Get Your Fill: Exploring The Double-Edged Sword of Injectable Fillers in Facial Rejuvenation

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Welcome back to Park Avenue
Plastic Surgery Class,

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the podcast where we explore controversies
and breaking issues in plastic

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surgery. I'm your co-host Doreen Wu.

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I'm excited to be here with Dr. Lawrence
Bass Park Avenue plastic surgeon,

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educator, and technology innovator.

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The title of today's
episode is "get your fill:

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exploring the double edged sword
of injectable fillers in facial

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rejuvenation."This episode is
focused on injectable fillers,

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Dr. Bass, you're a plastic surgeon,
injecting filler is not surgery per se.

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Why do you do it? Why is it so important?

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It's important for a number of
reasons. Dorian, first of all,

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we always want to have the full rainbow
of possibilities, both surgical,

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and non-surgical that address?

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All of the aging changes of the
face and aging changes that take

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place at all the different
stages of aging for people

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who have aged enough to have
surgery, injectable fillers,

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give us a more complete correction
and help correct things that surgery

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doesn't address for the very
large number of people who don't

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yet need surgical rejuvenation,

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injectable fillers provide
correction for many,

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many of the early aging changes
that we see in the face.

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Finally,

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it's better overall to maintain
appearance rather than letting appearance

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deteriorate and then try to
restore it with a big surgery.

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Ah,

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I see injectable fillers are a minimally
invasive procedure that helps combat

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aging and can provide many benefits.

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It makes sense by injecting fillers is
a part of your beautification toolbox.

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So where did the concept of
injectable fillers originate?

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People have injected all manner
of materials in the body for

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most of the 20th century.
Uh, and even before that,

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in order to try to augment appearance,

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but in the modern era of fillers,

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this really started in
the 1980s with injected

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bovine collagen collagen
that came from cows and

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was processed and purified
for injection in the face.

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More recently, uh, in the early 2000s,

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we saw the modern era
of fillers start, uh,

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with injected fillers that were more
durable and that had a whole range

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of physical characteristics
to allow us to target

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different individual facial features. Um,

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so that's really the modern era.

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And I'm talking here about
fillers that are FDA approved

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for use as cosmetic injectable
agents in the face for various

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indications. There are non-absorbable
materials that have always been injected.

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Uh,

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however FDA has not cleared
those materials for that sort of

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use in the United States.

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And there are significant safety issues
and problems associated with many of

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these products.

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What were the facial
features that were targeted?

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What did these fillers let us do?

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So the initial use of fillers
like collagen was for nasolabial

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folds and marionette lines,

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the folds between the cheek and the
upper lip and between the chin and

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the lower lip. Um,

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and also for lips both to
adjust size to chase lipstick

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bleed lines and to accent
the Vermilion border.

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So those were the big collagen uses.

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And those in fact were the same uses
that the early generation of modern

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fillers was applied to.

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And that early generation of modern
fillers were materials like Restylane

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and Juvederm.

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That sounds like a good thing, but
does that really make a big difference?

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So lips have always been a big
deal even before aging changes take

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place. It's a very popular area to
make the lip bigger or more curvy,

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or to try to balance the size
between the upper and lower lip.

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However, there are early aging changes,

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uh,

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that do start to show that
we are` not any longer in our

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youthful state, things like the
nasolabial fold and Marionette line.

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And so adjusting those features,
you know, if you're 80 years old,

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that's a drop in the bucket because
there are all kinds of things going on in

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the facial area and elsewhere on the
body that show that you're aging.

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But if you're in your
thirties or your forties,

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these small areas may be the only
things that are starting to give a hint

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that you're no longer in your twenties.

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So correcting those things actually
ends up being a big deal. Uh,

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however, uh, there's,

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there's a whole story to
this and volume in the face.

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In fact,

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we start losing fat in our face
in our mid to late twenties

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at 25, we have the baby face,

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but that fat loss starts.
And by the mid thirties,

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we typically have a more
sculpted and angular look.

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And that may be the best looking face
that we have actually in our thirties,

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not in our twenties,
however, fat loss continues.

