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Injectable fillers like Juvederm and Restylane and injectable paralytics like Botox represent a vast part of minimally invasive cosmetic procedures. The popularity continues to grow. Here are some questions to help you with your decision to use these medical treatments to improve your appearance.
What are Dr. Williams' qualifications to speak on this topic?
Dr. Williams: I am a board certified plastic surgeon. I attended Yale University medical school and received my plastic surgery training at Yale University. I have a busy practice which includes using injectable fillers and Botox in my San Francisco area practice. I encourage patients to speak with their physicans for specific advice. We offer this as useful information for people considering treatment with injectable filler.
Can you describe injectable fillers?
Dr. Williams: Collagen, was the first filler to be approved by the FDA in the 1970s. It had problems with allergic reactions and short longevity meaning that patients needed to be treated more frequently to maintain their look.
Hyaluronic acid fillers were approved in 2003. They do not typically trigger allergic reactions and last longer. These fillers tend to be somewhat thicker than collagen and need slightly larger bore needles. These are the most common type of filler used now and has an excellent efficacy and safety profile.
There are other fillers. Sculptura (poly-L-lactic acid), for example, is a filler that has been approved by the FDA for HIV patients with facial wasting. Some physicians use this off label for cosmetic improvements and the FDA is considering approving this treatment for cosmetic use. It stimulates new collagen production over a period of months and should have a long-acting effect, anywhere from 1 to 3 years after injection.
Can you describe some of the most common risks of injectable fillers?
Dr. Williams: The most common are pain, infection, bleeding (and of course bruising associated with bleeding), asymmetry and palpable nodules. In the hands of a well trained, experienced injector these are very rare.
The first three are caused by the mechanism of placing the material in the right place. Fillers are injected with a needle. With every injection there is a risk of bleeding and bruising - this risk can be increased by certain medications, high blood pressure, larger needles and other factors. Injections can be painful and depending on the patient and the area being injected, it can hurt a little more or a little less. Both of these problems can be reduced with cold compresses prior to treatment - a practice that we use regularly. In very sensitive areas like lips or for patients that are particularly sensitive topical or injectable anesthetic can be used. Infection is exceptionally rare.
The second two complications (nodules or asymmetry) are caused by placing the filler in the wrong area. It can be normal for an injected area to feel slightly lumpy or full and this usually resolves with massage or time.
The temporary nature of fillers means that less than satisfactory results are typically limited to a few months. Hyaluronic acid fillers can also be broken down by a separate injection of a medication called hyaluronidase.
What about longer lasting or permanent fillers?
Dr. Williams: I mentioned Sculptura, calcium hydroxylapatite is another 1-2 year lasting filler. With both of these medications there can be increased palpability and injection reaction. They also tend to increase volume as time goes on making them slightly more challenging to predict. Of course, if there is asymmetry or a result that a patient finds undesirable, there is no medication to breakdown the material.
Permanent fillers like liquid silicone are considered off label and most plastic surgeons and dermatologists will not use it. Permanent fillers have permanent side effects. Part of the problem can be with the body's immune system creating a local inflammatory reaction which can cause pain, redness and ulceration. I've had many patients request removal of silicone many years after injection.
Patients looking for permanent solutions should consider fat grafting.
Who should inject a filler?
Dr. Williams: This can be a controversial topic. In our practice only board trained plastic surgeons perform injections. In general, it is our belief that only "core trained" physicians should perform or supervise injectors. Plastic surgeons, dermatologists and facial plastic surgeons (all with their own respective board certifications) incorporate injections, their complications and an intimate knowledge of anatomy into their original training. This is a benefit that other doctors (internal medicine, gynecologists, etc.) do not have.
Supervise? So you're referring to nurses or physician assistants?
Dr. Williams: That's correct. It is well within the licensing guidelines of nurses and PAs to perform injections. The argument that the nurses make -- and it's a powerful one -- is that they get prescriptions to inject chemotherapy, which is a potentially life-saving and potentially dangerous treatment. They give medications in the intensive care unit without a doctor holding the syringe. Why shouldn't they be able to inject dermal fillers? In our practice the doctors perform the injections but I understand the role of supervised non-physicians performing injections.
Thank you Dr. Williams.
