/mL	10–30 IU per point	24–72 h; repeat to effect
Migration/asymmetry (lips/tear trough)	75–150 IU/mL	10–30 IU per thread/point	24–72 h; staged sessions
Dense/old depot	150–300 IU/mL	30–75 IU per point	Reassess 24–72 h
Cutaneous VO (skin ischaemia)	150–300 IU/mL	Flood ischaemic field; expect multiple vials	Every 15–30 min until perfusion

Evidence base supports low doses for Tyndall/superficial corrections and high‑dose pulsed infiltration for VO until reperfusion. ¹³ ¹⁰ ¹¹ ¹²

8. Vascular Occlusion (Skin) — Immediate Algorithm

Stop injection. Call for assistance. Photograph and map the area.
Warm compress + gentle massage; keep patient warm.
Infiltrate hyaluronidase throughout and just beyond the blanched/livedoid zone (high‑dose pulsed). Use enough total IU to saturate tissue; expect ≥1500 IU and repeat.
Reassess capillary refill/pain every 15—30 min; repeat until clear clinical improvement.
Consider aspirin if not contraindicated. Provide analgesia and safety‑netting; schedule next‑day review.
Report serious device events via TGA IRIS; document fully in clinical record.

Rationale and protocols: ¹¹ ¹² ¹⁸

9. Any Visual Symptom — Ocular Emergency Pathway

Cease all injections immediately; call 000; initiate urgent ophthalmology transfer.
While awaiting transfer: perform rapid vision checks; keep patient warm and calm.
Inject SC hyaluronidase promptly in the injection territory and along involved vascular pathways (do NOT delay transfer). Bring hyaluronidase with the patient.
Do not attempt retrobulbar injections unless trained and credentialed with ophthalmology support.

Follow the RANZCO 2024 filler blindness guideline pre‑hospital steps. ⁹

10. Anaphylaxis — Do Not Hesitate

Stop procedure. Call 000.
Administer IM adrenaline 1:1000, 0.5 mL in lateral thigh; repeat every 5 minutes as needed.
Lay flat; high‑flow oxygen; establish IV access; consider fluids.
Monitor until handover to ambulance/ED. Record timings and doses.

Follow ASCIA acute anaphylaxis guidelines. Lipid rescue (Intralipid) is NOT a treatment for hyaluronidase reactions—reserve for LAST (local anaesthetic systemic toxicity). ⁸

11. Post‑Treatment & Follow‑Up

Review at ~24 hours and 72 hours. Stage further dissolving conservatively to avoid over‑correction.
Avoid re‑filling for at least 2 weeks (longer after VO).
Provide written aftercare and red‑flag advice; take follow‑up photos.

12. Documentation & Reporting

Record dose (IU), concentration, volumes, sites, batch/lot and expiry (ARTG ID if available).
Informed consent and any IDT results filed in the EMR.
Serious adverse device events → report to TGA (IRIS/MDIR). Apply NSW Incident Management for Harm Score events. Follow NSQHS Medication Safety and Clinical Governance standards.

Governance and reporting frameworks: ² ¹⁸ ⁴ ⁵ ⁶ ⁷

13. Audit & Continuous Improvement

Quarterly review: case numbers, indications, total IU used, outcomes, complications.
Critical incident review for any VO/ocular event with external reporting where required.
Annual drills: anaphylaxis, VO, ocular emergency; ultrasound skill refresh.

