Hyaluronic acid – what fillers can really do (and what they can’t)

Hyaluronic acid (hyaluron) is one of the most effective substances in modern aesthetic medicine.

Natural-looking results, excellent tolerability, and broad applicability are some of its unique properties. The harmonious and safe outcome depends on correct placement: the right amount in the right anatomical layer!

How Hyaluronic Acid Is Produced Today

In the past, hyaluronic acid was extracted from animal sources, primarily rooster combs.
This carried a higher risk of allergic reactions and offered lower purity.

Today, it is produced biotechnologically using bacterial fermentation of Streptococcus species.
The result is a highly purified, vegan, and well-tolerated substance that is almost identical to the hyaluronic acid found naturally in the human body.

Because hyaluronic acid naturally occurs in the skin, connective tissue, and joints, it is very well tolerated. These advancements have significantly increased the safety of hyaluronic acid fillers in recent years.

Crosslinked vs. Non-Crosslinked Hyaluronic Acid

The difference lies in the structure—affecting durability, stability, and consistency.

Non-crosslinked hyaluronic acid

• Thin and fluid
• Hydrates and revitalizes the skin
• Distributes evenly in the superficial layers
• Ideal for mesotherapy (e.g., around the mouth, neck, or décolleté)

Crosslinked hyaluronic acid

• Thicker and more stable
• Remains longer in the tissue
• Suitable for volume restoration, contouring, and wrinkle correction
• Crosslinking technology resorbed slowly: depending on the product, 6–18 months

The aesthetic art lies in choosing the right product for the right region: matched to tissue thickness, dynamic vs. static areas, and the desired outcome.

How Hyaluronic Acid Can Be Dissolved

A major advantage compared with other filler materials is the ability to dissolve it the hyaluronic acid when needed.
We use the enzyme hyaluronidase (Hylase), which breaks down hyaluronic acid chains and accelerates natural degradation.

We use this option for:

• Overcorrections or asymmetries
• Undesired outcomes
• Emergencies where a vessel is compressed or occluded

This makes hyaluronic acid one of the safest materials in aesthetics.

Benefits and Drawbacks

Benefits:

• Naturally occurring and well tolerated
• Immediate visible effect
• Reversible (can be dissolved)
• Individually dosed
• Compatible with other treatments (e.g., Botox, PRP)

Possible drawbacks:

• Temporary swelling, redness, or small hematomas
• Rare: small lumps or uneven distribution
• Very rare: vascular occlusion — requires immediate medical intervention

Therefore: Hyaluronic treatments should only be performed by experienced physicians with precise anatomical knowledge.

Recognizing and Managing Complications

If a complication occurs, every minute counts. A vascular occlusion may present as sudden blanching, pain, or skin discoloration.

Treatment protocols include:

• Immediate injection of hyaluronidase
• Aspirin and manual  massage
• Ultrasound (sonographic) guidance to assess vessels and injection sites precisely

This structured approach greatly improves safety and reduces the risk of damage.

Techniques: Blunt Cannula vs. Sharp Needle

The choice of instrument is important:

Sharp needle:

• Allows precise placement for fine lines or small depots (lips)
• Slightly higher risk of vascular injury

Blunt cannula:

• Significantly reduces the risk of hematomas and vessel trauma
• Ideal for sensitive areas such as jawline, cheeks, chin, or temples

The technique is individualized based on region, treatment goal, and tissue characteristics.

Injection Depth: Superficial or Deep?

Injection depth depends on the goal:

• Superficial injections: fine lines (e.g., perioral lines, neck, décolleté)
• Medium-to-deep injections: volume restoration, contouring, structural enhancement

The deeper the injection, the more critical precise anatomical knowledge becomes, especially vascular structures.

Treatment Areas & Indications

1. Lips: shape, contour, volume—natural and individualized
2. Perioral barcode lines: fine superficial injections with soft fillers
3. Nasolabial folds: softening the shadow for a fresher look
4. Marionette lines: lifting mouth corners, reducing tired expressions
5. Chin: projection, profile harmonization, definition
6. Jawline: contouring and tightening effect
7. Midface/cheeks: restoring youthful volume and shape
8. Nose: non-surgical rhinoplasty (for highly experienced injectors only)
9. Glabella & forehead: caution! high-risk area; only for very experienced physicians with ultrasound guidance
10. Temples: volume restoration; anatomically demanding
11. Neck & décolleté: revitalization with lightly crosslinked fillers for hydration and firmness

Conclusion

To me, hyaluronic acid is a fascinating substance that creates natural and harmonious results that patients truly love.

Thanks to modern technology, precise anatomical knowledge, and the ability to dissolve fillers, treatment has never been safer.

Ultimately, the practitioner’s experience and aesthetic sensitivity determine the outcome, because aesthetic medicine is not a standardized procedure, but an individualized art.

“Be your own kind of beautiful.”

— Dr. Felix Cromme, Plastic and Aesthetic Surgeon, Hamburg