Overview of Injectable facial fillers
What are Dermal Fillers?
Fillers are substances that are injected into the skin of the face to add volume where it has been lost subsequent to the aging process, or when it was not present in adequate amounts all along.
Fillers can be classified as temporary, semi-permanent and permanent. Temporary fillers last up to about one year, semi-permanent fillers last for a few years and permanent fillers last for the life of the patient. Although it may seem best to choose a permanent filler because it does not have to be administered again, remember that the aging process is a dynamic process and that the skin will gradually thin as aging proceeds. What may look good today may be very noticeable under the skin in five or ten years.
What do fillers treat?
As fillers ad volume, they are ideally suited to treat lines of the face that result secondary to atrophy of the skin and sagging of the skin due to gravitational influences. Examples of these areas are the nasolabial folds (the creases between the lips and the cheek), the marionette (puppet) lines which are natural downward extensions of the nasolabial folds, and the corners of the mouth.
Fillers can also add volume to areas that have lost their fullness, again secondary to subcutaneous atrophy. This includes the tear trough area (the curved indentation at the junction of the lower eyelid and the upper cheek), the area over the cheekbones, lips (upper and lower), pre-jowl recess (the part of the jaw line in front of the jowl and behind the chin – fillers here help mask the outline of the jowling), and the cheeks.
Fillers can also be used to augment the nose and change the contour (“a rhinoplasty without surgery”) and supplement the use of Botox in the glabella area of the forehead (the “11″ lines above the root of the nose)
What are the types of fillers?
Collagen is a substance obtained from the dermis (a layer of the skin). Originally produced from bovine (cow) tissue, recent advances in recombinant DNA technology have allowed it to be produced in such a way that it resembles the chemical structure of human collagen, thus eliminating the allergic reactions occasionally seen with Bovine collagen and the need for allergy testing. Although Collagen can produce some nice results, the main problem with it is the relatively short duration of the result, typically a few weeks to a couple of months. For this reason, Collagen (Zyderm I & II, Zyplast) is rarely used in my practice.
Hyaluronic acid (Juvederm® XC, Juvederm Voluma® XC – hyaluronic acid is a normally occurring substance within the dermis of human skin. ®) These products are not made from human or animal tissue, but rather manufactured using DNA recombinant technology in the laboratory. Hyaluronic acid (HA) is an extremely versatile product. Each of these HA’s have specific characteristics that lend them to different indications on the face. For instance, Juvederm Voluma® is best to add volume to the cheeks where as Juvederm Voluma® is great for Lip Enhancement.
What fillers do we offer?
- Juvederm Ultra Plus®
- Juvederm Voluma®
- Juvederm Vollure®
- Juvederm Volbella®
In our office, we offer several of the more commonly used fillers:
Juvéderm® family of fillers– these are non-animal derived hyaluronic acids – a naturally occurring substance that plays a vital role in hydrating your skin and replenishing its natural volume. Juvederm typically lasts about 9 – 12 mos with Juvederm Voluma lasting 1- 2 years.
Juvéderm® has been FDA approved to last up to about one year. Juvéderm Ultra Plus is a little more robust formulation for volumizing deeper wrinkles and folds.
Do I require skin testing to see if I am allergic to the fillers?
None of the fillers used by Dr. Epstein are derived from animal tissues; therefore skin testing is not required. Juvéderm is an NASHA – Non-Animal Synthesized Hyaluronic Acid.
Do I require skin testing to see if I am allergic to the fillers?
None of the fillers used by Dr. Epstein are derived from animal tissues; therefore skin testing is not required.
How are the fillers administered?
Topical anesthetics are available to numb your skin prior to the injection process. These agents are helpful in reducing discomfort during injection. In the past, I have used dental blocks, which are injections of local anesthetics into various areas of the mouth and lips to numb these areas. However, the injection process to place the dental block is uncomfortable in and of itself.
A few years ago, I have switched from using sharp hypodermic needles to inject fillers to a blunt cannula. A cannula is like a hypodermic needle except that the end is blunt and closed. There are tiny holes along the side of the cannula at its end. To use a cannula, a small, sharp hypodermic needle is used to puncture the epidermis (outer layer of the skin) and dermis. It is not inserted further into the skin. Next, the blunt cannula can now be inserted through this tiny hole in the skin and advanced into the facial tissues to place the product. The advantages of the cannula are the following:
- Much less discomfort – there is no sharp needle being advance into your face
- Bruising is very rare – there is no sharp needle causing bleeding in to the tissues
- Better dispersion of the filler
- No need for dental and facial nerve blocks
- Much less risk for injection into a blood vessel – a known cause of complications
Can fillers be combined with Botox?
Yes. In some treatment areas, such as the lips, there can be a synergistic effect when Botox is combined with fillers. Upper lip lines are caused by muscle activity (Botox relaxes the muscles) as well as by loss of volume of the lips (Fillers add the necessary volume). Sometimes, filler is used in the glabella as well to supplement the action of the Botox.
Do you ever mix different types of fillers at one time?
Yes. There is no problem with using different fillers on different portions of the face, matching the problem area with the optimal filler substance.
How do I decide which filler is right for me?
I will listen to your concerns and perform a comprehensive assessment of your facial anatomy. He will then make recommendations and help you to decide what course of treatment is best for you.
How long does a treatment with fillers take?
A typical filler treatment takes about five to ten minutes. If topical anesthesia is used, then add another ten to twenty minutes for the topical agent to take effect.
What is the downtime?
With the use of the injection cannula, bruising is very rare. Swelling is also less. Swelling maximizes on day 3-5, so do not mistake swelling for “over correction”. After about one week, the swelling should be mostly resolved, but this varies among individuals. If you have a special event where you cannot afford to have a bruise on your face, you should schedule treatment no sooner than 1 – 2 weeks before the event to allow any bruising to resolve.
Is there anything I can do beforehand to minimize the downtime?
Avoid substances with aspirin and non-steroidal anti-inflammatory agents (NSAID’s) such as Motrin and ibuprofen within one week of your treatment.
What is the aftercare?
Arnica/Bromeline oral supplements are well known to reduce swelling and bruising. Since using the injection cannula, we have found this unnecessary. Bruising when it happens is usually easily covered up with camouflage makeup, which may be applied immediately. Application of cold packs (20 minutes on, 20 minutes off) for the first few hours up to the first 24 hours, and keeping your head elevated the first two days will also help to minimize swelling and bruising. If you feel any small irregularities or “lumps”, you may massage them until they feel smoother.
If you should develop bruising, blistering, pain or anything unusual after your injection, please call us immediately.
If I have an important event scheduled, can I have a filler treatment?
It is not advisable to have a filler treatment if you have an important event scheduled in the next week or two where your facial appearance is important.
Can I do this on my lunch hour?
From a time standpoint you can, but if the immediate appearance of your face is important, you may wish to do this when you do not have to return to work. It will also be easier to apply cold packs at home than at work.
Are fillers reversible?
The fillers described above are generally not reversible; the effects will fade over time. The effect of hyaluronic acids such as Juvederm can be diminished with injection of a drug called hyaluronidase, but the indication for this is extremely limited.
When should I schedule a follow up appointment?
Two weeks after treatment. By then all the swelling should be resolved and it will be easier to assess your result.
When should I schedule my next treatment?
This is a very personal decision. As duration of effect varies among individuals, the area treated and the type of filler material injected, the best way to answer this question is for you to return when you feel the desire to add additional volume in a given area of your face.