Sources

Ahpra (2025) Performing non‑surgical cosmetic procedures — Guidelines hub., viewed 05 November 2025, https://www.ahpra.gov.au/Resources/Cosmetic-surgery-hub/Cosmetic-procedure-guidelines.aspx ↩
TGA (ARTG) — HYALASE hyaluronidase 1500 IU (ARTG 27749)., viewed 05 November 2025, https://www.tga.gov.au/resources/artg/27749 ↩
Sanofi‑Aventis (2024) Australian Product Information — Hyalase® (hyaluronidase) 1500 IU., viewed 05 November 2025, https://medsinfo.com.au/api/documents/Hyalase_PI?format=pdf ↩
NSW Health (2020) Incident Management Policy PD2020_047., viewed 05 November 2025, https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2020_047.pdf ↩
NSW Health (2022) Medication Handling in NSW Public Health Facilities PD2022_032., viewed 05 November 2025, https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2022_032.pdf ↩
RACGP (2024) Infection prevention and control guidelines for general practices., viewed 05 November 2025, https://www.racgp.org.au/running-a-practice/practice-standards/racgp-infection-prevention-and-control-guidelines ↩
ACSQHC (2021) National Safety and Quality Health Service (NSQHS) Standards (2nd ed.)., viewed 05 November 2025, https://www.safetyandquality.gov.au/sites/default/files/2021-05/national_safety_and_quality_health_service_nsqhs_standards_second_edition_-_updated_may_2021.pdf ↩
ASCIA (2024) Acute management of anaphylaxis — Australian guidelines., viewed 05 November 2025, https://www.allergy.org.au/images/ASCIA_HP_Guidelines_Acute_Management_Anaphylaxis_2024.pdf ↩
RANZCO (2024) Filler Blindness Guidelines — Pre‑hospital pathway., viewed 05 November 2025, https://ranzco.edu/wp-content/uploads/2024/06/RANZCO-Filler-Blindness-Guidelines_2024.pdf ↩
ACE Group (2024) The Use of Hyaluronidase in Aesthetic Practice (v3.1)., viewed 05 November 2025, https://uk.acegroup.online/wp-content/uploads/2024/01/ACE-Group-Hyaluronidase-v3.1.pdf ↩
ACE Group (2020) Management of Vascular Occlusion associated with cosmetic injections (v2.5)., viewed 05 November 2025, https://uk.acegroup.online/wp-content/uploads/2020/10/Vascular-Occlusion-v2.5.pdf ↩
DeLorenzi, C. (2017) New High‑Dose Pulsed Hyaluronidase protocol for vascular events., viewed 05 November 2025, https://bdng.org.uk/wp-content/uploads/2017/08/New-High-Dose-Pulsed.pdf ↩
Kroumpouzos, G. (2024) Hyaluronidase for Dermal Filler Complications. J Cutan Aesthet Surg (PMC)., viewed 05 November 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC10836581/ ↩
Bertlich, M. et al. (2024) Sensitisation against medical hyaluronidase in wasp‑allergic patients., viewed 05 November 2025, https://pubmed.ncbi.nlm.nih.gov/39005205/ ↩
Murray, G. et al. (2021) Guideline for the Safe Use of Hyaluronidase in Aesthetic Practice., viewed 05 November 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC8570661/ ↩
CMAC/AAMSSA (2023) Hyaluronidase — Pharmacology, Allergy and Elective Use., viewed 05 November 2025, https://aestheticdoctors.co.za/wp-content/uploads/2021/10/CMAC-Hyaluronidase-Pharmacology-Allergy-and-Elective-Use.pdf ↩
Bravo, B.S.F. et al. (2024) Ultrasound‑guided investigation of HA filler dissolution., viewed 05 November 2025, https://pubmed.ncbi.nlm.nih.gov/38769647/ ↩
TGA (2025) Reporting of medical device adverse events by healthcare facilities (IRIS/MDIR)., viewed 05 November 2025, https://www.tga.gov.au/resources/guidance/reporting-medical-device-adverse-events-healthcare-facilities ↩

Disclaimer for Newcastle Cosmetic Doctor Policies & Procedures

The policies and procedures contained within this document are the exclusive property of Newcastle Cosmetic Doctor and are provided for internal clinical governance and educational purposes only. These materials represent the internal operational framework, safety standards, and evidence-based protocols developed and implemented by Dr. Bart John Scanlon and the Newcastle Cosmetic Doctor team. They are designed specifically for use within Newcastle Cosmetic Doctor and reflect our clinic’s own professional standards, risk assessments, and compliance obligations under Australian law and regulatory authorities. External individuals, practitioners, or organisations must not copy, reproduce, distribute, or rely upon these materials, in whole or in part, for their own clinical, commercial, or educational use without prior written consent from Newcastle Cosmetic Doctor. These materials do not constitute medical, legal, or professional advice and are not intended to be adopted as official protocols or procedures by any other entity. Any external use or adaptation must be independently reviewed and modified to meet the relevant laws, guidelines, and standards applicable to the user’s own jurisdiction, scope of practice, and facility operations. Newcastle Cosmetic Doctor and Dr. Bart Scanlon accept no liability for any loss, injury, or damage arising from the unauthorised use, reliance upon, or misinterpretation of this material.