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Injectables

What exactly are “injectables”?

Injectables refer to products that are injected either in the skin or below the skin to add volume to the face or reduce wrinkles. Most products are temporary. However, products like Scuptra have permanent results (More on Sculptra below). Under the umbrella of injectables are “fillers” and “chemodenervation” (AKA Botox, Dysport)

The function of Botox is much different than the function of fillers. Botox and Dysport act to relax muscles of the face (forehead, crow’s feet) to reduce wrinkling. Botox doesn’t “fill”. Fillers add volume to areas where fat was lost with aging, or to camouflage areas where tissue has fallen from age. This latter strategy is often termed “liquid face lift”.

What are the different injectable products and how long do they last?

fill3fill3The most common products are the hyaluronic acid based products such as Restylane, Juvederm, Perlane, Belotero, and Voluma. They differ by manufacturer, indication, and duration.

Restylane is the most diverse (and predictable in my opinion). It is FDA approved for the lips (Juvederm isn’t). Juvederm lasts about 6 months, Restylane 6 months or a little more, Belotero maybe 3 or 4 months, and Voluma probably longer than a year.

Voluma is the newest “long lasting” hyaluronic acid product available. The company that manufactures it, Allergan, claims it lasts 2 years. However, the product hasn’t been around for use for 2 years. Thus, I can’t tell my patients to expect it to last longer than the other products and justify double the price (product cost twice as much as Restylane and Juvederm). However, I have used it and am very pleased with its ability to “lift” tissues.

Belotero is indicated for fine wrinkles of the face such as the smoking lines of the upper lip. Restylane and Juvederm is often used for deeper wrinkles, folds, depressions from volume loss, or cheek enhancement. While fine wrinkles can be reduced with Belotero, the results are temporary. Often is the case that fine wrinkle reduction can be a permanent solution with a good, deep CO 2 peel. The indication for Belotero is small, but it does work in the right person for the right problem.

Radiesse is calcium hydroxylapatite, the natural mineral component of bone and teeth. It is less diverse than the hyaluronic products but probably lasts longer because it may stimulate production of your own collagen. Thus, it probably best described as a sem-permanent filler. Radiesse cannot be used in the lips or close to the eyelids – it can leave nodules. However, it works well for filling the cheek and lower third of the face. Because the product is more firm than the hyaluronic acid products, Radiesse is my product of choice for the jawline in men and women. Unlike hyaluronic acid products, Radiesse cannot be reversed. It must be removed by aspiration or surgery. Thankfully, it is an exceptionally rare situation that one would ask for the removal of this product. However, in patients who have never had fillers, I often like to start with a hyaluronic acid product for this reason.

Sculptra is perhaps the longest lasting injectable. It is made of polylactic acid. It is generally injected multiple times over the course of several months to stimulate production of collagen. It cannot be used in the lips. The drawback to this product is price (it is more expensive than the other products), it must be pre-mixed 24 hours prior to injection, and it can cause granulomas if not injected deep enough.

Sculptra probably requires the most experience for injection than the other products. The results are not immediate, and thus a good understanding of facial subunits and beauty is critically important for good results.

Chemodenervation (Botox and Dysport) act by weakening muscles. Since it is the muscles that contribute to wrinkles of the forehead, injections of these products can reduce or eliminate these wrinkles. The downside to neurotoxin therapy is that It only last 3.5 to 4 months (Dysport probably longer than Botox), and over injection can cause paralysis of the muscle resulting in the frozen face which has given these products a bad name. However, when used in moderation, these products truly refresh the face while still allowing animation of the brows.

Bruising from Botox and Dysport is rare. The most dreaded complication with these products is lid ptosis (dropping of the upper eyelid). While this is uncommon, the risks are not zero. It is generally thought that this develops from inadvertent migration of the toxin to the small muscle that helps keep the upper lid raised. Hence, weakness in this muscle results in a dropped lid. If an injector tells you that this never happened to them, it is likely that they simply haven’t injected enough foreheads, or, they are not being truthful. To minimize this risk, an understanding of the regional anatomy is important. In addition, patients should be told not to exercise for 24 hours when the lower forehead is injected for fear of vasodilation and toxin migration. The good news is that this rare event is temporary and generally resolves within 3 to 6 weeks. Sometimes specific eye drops to stimulate the muscle can be alleviate the droop.

