A Discussion of Injectables

The field of injectables has really blossomed in the past few years. We have progressed from collagen which was stiff and only lasted 3 months to a wealth of choices which last much longer. This discussion will try to help sort out these choices for you.

Hyaluronic acids (Juvaderm, Voluma, Volbella, Vollure, Restylane, Resylane Lyft (previously Perlane), Restylane Silk, Bolatero, Versa and others) have brought easy-to-use, longer-lasting (up to 2 years), clear and reversible products to the market. They have different particle sizes and, therefore, each is appropriate in different areas of the face. They can actually be dissolved if the patient does not like the effect. I like to use these fillers throughout the face in the cheeks, because these tend to flatten and hollow over time, in the hollows under the eye, in the nasolabial area (the grooves on the sides of the base of the nose), in the marionette area (the indentation just in front of the jowl because filling this can hide the jowl), or the parenthesis area (the indentations on the side of the mouth either above or below). They can also be used to give a patient a chin instead of a chin implant. I also like to use filler more superficially around the chin to fill in the wrinkles and lines that we tend to develop there as we age. Filler can even be used in the earlobes if these have shriveled. It can also be used beneath the brow to give an illusion of a brow lift, or eyelids to make the eye look both softer and more open. It can be used in the lines of the neck or in the temples as these become hollow with age or weight loss, or in the forehead instead of botox to make it smoother.

Another hyaluronic acid filler recently introduced to the United States market is called VERSA. It has been on the international market for 10 years and has 18% of the hyaluronic acid market share in Canada. The advantage of VERSA is that it is not very hydrophilic. What that means is that it doesn’t attract water from the patient’s tissues and cause swelling. Juvederm products tend to swell the most which is useful when you’re trying to plump the cheeks or chin or the marionette area. Restylane products tend to be less hydrophilic. Too much swelling can lead to unnatural puffiness in thinner tissues such as under the eye. Although I have only started using VERSA since March of 2018, I think it will be very useful under the eyes, especially in patients who have had issues with swelling and puffiness after filler in the past. It should have the same longevity as other fillers, that is, at least a year in this location, and like all the hyaluronic fillers, it can be melted out in the office with hyaluronidase if for some reason you do not like the effect.

An innovation since 2011 has been to dilute the hyaluronic acid fillers with lidocaine containing epinephrine prior to placement. This minimizes visibility of the filler in terms of color or lumpiness yet is still long-lasting. It also hurts less and bruises less because of the lidocaine which numbs as it injects and the epinephrine which causes the blood vessels to constrict temporarily. Dilute filler to the hands is another good option. Dilute filler also gives us something to inject into sharp lines of the face such as lipstick and cheek lines. If you have diffuse wrinkles, a laser may still be the best option, but for specific lines, filler works very well.

Another innovation in my office since 2013 has been to use an infrared vein finder called AccuVein so that I can avoid the veins of your face and minimize the risk of a significant bruise. This technology has been very popular with our patients.

Radiesse is a long-lasting filler, but it has the color and consistency of toothpaste and is very firm, so I only use it deep in the face on the cheekbones, along the jaw or under the chin where it cannot be seen or occasionally to re-inflate a nipple reconstruction that has lost some volume.

Sculptra is a unique volumizer. It generally and diffusely fills the face. It is ideal for a patient, say a runner, who is slender but feels his/her face is looking gaunt with age. It can also be used to volumize and rejuvenate hands that are starting to look bony. The disadvantage of Sculptra is that although it lasts about 2 years, several sessions are sometimes necessary, and it can be a little pricey compared to other fillers.

Fat is in some ways the best filler because it is permanent where it takes. The problem is that even with the most current techniques, how much fat grafting will survive is unpredictable. For this reason, if I already have a patient under anesthesia for some other reason, fat grafting will be only a minimal charge and well worth the effort. As a stand-alone procedure, it is not worth the cost, in my opinion, because of this element of unpredictability. It should also be used cautiously in the lips. In patients who tend to put on weight, the lip will expand with weight gain and cause a strange-looking deformity.

An exciting new filler in 2017 is Renuva. This is processed, sterilized and non-immuno genic cadaveric fat. This should be a permanent filler. It can be used instead of a chin implant to augment the chin. It can also be used under indented scars, in breast reconstruction for depressions, and to help nipple reconstruction project more. It can even be used for small buttock augmentation in patients who do not have fat to donate. Basically, it can be injected in most places fat can be injected.

The risks of fillers are minor. They include bruising and swelling. Allergic reactions are EXTREMELY rare. The bruising is usually minor especially now that we are using the vein finder.

I believe that dilute hyaluronic acid in the hollows under the eyes is probably the most rejuvenating filler of all, but occasionally (about 5% of the time) it can look puffy because it holds onto water (hydrophilic). If you develop unusual puffiness that persists beyond a few days, I can melt it out and use another filler which doesn’t puff but may not last as long (Versa).

In my opinion, it is very important to receive your injection from an experienced injector who is very familiar with facial anatomy so that inadvertent injection into the blood vessels and nerves of your face is extremely unlikely and your safety is more guaranteed.

There are medications and herbals that can increase bruising and bleeding you should avoid for two weeks before receiving fillers. These are: Advil, Aleve, Alka Seltzer, Anacin, Anaprox, Aspirin, Ascriptin, BC Powder, Bufferin, Coricidin, Dristan, Estrin, Empire, Excedrin, Fiorinal, Filene, Ibuprofen, Indocin, Lortab, Midol, Motrin, Naprosyn, Unpin, Pepto Bimal, Percodan, Sudafed, Vitamin E and Voltaire. Tylenol is fine! Many herbals can cause bleeding — Echinacea, Ginkgo Biloba, Ginseng, Licorice Root, St. John’s Wort, garlic tablets — and others have not been studied well enough to know what impact they will have, so it is prudent to stop ALL herbals two weeks before receiving fillers.

For your information, each filler product has a rewards program. Please go to ASPIRErewards.com for all Restylane products and brilliant distinctions program.com for Juvaderm, Voluma and Botox to sign up if you are interested.

Fillers can be very transformative for a reasonable cost and little down-time. Some have called them a liquid facelift, but I think that is a little exaggerated and mainly a marketing ploy. Nonetheless, my filler patients are some of my happiest.

It will be a pleasure to discuss fillers with you. If you have any questions, please call my office
(804) 320-8545.