Under your skin | Before and After - Episode 3 | BB investigates the injectable industry

Key Concepts

• Dermal Filler: A cosmetic injectable, considered non-surgical, used to soften and refresh the face by adding volume. Hyaluronic acid is a common type.
• Hyaluronic Acid Filler: A specific type of dermal filler made from hyaluronic acid.
• Hyaluronidase (Dissolver): An injectable enzyme used to break down hyaluronic acid. It has approved uses in medicine and cosmetics but can also be used "off-label" for dissolving dermal filler.
• Instagram Face: A beauty standard popularized on social media, characterized by plump cheeks, plump lips, and smooth, wrinkle-free skin.
• Post-Hyaluronidase Syndrome: A proposed syndrome characterized by a constellation of symptoms affecting the skin, fat layer, and deeper facial tissues, potentially caused by repeated hyaluronidase treatments.
• TGA (Therapeutic Goods Administration): Australia's regulatory body for therapeutic goods, including medicines and medical devices.
• Off-label Use: The use of a drug or medical device for a purpose other than what it has been officially approved for by regulatory bodies.
• Body Dysmorphia: A mental health condition where a person is excessively preoccupied with a perceived flaw in their appearance.

Lana Ristovski's Experience with Dermal Fillers and Hyaluronidase

This episode of "Before and After" details the concerning journey of Lana Ristovski, who experienced significant negative consequences after receiving dermal filler injections and subsequent treatments with hyaluronidase.

The Allure of Social Media and the Initial Procedure

• Social Media Influence: Lana, a single mother in her 40s, was influenced by social media feeds showcasing ageless faces with plump cheeks and lips, setting new beauty standards. She felt pressure to achieve a similar look as she aged.
• Cosmetic Clinic Experience: She visited an elegant cosmetic clinic, where she was recommended dermal filler, specifically hyaluronic acid filler, by a cosmetic doctor. The doctor described it as a subtle, non-surgical injectable that would "soften and refresh" her face.
• Immediate Dissatisfaction: Upon receiving the injections, Lana was devastated by the results, stating she "totally hated it" and "couldn't recognize myself." She described her cheeks looking like "golf balls" and her smile as unnatural. She felt the fillers had changed her appearance instantly and significantly.
• Long-Term Persistence of Filler: Despite being told the filler would metabolize over months (up to 18 months), Lana found it did not disappear. She experienced years of anxiety, isolation, and paranoia about her appearance, even quitting her job as a table games dealer due to her distress.

The Diagnostic Challenge and the MRI Revelation

• Medical Referrals and Skepticism: Lana sought help from numerous specialists, including dermatologists and surgeons. Many dismissed her concerns, suggesting body dysmorphia or disbelieving that filler could still be present after years. Some even suggested dangerous surgical removal.
• The MRI Breakthrough: In 2018, a cosmetic surgeon suggested an MRI to definitively determine if filler was still present. This was a "glimmer of hope" for Lana.
• MRI Findings: The MRI report confirmed the presence of dermal filler in her cheeks (up to 4mm) and, unexpectedly, in her lips. This indicated that the filler had migrated from its original injection sites. The radiologist referred to the lip filler as "lip implants," which was shocking to Lana as she had only received dermal filler.
• Confirmation and Ongoing Scans: The MRI provided Lana with crucial confirmation that she was not "delusional" and that the filler was indeed still in her face. She has since undergone five MRIs, all confirming the persistent presence of filler.

The Emerging Research on Filler Longevity

• Dr. Moin Master's Observations: Radiologist Dr. Moin Master began noticing filler on MRIs of patients who claimed they hadn't had filler for years. This led him to investigate.
• The "Pandemic of Filler": Dr. Master described a "pandemic of filler" around 10 years prior, driven by the pursuit of "Instagram face," with the assumption that fillers were temporary.
• Eight-Year Study: Dr. Master and colleagues conducted an eight-year study involving 33 patients, finding that dermal filler can last anywhere from two to 15 years.
• Landmark Peer-Reviewed Paper: This research resulted in a peer-reviewed paper demonstrating that certain hyaluronic acid fillers are not always temporary, contradicting initial product information.
• Limitations of Previous Studies: Previous studies, often funded by pharmaceutical companies, relied on subjective photographic evidence rather than imaging, making it appear as though fillers dissolved when they may have simply migrated or become embedded in deeper facial tissues.
• Product Information Discrepancies: Product information for Lana's filler indicated sustained effects for up to 18 months, with a majority maintaining cheek volume for at least six months, but made no mention of years of longevity.