How does a filler make one look younger?

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This is a good question because it is somewhat counter-intuitive that by putting in volume to a face it can make one look younger. To understand this phenomenon, one has to understand the components of a youthful face.

Skin: Young skin has small pores, good elasticity (tightness), and consistent color that lacks colored “spots”. It is generally void of wrinkles at rest.

Volume: Young faces are filled with fat., even in the thinnest man or woman. An extreme example of a fat, youthful face is a baby. How would you describe an baby’s face? Filled with fat, I bet. But as one ages, this fat is slowly lost. The fat that does remain descends. The result of this is shadows from depressions or valleys. By filling valleys or depressions we are basically restoring a face into one that is younger.

Shape: Young faces in women are heart shaped, or top heavy. As we age and volume is lost, the heart shape flips upside down and one is left with an older, bottom heavy face. The goal for facial reshaping with fillers is to restore volume of the upper third of the face. Thus, cheeks and cheekbones can be augmented with Restylane, Juvederm, or Radiesse. The lower third of the face that may have developed jowling can be camouflaged with the addition of these products in front of and behind the jowl to generate a smooth jawline.

In the right hands, a combination of filling and camouflaging with products can take years off someone’s face. In fact, when used properly, it can give the illusion of a facelift. Thus, such procedures have been termed liquid face lifts. The results can be dramatic.

Are injectables safe?

Yes. Every time someone elects to receive an injectable they are asked to sign a consent form. The consent forms for these products are very long and they discuss every potential complication with injectables. The good news is that complications to injectables are often limited to bruising and swelling that resolve within a week. However, this is a buyer beware industry, meaning that anything on those consent forms can potentially happen. It must be emphasized that even in the most skilled hands from board certified plastic surgeons, unfavorable results can occur. Thus, consumers should do their research and take injectables very seriously. At best, complications can be reduced, never eliminated. In the event of something unpredictable and rare, you are better off with an experienced plastic surgeon to manage it. The following is an example illustrates why you should have someone qualified to inject your face:

Skin necrosis. This is a very rare complication where the product embolizes or compresses an artery that provides blood flow to the skin. This can happen to the nose when the laugh lines are injected. Generally, a skilled plastic surgeon will ask (or evaluate) the patient to see if they had a prior open rhinoplasty. If so, he or should should know that one major artery to supply blood flow to the nose has been cut (columellar artery), leaving just the right and left angular arteries to supply the nasal tip. These vessels sit deep near the laugh lines. If products are injected into this area without a good understanding of the anatomy, the vessel can be injured, compressed, or embolized, rendering insufficient blood flow to the tip. If it happens, it can be identified immediately if one knows what to look for. If it isn’t detected immediately (ie. In the office right after the injection), the results can be devastating. The tip of the nose will turn white, then gray, then black, then fall off in a week. Thankfully, this can often be reversed if identified AND if the doctor knows how to manage it (aspirin and immediate injection of hyaluronidase injection, possible hospitalization for intravenous heparin). However, many offices don’t have this product available or have never used it. Let’s say the complication is detected, the office has hyaluronidase (Vitrase), and it is immediately injected. There is a very, very small chance that anaphylaxis can develop resulting in intense swelling of the airway, obstruction of breathing, and death. I am aware of this happening at least once in Beverly Hills (to a major celebrity), and it was reversed with an epinephrine injection from the doctor who was smart enough to have it stored and ready to use. The patient almost died.

While this is an extreme example of what can go wrong, it is intended to just make a point. Don’t skimp. Make sure the person injecting you knows what they are doing and your chances of something bad happening will be reduced tremendously.