Facts & Fallacies #2: Injectable Fillers

Summer Hardy (00:01):
Welcome to Park Avenue Plastic Surgery Class, the podcast where we explore controversies in breaking issues in plastic surgery. I'm your co-host, Summer Hardy, a medical student in New York City. I'm excited to be here with Dr. Lawrence Bass, Park Avenue Plastic Surgeon, educator, and technology innovator. The title of today's episode is Fax and Fallacies: Injectable Fillers. How did we get to this topic, Dr. Bass?

Dr. Lawrence Bass (00:25):
Basically, I pick one of these facts and fallacies topics when I repeatedly read things on the internet or social media or beauty media like fashion and beauty magazines that I believe to be completely untrue on a factual basis.

Summer Hardy (00:44):
That makes sense. So why is this happening?

Dr. Lawrence Bass (00:47):
Injectable fillers by number of procedures is number two in all of medical and surgical aesthetics after neuromodulators like Botox. There's so much on the internet about this and many, many people speaking on this subject. Much of what's said comes from sources that very clearly have a vested interest in promoting fillers or in tearing them down. The stakes are high. There's a lot of money involved in aesthetic medicine, billions of dollars a year. Companies that sell these products want to extol the virtues of fillers. People who don't do surgical aesthetics see a broad role for fillers and other non-surgical treatments. Surgeons who don't offer non-surgical treatments and others who provide services only to surgical patients and practices see the world from that perspective surgery fixes everything and the other options are not very worthwhile. Also, there's a focus and we've talked about this before on the podcast on the extremes and on sensationalism by all forms of media that are struggling to attract the largest possible audience.

(02:16):
So I'd really like to try in this series to provide some reality and when it comes to fillers in this what's become a very highly charged atmosphere. Knowing the facts rather than the hype one way or the other for good and for bad allows a more reasoned decision about what treatments to add to your beauty plan.

Summer Hardy (02:40):
How so? Can you elaborate on that?

Dr. Lawrence Bass (02:44):
Well, if you know real risks and real benefits, that's useful to making a decision about whether something is a good fit for your current stage of aging and for you personally for your personality or lifestyle, fear mongering or distorted realities in either direction, good or bad, may lead to a poor decision. Any decision not based on reality is likely to be disappointing at the end of the day. So to have success with your beauty planning, getting the real deal is very important.

Summer Hardy (03:21):
Okay, that makes sense. So let's move on to the first statement about fillers. Here it is. Fillers distort your appearance looking unnatural or puffy.

Dr. Lawrence Bass (03:31):
What does everyone think about that? Certainly it's been suggested very widely that fillers create this unnatural puffy appearance, but I believe this is false. How fillers look is simply a matter of the amount used and the skill of the injector. That skill varies widely from very brief training and just taking baby steps in filler use to years of training in facial anatomy and aging and years of injecting fillers and using other modalities to restore the aging fac. To even more experienced people, those of us who have performed some of the approval studies and were there at the beginning of this modern age of fillers, which started with the FDA approval of Restylane back in 2004. Think of filler like paint. The quality of a painting you get depends on the skill of the artist and the nuanced application of the right amount of paint to create a beautiful work of art.

(04:41):
If you give a five-year-old a paint set and Rembrandt, either way you'll get a painting, but they really will not be the same quality and none of that is the fault of the paint.

Summer Hardy (04:55):
Okay, fillers aren't necessarily unnatural or puffy. Let's look at an opposite sort of statement. Fillers can be repeated as many times and as often as you want.

Dr. Lawrence Bass (05:05):
To me, this one is just common sense. Nothing can be done at infinitum and doing a medical treatment too often or too close together can overstress tissues and cause complications. Plastic surgeons all know you can't repeat most plastic surgeries too many times. You can repeat them once or twice, but over and over is a bad idea. There's a limit beyond which control is lost or at least diminished and healing problems increase along with the risk of other complications. So you lose control of the aesthetic features more likely to get an unnatural look. And so there's really no reason this wouldn't apply with fillers as well. Now that being said, non-surgical treatments can be repeated many, many times unlike surgery. The safety track record of fillers that are FDA approved in the United States has been incredibly good and supports the repetitive use that plastic surgeons and dermatologists recommend.