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And that eventually becomes too
much of a good thing. At some point,

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you start to look hollow, folds

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start to deepen, and eventually
things start sagging.

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That's the,

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the role of injectable fillers to
restore some of that volume loss.

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Um, in addition, when we get in our
late fifties, sixties and beyond,

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we start losing muscle
and bone volume as well,

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which just accelerates the volume
loss, aging changes in the face.

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And where has it gone from there? What
progress has been made with fillers?

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So, as I said, you know,

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some of the earliest areas that show
deepening or aging change or things like

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the nasolabial fold or
Marionette, however,

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as those changes amplify,
and as time goes on,

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as I just described, there are many,

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many other areas of the face that
start to show obvious visible

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signs of volume loss. One
of those areas is the cheek,

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which is really several components,
the malar eminence or the,

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the curvy upper portion of the cheek,

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the arching that goes back from
there and the area under the cheek,

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which can become increasingly hollow.

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So restoring volume in that area with
fillers is something that's very popular

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these days and has evolved
beyond the nasolabial and

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Marionette applications, uh,
treating the lower eyelids.

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What in medical terms is called the
infraocular hollow is another area

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that makes the eye look
tired and worn, uh,

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and accents, the appearance of
any bulging fat as well. Uh,

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there are indications for the jawline.

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One was just approved
in the last week by FDA,

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uh, because the jaw line, which
is sharply defined and straight,

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typically when we're young
starts to become saggy and baggy

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and uneven as we age,

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and this can be corrected
nicely with injectable filler.

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Another area is the temples,
which hollow as we age,

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we never want them to be convex,

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but if they become more than
slightly concave or neutral,

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ideally then that starts to
look like an aging change.

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And when you think of someone at the
extreme of age well into their eighties or

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nineties, that hollowing
shows very clearly.

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That's what we're trying
to blunt in the aging face.

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People will also accent or
boost the brow or the chin and

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will make very nicely controlled,

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very small shaping changes in the
nose that might be difficult to

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achieve with surgery.

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So those are just a few examples of the
things that are being done with fillers.

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There are some other applications,

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skin remodeling applications with
fillers that stimulate collagen

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production, and that's being used
in some face neck and body areas.

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And there are body shaping applications
that are really developmental at

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this point. Um,

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and there are a lot of tantalizing
potential applications to accent,

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body shapes, but currently
in the United States,

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there's no product that's approved
for this. And so caution applies,

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and we've all heard horror stories
about people using non-medical materials

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to augment body shapes with
disastrous consequences.

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Right?

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It's so amazing that this many different
applications for fillers currently,

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and I'm sure there are many
more to come in the years.

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Can you break it down for me
now? What is the overall role?

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When we think about facial aging, there
are three big categories or pathways.

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Um,

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one is loose skin and that's
in the very early stages,

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energy devices and
mostly surgical lifting,

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whether it's mini lifting or, uh,
the formal facelift neck lift,

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there are skin surface changes
like wrinkles, age spots,

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and so forth.

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And this is typically treated with
energy based devices or chemical

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peeling. So these are things like
radiofrequency microneedling,

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laser resurfacing, and so forth.

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The third big category is
what we've been talking about,

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volume loss and volume loss applications,

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which occur early and continue
to gather momentum as we

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age.

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So we see it over almost
every stage of facial aging.

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Those volume loss problems
are largely treated in

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2022 with injectable fillers.

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When we need small volumes
or just one or two areas,

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it's almost universally
injectable fillers.

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If we need a large volume
or many, many areas treated,

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then this is sometimes done
instead with fat grafting,

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which is a surgical procedure
with bruising, swelling, recovery.

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And that's done in the operating room.

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We've all seen those people who have
so much filler in their faces that they

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look puffy and distorted, or
possibly even like a chipmunk.

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How much is too much? How do I avoid
getting in trouble with fillers?

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This is something we talk about a
lot in plastic surgery, in many,

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many areas. It's always a
case of not doing too much.

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And it's an American
sentiment. That more is better,

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but when it comes to plastic
surgery, that's certainly not true.