The Complications of Hyaluronidase (Dissolver)

• Lana's Attempt to Dissolve: Dissatisfied with the filler, Lana returned to the clinic and was advised that a "simple easy procedure" called dissolving could remove it. She received injections of hyaluronidase.
• Social Media Trend: Dissolving filler has become a trending topic on social media, with influencers documenting their "dissolve journeys" as they move towards a more "natural look."
• Lana's Negative Experience: Lana's experience with hyaluronidase was far from smooth. Despite multiple sessions over several years, she saw no dissolution of the filler. Instead, she believes the hyaluronidase dissolved her "connective tissue," leading to significant skin laxity, drooping, sunken tear troughs, and caved-in cheeks.
• Off-Label Use and Lack of Regulation: Lana discovered that hyaluronidase is used off-label in Australia for dissolving dermal filler. While approved for specific medical and cosmetic emergency uses (e.g., to break down filler injected into a blood vessel), its use for elective dissolution of dermal filler is unregulated, with no clear guidelines on dosage or technique.
• Tribunal Findings: Lana took the injector to the Victorian Civil and Administrative Tribunal, which found she had given informed verbal consent, despite not signing a consent form. Her complaints to the tribunal and another health regulator were rejected, with the clinic found to have administered the treatment appropriately.

The Formation of a Support Group and the Emergence of Post-Hyaluronidase Syndrome

• Online Community: Feeling isolated and unheard, Lana sought out others with similar experiences online. She discovered cosmetic surgery forums and eventually created a private Facebook group for women experiencing issues with fillers and hyaluronidase.
• Widespread Symptoms: The group, which grew to nearly 18,000 members globally, documented a wide range of severe symptoms, including bacterial infections, allergic and autoimmune reactions, burning sensations, redness, swelling, pain, dry eye, rash, inflammation, migration, festoons, abscesses, and skin issues.
• Mental Health Impact: The group has highlighted the significant mental health toll, with members experiencing overwhelming anxiety, depression, and even suicide due to the perceived damage to their appearance and the lack of help.
• Dr. Scott Turner's Public Acknowledgment: Dr. Scott Turner, a specialist plastic surgeon in Sydney, publicly acknowledged a syndrome he termed "post-hyaluronidase syndrome," which he believes is caused by repeated hyaluronidase treatments.
• Syndrome Characteristics: Dr. Turner suggests that hyaluronidase is not selective and can permanently affect facial tissues, leading to accelerated aging, skin laxity, and other symptoms. He bases this on his observations during facelifts.
• Limited Recognition and Emerging Research: Post-hyaluronidase syndrome is not widely recognized by the profession. The Australasian Society of Aesthetic Plastic Surgeons has stated it's not proven that dissolver causes the syndrome. However, a UK study of 90 patients found that 18% experienced disfiguring issues after dissolver treatment.
• TGA Consideration: The Therapeutic Goods Administration (TGA) stated they would consider changing product information for hyaluronic acid dermal fillers if sufficient adverse event reports are received.

Lana's Continued Search for Answers

• Consultation with Dr. Turner: Lana met with Dr. Scott Turner, hoping for a clear diagnosis and confirmation of the impact of hyaluronidase on her face.
• Diagnosis and Lingering Uncertainty: Dr. Turner diagnosed Lana with "significant soft tissue changes and facial laxity, most likely related to multiple hyaluronidase treatments," but also noted other contributing factors like aging and weight fluctuation. He did not attribute the issues 100% to hyaluronidase.
• Renewed Determination: Despite another perceived disappointment, Lana's meeting with Dr. Turner fueled her determination to continue seeking answers and potentially reclaim some of her life.

Conclusion

Lana Ristovski's story highlights the potential dangers and long-term consequences associated with cosmetic injectables like dermal fillers and their subsequent dissolution. The episode underscores the influence of social media on beauty standards, the lack of transparency regarding the longevity of fillers, and the significant risks associated with off-label use of treatments like hyaluronidase. The emergence of research and patient communities like Lana's Facebook group are crucial in raising awareness and advocating for better understanding and regulation within the cosmetic industry.