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Injectables Part 1: Fillers
Volume loss is a natural part of aging. As the face ages you lose bone, fat, and integrity of the skin. All the various surgical treatments are complimentary with the placement of volume. People that look strange often have had a lot of surgery but no volume. They've had too much pulling, and really what they need is the softness of volume. Volume is youthful. Even a skinny young person has volume in their face. This is why a heavier person often has a pleasant face, and they will look younger longer. If you are having a surgical procedure on the face, it might make sense to have fat injections if you have volume loss.
Most areas of the face can benefit from volume, from the forehead all the way down to the neck. The classical areas to treat are the naso-labial folds (the furrows that run from the nose down to the corner of the mouth) and the lines that run from the corner of the mouth down to the jaw. Those are great areas for filler. You can also fill the cheeks to get more roundness there. I often add volume above the eyebrow to give it a bit of lift. I've injected it along the mandible to make a straighter line at the jaw, and that helps to decrease the effects of laxity of tissue under the jaw line. You can put it in the chin to give a little more projection of the jaw and you can put it in the lips. However, it is important to be careful of putting it in the lips because it can look very strange if it isn't injected correctly.
The use of volume is a very high-finesse kind of procedure, and I don't feel that it should be attempted by practitioners with less training. There needs to be a deep understanding of what anatomic areas you're changing. Lesser-trained practitioners inject these products, but do they really understand how to recreate or enhance the natural structures of an aging lip? Do they know precisely where to put injections so that they don't look like a duck, and so that your friends don't immediately know that you've had something done? This is why I am such an advocate for having fillers injected only by the most qualified surgeons.
There are three categories of fillers being used today: Hyaluronic Acid Products, Fat Grafting, and so-called Permanent Fillers.
Hyaluronic Acid Products
Hyaluronic acid is a protein that is derived from cellular components which naturally occur in our cells and our bodies. The body makes hyaluronic acid and breaks it down all the time. These proteins are taken and cross-linked so that it's harder for the body to break them down, causing them to stay in place. These are more natural types of products, and I am using the two brands Restylane and Juvaderm.
The hyaluronic acid products tend to last a minimum of six months, usually a lot longer. But if the patients are touched up after six months it tends to maintain the effect even longer. This is a maintenance type of treatment, but the risk of complications is very small. One of the strengths of these products is their simplicity. These products are in syringes that come right off the shelf and you can be injected with minimal recovery.
Fat Grafting
Fat Grafting is the most natural of filler options because we use fat cells from the patients themselves. Fat cells are harvested with a light liposuction from areas such as the abdomen, hips, and thighs. They are sucked out gently because we don't want to damage the cells.
Once the fat is taken from the patient, it is processed and then injected into the face or other areas of the body. This tends to last long periods of time. It can last years, but the percentage of persistence is in the range of 30-40%. As a result, I overcorrect with it, initially injecting more than needed. One of the advantages of using fat grafting is that you can treat the whole face, including lips.
I often feel this procedure is the best possible option, but it is more involved than simply injecting the hyaluronic acid products. It's a surgical procedure to harvest the fat from the patient, so they need to have an adequate amount of fat to do that. There is anesthesia and more swelling as well as more recovery. The initial expense may also be higher, but that is not necessarily true over time. And like most procedures, it probably needs to be repeated at some point to get the best effect.
One item that has been getting a lot of media attention lately is stem cells. Contained in our own fat are a number of naturally occurring stem cells. These stem cells can have beneficial effects on the skin and other tissues because they have regenerative properties. So now we hear fat grafting has been marketed as a cutting-edge "Stem-Cell Facelift." This is funny to me, because these things aren't particularly new; they're just being marketed in different ways. I've been doing fat-grafting for many years, and I really do feel it works quite well.
Permanent Fillers
You also have what is being called "Permanent Fillers" that use a combination of things such as animal or human collagen, calcium-based compounds, and spherical plastic beads mixed into the product to provide a more sustained effect. But you are injecting things into the tissues that are not permanent and can cause a reaction, such as granulomas, which make lumps. You can also have ulcerations and things that need to then be treated surgically.
If you are using so-called Permanent Fillers, you definitely run a higher risk of problems. In the case of Artifill, the granuloma rate is 20-30%, which means you get lumps. And really there is no treatment for it except excision (surgical removal). Injecting these products into certain areas is contra-indicated. You can get hugely swollen and disfigured lips and have a long-term problem. When you are having injections, please consider who it is that is injecting the product. Are they capable of doing an operation to fix it if they have a problem? That's important to think about.
I just don't inject permanent fillers. I could, but it just doesn't make sense to me. With the elevated percentage of complications, why would you want to put your patients at risk? Is it so permanent you'll never need to do it again? I don't buy that. The face is not a permanent structure. As we age, it will continue to change and there will always be things you'll want to do. If you put in something permanent now, then later when the skin sags, there may be a lump there because you injected calcium or plastic. This is not a good idea.
In Conclusion
There are a lot of options. There is a lot of marketing and there are a lot of things to be understood about these products in order to make a good, informed decision. I tend to emphasize the fact that these are elective treatments that are being done for appearance. The face is not a permanent structure, so the idea of putting permanent things into it may not be sound. I like the natural products because you run an extremely small risk of having a problem and it can be adjusted over time. I also emphasize that with anything you do, you are going to have maintenance involved. It is an advantage for the patient to see someone that does ALL the different types of treatments in plastic surgery, so that you can understand how everything is interrelated and the benefits of each type of treatment, including skin care, injections or surgery.
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 James Green, MD | Plastic Surgery, Santa Fe | Phone (505) 988 2215
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