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The goal is an artistic,

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natural looking restoration
of your appearance,

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or perhaps a slight enhancement
or augmentation of your appearance

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rather than something that's heavy handed,

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which is always going to
be obvious and unnatural.

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So this is the Goldilocks principle,
not too much, not too little,

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just right. And, um,

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this is where the skill of the
injector is really critical.

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It's like painting with a paint set.
If you give a child a paint set,

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you'll get a painting. If you give
a master artist like Rembrandt,

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a paint set, you'll get a masterpiece
because the skill is different.

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The paint is the same. It's
not the fault of the paint.

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It's the fault of the people applying it.

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So it needs to be
artistically applied, uh,

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and you need to follow the
guidance of the provider,

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the experienced injector who's doing it.

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And that's an important thing
to realize also about filler.

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Filler is highly dependent
on the skill of the injector.

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It is not easy to inject
and get an artistic result.

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An example is something like
the liquid facelift also, uh,

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not a term I'm in love with,

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but it's something you hear
bandied about and on the

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internet liquid facelift
describes using injectable fillers

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to restore facial volume,

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which is a good thing to the
extent that you've lost volume,

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but also to reduce laxity in the face.

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Now you heard me say before
that laxity is mostly about

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lifting surgery and occasionally
energy based devices while adding

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volume helps you with laxity as well.

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And if you only have mild laxity,

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restoring some volume in the
face may be a good thing.

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And you land up looking like yourself,

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the way you used to taking that
mild amount of laxity out of the

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face and all as well.

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But if you have enough laxity where
you really need lifting surgery,

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and you're trying to
chase that with filler,

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what you can end up with is
pumping someone up like a balloon,

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which looks distorting and unnatural
because you're chasing laxity with a

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modality, which is not well suited
to do that. So that's a mistake.

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And it's an example of doing too much.

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With so many products on the
market, which one is the best.

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So that's a loaded question.
And the manufacturers of course,

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would say their product is
the best each manufacturer.

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In reality,

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the FDA approved fillers
in the United States are

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extremely safe products.
There's tons of data,

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both data leading up to the FDA
approval and data in clinical

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use since then, because there are many,

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many injections a year just in the United
States alone. Well, over a million,

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the original group of fillers, uh,

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were basic hyaluronic acid
fillers. These are absorbable.

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The treatments have to be repeated, uh,

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but they were good at covering
all the bases because that's all

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that was out there. Wrestling in Juvederm.

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Most of the filler manufacturers
have next generation products,

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which were really different
lines of hyaluronic acid fillers,

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or in a few cases,

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other materials that were on
the European market and that

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showed particularly useful properties.

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And so what's really happening with
fillers now is products are coming on the

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market in the United States,

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FDA approved for specific indications.

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So they've been tinkered to have exactly
the physical properties that will

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be good for superficial fill
or fill under thin skin or

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heavier applications like cheek

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and jawline. Finally,

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there are what are called
active dermal matrix products.

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So all of the fillers when they're
injected stimulate a little collagen

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production,

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but there are two fillers
in particular Radiesse

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and Sculptra,

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which stimulates significantly more
collagen production in the skin

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when they're injected. So
these products, in addition

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to having a filler or volumizing property

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also structure and densify
the skin because our skin
thins and has less collagen

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as we age. And so this brings the skin
back towards a more youthful state.

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So use of these products,

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as I mentioned in areas like

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neck, hands and face for these
purposes in some of which is off

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label, not specifically FDA approved,

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but these properties and the
fillers are an additional benefit

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for those particular individual fillers

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really picking which filler
you should be using is,

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is all about working with your doctor
because they're the one who's going to be

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injecting it.

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They know what works well in
their hands for a given particular

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indication, whether it's the
cheek or the temple or the eyelid.

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And so each provider knows what
they can get a good result with.

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And it's also partly a product of
what your response to previous filler

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treatments was like. So if you're
working with your provider over time,

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which is always a better idea than
jumping around from provider to provider,

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they can judge how you
responded previously.

