Introduction

“Welcome to Plain Talk About Plastic Surgery, a podcast narrated by myself, Dr. Elizabeth Kerner, giving you practical and down to earth information about plastic surgery operations, procedures, and other news of interest.

Today I’m going to talk about fillers, and mostly, I’m just going to talk about the fillers that I offer in my office. Obviously, if I don’t offer it, I don’t have much experience or any experience with it, so I shouldn’t speak to other fillers. And we’ll talk about the good, the bad and the ugly of fillers.

The War on Wrinkles: from The Early Days of Animal Collagen and Silicone, to Today’s Injectable Dermal Fillers

So what are fillers? Fillers are hyaluronic acid. Medical science has created a hyaluronic acid that mimics the hyaluronic acid that is naturally occurring in our collagen. Because hyaluronic acid is hard for me to say repetitively without stumbling, I’m just going to call it an ‘HA’.

HAs (hyaluronic acid) constitute a good part of our collagen. So, as you probably know, when we age, our collagen becomes deficient. That leads to flattening of the skin and more wrinkle lines. And it’s of course, way, way, way, way more complicated than this. Hyaluronic acid and changes in collagen are not the only things that create aging but, for our purposes, that’s what we’re going to talk about today.

So HAs can be injected into areas that need to be plumped up. I’m surprised there’s still so many people that are a little confused about Botox, which is a neurotoxin, meaning it makes things not work – in other words, muscles not to contract – which will make wrinkles less. And then HAs will actually fill the indention.

In the old days we had collagen, which had to be patched tested because there was pretty high allergic reaction to it. And it really only lasted about three to four months. So you had to be prepared for some pretty significant maintenance when you used collagen.

Women have also had silicone injected into the wrinkles. This was popular kind of late 60s, early 70s. And came with all the complications that you would imagine, which would be nodules, and infections, and extrusion.

Absorbable Fillers for the Lips, Cheeks and Face – Advantages over Permanent and Semi-Permanent Fillers

I only inject absorbable fillers. Silicone is a permanent filler. I don’t like the permanent fillers, or even the semi-permanent fillers that you know are going to last three to four years, because there’s no out for them.

So if there’s a problem, let’s say you get a little nodule or a bump, or it’s just in the wrong spot; if I put an HA in, I have an enzyme, hyaluronidase, meaning that enzyme that dissolves hyaluronic acid, that I can inject into that little bump and ‘presto change-o’, it’s gone. With some of the others, like Radiesse, there isn’t any out for that. So if you have a problem, you’re kind of stuck with the problem.

So the fillers I used are the Juvederm family which, unfortunately, all start with a ‘V’ now. They used to be different names, but there’s Volbella, Vollure, and Voluma. They’re thin, intermediate, and thick if you want to think about it that way.

Juvéderm Volbella® and Vollure®: Properties and Uses for Varying Depths of Wrinkles

Volbella is the newest addition to the family, and it’s a very thin preparation of hyaluronic acid, and it’s designed to be used in lip lines. So the lines above your lip; the vertical lines; the bleed lines right along the vermilion border, which is the pink part of your mucosa where it touches your skin, that little red line there; and then you can also put it into the lip proper.

If you don’t need much fill, Volbella will do quite well for lips. If your lips are quite deficient, then I would use Volbella on the lip lines because, quite frankly, nothing works as well as that; and then do Vollure, which is the intermediate one, to actually give some more volume.

Occasionally a patient will have such deep cracks around their lips that I’ll actually start with Vollure, the intermediate one, and put that in as a kind of deep layer on the wrinkle; and then come back a week or two later and put a little bit of Volbella on top, because Volbella we can put very close to the surface of the skin.

For the folds, which are the two parentheses lines by your nose, the corners of the mouth – the kind of marionette lines, the deep lines that go down along your chin; and the creases between your eyebrows, those are called the glabellar creases, I think Vollure works very well, that’s the intermediate one. Vollure is kind of the workhorse, and it goes kind of right at the top part of the dermis. You can put a moderate amount in without having to worry about lumpiness.

Juvéderm Voluma®: A Deep Facial Filler for the Cheeks to Build Volume

If you really need a deep filler, then we have Volluma. Obviously ‘Volluma’, based on ‘volume’, would signal that this is used when you really need to volumize an area. Volluma is approved for along the cheeks. So if you have someone who’s gotten a lot flatter along the mid to lateral aspect of their cheekbone, putting in Volluma works extremely well there.

It is supposed to be placed down adjacent to the bone. I don’t use Volluma hardly ever any other place. You can put it along the prejowl sulcus, which is that little dip right in front of your jowls, because that would be down along the bone. I don’t use it underneath of the eyelids. I think that it’s just way too thick to put there and very, very occasionally I’ll put it in the upper part of the nasolabial fold, which is by the nose, if someone is really really deep.

Undercorrection: The Problem with Facial Fillers and Lip Fillers

The biggest problem with all of the fillers, I think, is underuse. Most patients that come in, when I look at them, I can kind of tell in my head when I look at the areas that are bothering them how many syringes they’re going to need and, unfortunately, it might be a lot more than what you want to pay for.

If you undercorrect an area, so if I look and say, “I really think you’re going to have to have three syringes to get to a really reasonable correction, and something that you’ll be happy with”, and you say, “Well, I can only afford one syringe”; because it’s undercorrected, you’re just not going to see as much.

So as the injector, and as your advisor for fillers, it’s always a balancing act between: I want you to get the nicest result – I want to be able to use as much product as you need; but I also don’t want to break the bank, and unnecessarily have you pay for more product than you might need.

How Does the Process Work? What About Swelling?

We do injections in the office. We have you come in and take a photograph to document what you have, because it’s amazing how quickly we will all forget what the wrinkles look like. And then numbing cream will be put on for usually 20 to 30 minutes. It will really help to numb the surface of the skin.

The fillers all have lidocaine, which is a numbing agent, in them. So as we inject the area deep, it becomes more numb. If someone is really quite needle-phobic and quite concerned about their lips, I can do a dental block, that’s certainly a possibility.

So we take pictures, put the numbing cream on, and then the injection is just done. The needles are little bitty. Vobella is a 32-gauge, which is really tiny. Lower lip, I’d say, very little discomfort. Actually in the lip proper, a little discomfort from it. Upper lip lines, they’re kind of touchy even with the numbing cream.

After, we do put ice on, and we’ll give you a small package of Arnica that will help for any swelling and bruising.

Most people don’t get too much swelling and hopefully very little bruising. The bruises you get are because I’m injecting through the skin and I can’t see where the veins are, and occasionally we will get a small bruise. The Arnica will help with that. Of course, time and ice will help as well.

Upper lips – you will definitely have some swelling, usually two to three days. If it’s the lip and the lip lines, you may have kind of noticeable swelling for four to five days. By about 10 days the product is settled in. It will pull water into, it’s kind of cool. So it plumps up a little bit, which is why I always undercorrect just a bit. Then you can look and say, “Gosh, like this result” or, “I think I need more.”

Fine Tuning for the Best Results

If I’m uncertain whether you need a touch more on a wrinkle line or an area, I may leave a little bit out and just have you come in at about 10 days after the injection, and look at that particular wrinkle line or the area. And if we’ve left a little bit out, then we can just re-inject to get it up to correction without you having to purchase a new syringe.