(06:20):
But to go back to my point with surgery, nothing is repeatable at infinitum without limit and particularly repetitive closely spaced treatments, which can be traumatic to tissue more from the process of injecting than from the fillers themselves can result in trouble. And I suspect a lot of injectors are working on the notion that there's no limit to how often, how much or how frequently you can inject. The problem is there's not a specific exact limit. If we knew exactly what it was, it would be easy to stay on the right side of the line and not go across the line and get in trouble. It's much larger than with surgery, but it's als much more variable depending on age, skin type, and other treatments that have been done previously. Careful examination of the skin by an experienced plastic surgeon or dermatologist can usually reveal whether overtreatment is taking place, but going ahead without any of that careful oversight can mean trouble.

Summer Hardy (07:36):
Understood. Can you give me an example and explain what the consequences of too frequent or excessive treatment are?

Dr. Lawrence Bass (07:43):
I've seen patients who had one or two dozen treatments over a three-month period of time. This is often the result of obsessively chasing very small shapes that are perceived as imperfect or undesirable. There's a lot of trauma to the tissues to be injected over and over that many times during this short period of time that's shorter than the typical retreatment interval, which is often six months or a year or sometimes even longer in areas like the eyelids. This can create redness and edema or swelling in the skin and increased skin fragility. The other consequence of having so many fillers of so many vintages is that as the fillers absorb, you'll see them exit in reverse order with the oldest filler absorbing first. And so all the shapes that you were camouflaging as you added little bits of filler are going to reemerge in reverse as that filler breaks down and leaves the tissues.

(08:59):
So this means perfect is the enemy of good and it reminds me of a movie they showed me in high school English class called Shaving and a man came and stood in front of the mirror and lathered up and shaved his spirit and he looked clean shaven, but he noticed a couple of spots that weren't and he went back and shaved a second time and then a third and then another and eventually he was bleeding and his face was a mess. So it was a rather heavy-handed way of expressing the notion that perfect is the end may of good. He should have quit after one shave when he was clean shaven. Everything looked good, even though it wasn't quite perfect.

Summer Hardy (09:43):
Okay. Thanks for explaining that. So here's another one. Fillers are only for young people or early in aging.

Dr. Lawrence Bass (09:51):
Well, if you've been listening to the podcast, you should know the answer to this one. This is a fallacy. In my view, fillers are part of the beauty plan for all stages of aging.

Summer Hardy (10:03):
Okay. And what changes and what stage the same with aging in terms of using fillers?

Dr. Lawrence Bass (10:09):
So as I said, it's always part of the beauty plan, but the amounts you may need to get a good correction may increase as you get older or sometimes you need to switch from a softer filler to a firmer filler to push out the looser tissues a little more effectively. The main focus areas that you're treating may shift as other areas become the prominent problem areas when you're older that are different from the most noticeable problem areas when you're young, or sometimes you need to add more areas as you age. In all cases though, the idea is to restore volume in proper measure, not to push things with fillers as hard as you can. That's always a mistake and not because of late issues, but because of the immediate issues like an unnatural look.

Summer Hardy (11:05):
Okay, that makes sense. So now let's go with this one. Fillers can lift the face.

Dr. Lawrence Bass (11:12):
So this is a definite no. This is a fallacy and in early stages of aging, a little bit of volume restoration may deal with minimal laxity in the face, but in terms of lifting, taking tissues that have sagged closer to our feet and bringing them back closer to the top of our head, we currently don't believe that this takes place. And there have been some very sophisticated studies of the aging face done by a plastic surgeon named Val Lambrose, who's in Newport Beach, California, looking at photoanalysis and photoanalysis three dimensionally before and after fillers, trying to see if the cheek could be lifted or the jawline or gel lifted. And his data is in line with what I just said that fillers do not create a lifting effect. It's a volumizing effect, not a lifting effect. Another example is one of the early proponents of fat grafting in the face for aging changes, a plastic surgeon named Sydney Coleman, who was in New York and he taught a great deal about how to successfully do fat grafting in the face and that's a very powerful and important tool for restoring volume in the aging face, but he became so enamored with fat grafting that he came to the conclusion that all aging in the face was the result of volume loss and could be fixed with fat grafting.