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You can give feedback on how
well the feature was corrected,

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or if you had any other issue that
you liked or did not like about that

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treatment. And you can adjust from there.

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And that's really the best way to pick
because all of these fillers absorb and

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you do the treatments over and over,

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it's reasonable to tinker
with your provider to really

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find what the right filler
is rather than bank on, uh,

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reputation on the internet that
this filler is great for X,

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Y, or Z. In reality,

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all of these fillers are
really variations on a theme.

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So they're little fine tuning as I said,

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in the physical properties
from filler to filler,

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like the difference between vanilla
ice cream and French vanilla ice cream,

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they're kind of the
same, but not exactly. So

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providers,

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doctors who are experienced
injectors use these fillers for

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their exact characteristics to
just customize the result you get.

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And again, that's really about the
artist more than it's about the paint.

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Before we close Dr. Bass, can you give
us some final thoughts on dermal fillers?

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Sure. Um, there are a lot of
issues with fillers and again,

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this is very popular, a lot
of treatments being done.

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So it's important to get the most out of
it because it's something you're doing

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over and over. It's important
to do the right amount, uh,

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because when you do the right amount,

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you're most likely to get a good
correction of the feature you don't like.

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You're unlikely to get an
unnatural result or a problem.

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You have to do the treatment
often enough, but not too often.

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If you do it often enough,
you'll maintain the result well,

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but you won't traumatize the
tissues by, by over injecting them.

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This is one of the big three

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mainstays of facial aging.

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So it's really an essential
part of everybody's beauty plan.

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As they try to maintain their appearance
or enhance their appearance with aging,

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your provider can tell you
when you're doing too much,

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or when you're pushing
too hard on a feature,

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that's really exceeding the ability
of the fillers reasonably to provide a

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result. And remember, it's technically
very demanding to inject fillers.

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It takes a lot of skill and experience
as well as a lot of understanding of the

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aesthetics of the face. So in my opinion,

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it really matters to have
an experienced injector.

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Overall fillers are the second
most popular non-surgical

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treatment in the United States with
about 1.3 million injections of filler

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in 2020,

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00:20:52,960 --> 00:20:56,800
which is the last year
for which statistics were
available from the aesthetic

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00:20:57,440 --> 00:20:58,273
society.

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So this is a big part of what we do
now in treatment of facial beauty.

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Thank you for sharing all
of these insights, Dr. Bass.

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It sounds like injectable fillers in the
hands of an experienced injector can be

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very helpful in sting off the early signs
of aging and postponing the need for a

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facelift.

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I hope our listeners found this episode
equally interesting and informative.

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This is Doreen Wu,

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thanking you for joining Dr. Bass and
me for this discussion of injectable

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00:21:27,801 --> 00:21:31,640
fillers and its role in nonsurgical,
facial maintenance and rejuvenation.

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Be sure to tune in next time for
our episode on neuromodulators,

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another injectable commonly
used for facial rejuvenation.

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00:21:39,160 --> 00:21:43,590
Thank you for joining us in this
episode of the Park Avenue Plastic

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00:21:44,110 --> 00:21:48,270
Surgery Class podcast with Dr.
Lawrence Bass Park Avenue plastic

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surgeon, educator, and
technology innovator.

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The commentary in this
podcast represents opinion.

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00:21:54,860 --> 00:21:57,270
This podcast does not
present medical advice,

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00:21:57,570 --> 00:22:01,700
but rather general information about
plastic surgery that does not necessarily

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00:22:01,760 --> 00:22:04,860
relate to the specific conditions
of any individual patient.

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No doctor patient-relationship
is established by listening
to or participating

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00:22:10,080 --> 00:22:10,913
in this podcast,

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00:22:11,170 --> 00:22:15,140
consult your physician to advise you
about your individual healthcare.

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00:22:15,400 --> 00:22:16,780
If you enjoyed this episode,

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00:22:16,920 --> 00:22:21,250
please share it with your friends and
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00:22:21,251 --> 00:22:25,130
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00:22:25,430 --> 00:22:27,730
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