Enzymatic Management of Facial Overfilled Syndrome: A Case Series and Narrative Review

Abstract

Background: Facial overfilled syndrome (FOS) is an increasingly recognized complication of injectable aesthetic procedures, characterized by undesirable facial volume and contour irregularities. While hyaluronidase is well-established for managing hyaluronic acid (HA) filler complications, treating FOS caused by non-HA fillers, such as fat and silicone, remains challenging.

Objective: This study aims to present the results of a novel enzymatic therapy combining hyaluronidase, collagenase, and lipase for treating FOS in five patients with complications from HA, fat, and silicone fillers. Additionally, we conducted a narrative literature review of studies published between 2015 and 2024, focusing on FOS and its management.

Methods: We performed a narrative literature review using PubMed and Google Scholar databases, identifying six key papers that specifically address FOS. Following this, we present a case series of five patients treated with a combination of 1.5 mL collagenase, 1.5 mL hyaluronidase (HASA), and 1.5 mL lipase (total volume: 4.5 mL). Enzymatic therapy was administered via cannula under ultrasound guidance, and outcomes were assessed through clinical evaluation and patient-reported satisfaction.

Results: All five patients significantly improved facial volume and contour restoration after a single treatment session. The enzymatic combination effectively addressed complications from HA, fat, and silicone fillers, with no significant adverse events reported. Patient satisfaction improved significantly, highlighting the psychological benefits of the treatment.

Conclusion: Combining hyaluronidase, collagenase, and lipase represents a safe and effective approach for managing FOS caused by various filler types. Our study, supported by a narrative review of six key papers on FOS, underscores the importance of tailored enzymatic therapies in aesthetic medicine and calls for further research to optimize treatment protocols and expand the evidence base.

Keywords: collagenase; hyaluronidase; lipase; overfill face; overfill syndrome; recombinant enzymes.

FIGURE 1

Patients 1 and 2, women who experienced facial overfilled syndrome (FOS) following hyaluronic acid (HA) filler treatments. (A) Pretreatment photographs showing overvolumization in the midface and lower face. (B) Posttreatment photographs after a single session of enzymatic therapy using a combination of 1.5 mL collagenase, 1.5 mL hyaluronidase (HASA), and 1.5 mL lipase (total volume: 4.5 mL), administered via cannula. The treatment resulted in significant improvement in facial volume, restoration of natural contours, and enhanced patient self‐confidence and comfort with their appearance.

FIGURE 2

Patient 3, a 55‐year‐old woman who experienced facial overfilled syndrome (FOS) following hyaluronic acid (HA) filler injections in the cheeks and midface, as well as silicone filler in the glabella and nasal dorsum. (A) Pretreatment photographs showing overvolumization in the midface and nose. (B) Posttreatment photographs after a single session of enzymatic therapy using a combination of 1.5 mL collagenase, 1.5 mL hyaluronidase (HASA), and 1.5 mL lipase (total volume: 4.5 mL), administered via cannula. The treatment significantly improved facial volume and restored the natural look, especially on midline face, with better nose projection, and enhanced patient self‐confidence and satisfaction with their appearance.

FIGURE 3

Two female patients: Patient 4 (35 years old) experienced facial overvolumization (FOS) following fat grafting. After fat grafting in the midface, the fat was positioned on the temporal area, nose, and nasolabial folds, and Patient 5 (27 years old) experienced FOS due to silicone‐based fillers in the chin and facial contours. Both patients received two sessions with 1‐month interval. Panel (A) shows the patients administered via cannula before treatment with a single combined enzyme therapy (1.5 mL collagenase, 1.5 mL hyaluronidase, and 1.5 mL lipase; total volume: 4.5 mL). Panel (B) shows the improvement in facial overvolumization after two treatment sessions, with 1‐month interval.