(12:51):
Facelifts were not needed. All that was needed was fat grafting and this very clearly is not true aging in the face and everywhere else in the body is multifactorial and unfortunately multiple different types of treatments are needed to correct each type of aging change. And even if you believed what Sid Coleman at one point believed, and I think he eventually came to understand better that this was not really a correct viewpoint, but even if you believed that it still would not help you with lax skin in the neck area where fillers really don't have a role.

Summer Hardy (13:34):
Okay. Thanks for clarifying that. Now how about this statement? Fillers stretch out tissues and accelerate aging.

Dr. Lawrence Bass (13:43):
This seems like it might be a concern logically with skin that's older and less elastic. If you push it with filler, it's going to stretch out and be looser, but it's actually a fallacy because it overlooks the effect fillers have to stimulate new collagen and to replace materials in the skin that are lost with aging. Like hyaluronic acid, most fillers that we're using are hyaluronic acid fillers. Some are active dermal matrix fillers with even more collagen stimulating ability, but the hyaluronic acid fillers are replacing the ground substance material in our skin as well as helping in a more minimal way than active dermal matrix fillers to stimulate new collagen formation. And again, all of this is with the proviso that the amounts that are being used are appropriate and the really overblown treatments in terms of amounts or frequency can cause trouble in skin, but we're talking about measured treatments that are restoring lost volume and proper measure.

Summer Hardy (14:55):
Okay. And here's our last statement. Fillers are forever chemicals.

Dr. Lawrence Bass (15:01):
This is a very inflammatory statement, but I've seen it out there, believe it or not. Forever chemicals have a very specific meaning so they're PFAS chemicals per and polyfluoroalkal substances. So these are synthetic, highly persistent chemicals that do not break down in the environment or in the body and they're used for waterproofing and grease proofing and stain resistance in products like nonstick cookware, fast food wrappers, waterproof clothing, and they contaminate a lot of water and food sources worldwide. Exposure to these chemicals is definitely a bad thing. It's linked to severe health risks including cancer, immune system damage and metabolic issues. So it's true that fillers are not exactly like endogenous material. So we have hyaluronic acid in our bodies. The hyaluronic acid polymer that gets injected with injectable fillers is modified and doesn't exactly match the pattern that we have in our bodies and we don't typically completely clear all of the filler that was injected before the next treatment interval so that potentially allows some buildup of the material in the body over several treatments.

(16:37):
And that actually is a good thing because it means you don't go back to baseline and need exactly the same amount of filler. You get a little bit more completely and a little bit more durably corrected after a few treatments. But if we look at this issue of fillers being forever chemicals, they're not toxic. They're not carcinogenic and they are eventually cleared from the body. It's not that they're never cleared from the body. Furthermore, they can be broken down with an enzyme and cleared in nearly complete measure immediately if need be. Filler materials are not endocrine disruptors, basically fillers meet none of the criteria of a forever chemical like the PFAS chemicals aside from the fact that they don't bear any resemblance in chemical structure to the PFAS chemicals.

Summer Hardy (17:41):
That's a relief and good to know. Okay, Dr. Bass, time for your takeaways.

Dr. Lawrence Bass (17:47):
So takeaways are pretty simple. This is something that's very widely out there in public use. As I said, number two, aesthetic treatment, surgical and non-surgical. It's safe. It's incredibly effective. Like everything, there can be too much of a good thing so it's important to do not too much, not too little, just write and have a very skillful plastic surgeon or dermatologist injecting. Fillers along with fat grafting have a unique role in facial aging restoring volume in the aging face separate from laxity treatments and skin quality treatments. The FDA-approved fillers are outstanding products with an impressive safety record in properly trained and experienced hands and used appropriately. Like any tool, if intentionally used in a reckless manner, they're not immune to trouble. My advice is use fillers for what they're good at as they were intended to be used and not for trying to make them do a job for which they were never intended like significant skin laxity.

Summer Hardy (19:04):
Wow, it sounds like there's a lot of noise about fillers these days. Thank you for sharing so much information and clearing up so man fallacies about fillers with some facts. Thank you for listening to the Park Avenue Plastic Surgery Class Podcast. Follow us on Apple Podcasts, write a review, and share the show with your friends. Be sure to join us next time to avoid missing all the great content that is coming your way. If you want to contact us with comments or questions, we'd love to hear from you. Send us an email at podcast@drbass.net or DM us on Instagram @drbassnyc.