Fillers: Friend or Foe?

Are fillers the key to erasing worry lines or are they products you should worry about? Welcome to Skintuition. I'm Heather Furnas.

And I'm Josh Korman. From pimples to wrinkles, our skin affects how we feel about ourselves. As two plastic surgeons, we discuss what's new, what's safe, and what to look for when you're ready to hit refresh.

So Josh, what would you say? Are fillers great? Are they erasing our lines, our worry lines, or do we need to worry about them?

Well, I think they are great, they can be great and they can be problematic. And at the top of the list is, you know, they always talk about that the most important thing about the filler, is the filler, except I would say it's not what the product is, it's about the person doing it. And I think that's really important.

That filler.

Yeah, that filler, not the other filler <laugh>. And that's, there's a lot of finesse that comes with injecting fillers. There's lots of examples where people 20 years ago had surgery and then 20 years later they just have fillers. And fillers include a lot of different things we'll talk about, but everything in moderation including moderation. So you need to kind of figure out what the products are and how to do it. It's not the kind of thing that you just, it's not the quick and dirty, oh let's just do it and get it over with. There's more involved here.

And there are different purposes. One is sort of an anti-aging thing because as we age, it's not just that the skin is pulled by gravity and we droop, we actually lose volume. We atrophy, our bones lose volume, our bones recede and then our soft tissues, our muscles and our fat also lose volume and our skin thins. And so filler is really a great way to mask that. We can put filler right along the bone and that really helps. We can put it in the deep to the skin and then we can put it intradermally. So what areas do you like to inject, Josh?

Well, I like to inject a lot of places. It's what I like to think about is hills and valleys. It's the valleys. You're filling in the valleys to try to bring the valleys up to be at more of a level as the surrounding areas. So I think there are lots of places to put it in the face. It's very satisfying because there's so many versions of wrinkles in the face. They're really superficial ones. And then there's slightly deeper ones and then they're the big folds near the cheeks where the cheeks meet the lips called the nasal labial fold near the nose. And I will tell you, sometimes when I go to a museum, I sit and look, people think I'm looking at the paintings, but I'm actually looking at the people and I try to look at different parts for each time. So like the last time I went I was looking at nasal labial folds. And it's interesting cuz, because of bone structure, there are some very young people that have a nasal labial fold even in their teens or even younger, whereas other people they don't. And then they develop them as they age. So I think it's important to kind of figure out what you're looking at to start.

Yeah, so the nasal labial fold is that that line that connects the corner of your nose, your where your nostril is and goes right along to the corner of your mouth. And it can deepen with age. Some people have a prominent nasal labial fold just because of the way the muscles attach there, but it's on the platform of your bone. And so with time, as the bone resorbs with age, then the nasal labial fold doesn't have the great foundation and it can actually look deeper. So one area to inject is actually right along the bone, right at the base of deep to where the nostril is. And then we can also inject more superficially. It really takes artistry, but you have to know what you're doing. And you want to talk about that Josh?

Well there really are so many things about fillers. There's lots of different kinds of fillers that we'll talk about a little bit later. And there's also, how to put it in, there's certain fillers that are designed to put just under the skin and then some to put a little deeper and deeper. You know, you don't want to put them too deep and then lose the product, meaning it doesn't have a good effect and you don't want it too superficial that it causes lumps and bumps. But really what's important, I think this is what you're alluding to, Heather, is that safety. And I think we need to be very mindful of the safety because there are a lot of blood vessels in the head and neck and in the face. And it's really important that the fillers do not get injected into the blood vessels. That it's important to have a really good idea of where the blood vessels are. Obviously not the patient, it's the person, the filler, the person doing it. Because if you do inject into the blood vessels it can have really disastrous consequences. So it's imperative, I cannot stress it enough, it's imperative that you have a very trained practitioner who not only understands the anatomy and the safety, but also the artistry of how to make the fillers look like they don't exist. Meaning that you always came that way and that's an important thing. How do you do it in your practice, Heather, about how to decide who does them?

Well in our practice we've got nurse injectors, you know, and that would be RN, the nurse, uh, physician assistant and nurse practitioners. Now we do a lot of training with them. We send them to training courses, we train them ourselves. We go over cases. We are involved directly in their training and oversight ourselves. We have injected, my partners and I, and we are just so busy doing surgery that we don't do a lot of injections at this point in our careers. But we do work very closely with our nurse injectors and safety is number one. We're always reviewing safety. I read articles, show them these articles, review videos and because you know, we, we just imagine if we're in the chair, which I am, I'm in fact I'm going in on Wednesday for one of my nurses to do my injections and I want her to know everything she needs to know to inject me.

Yeah, I think in, in my practice I do still some fillers, but for the most part also highly, very highly trained nurses do the injections. I think what is also important is that from the patient's perspective, they like the idea not just of the actual injection, it's the whole experience of coming into a office room where you have a good sense that the injector is really connecting with you and helps you to decide together what the right thing to do is. I find it, it's nice when you have the patient you can see in a mirror, it's a little bit like when you get your haircut, you know, they wait till the end of the haircut and they give you this mirror to look around. But what are you supposed to do? It's done already. Whereas I think with, with fillers, I like to do it where, where the patient can see in real time.

(08:00)
I did stop giving them the mirror during the injection because once a patient knocked the syringe out of my hand with the mirror. So <laugh>, I don't do it in exactly real time, but I think it's, it's all part of a good experience where you're feeling like you're communicating to the patient and the patient is communicating to the practitioner about what they're trying to achieve. It is interesting though when you have people trying to figure out what is the right product and what is the right amount. And I think that's sometimes a question where patients have decided in advance because they read it at on internet university and they've decided what is the right amount of filler. And I think that sometimes it's important to be able to communicate but also to respect the practitioner who is trying to help you and how much of a filler in terms of how many syringes to put in. It's not so easy.

Yeah, you bring up a really good point cause a lot of people come in and they just want the one syringe, and they don't want spend too much money. And we'll just tell 'em a, one syringe when you actually need three syringe is just throwing your money away, because you won't be able to really see the impact. Each syringe is building on itself. And so it's better to save for the three syringes that you really need and not have that one syringe. On the other hand, you don't want to over inject. And I, I think that one of the places that we've probably all seen over injected are the lips, particularly the upper lip, depending on the age. Some people who are younger want full lips and they just go for the gusto and have lips that are so large that they look distorted. And then there are older patients who wanna get rid of the lip lines and all they focus on are the lip lines. And so they inject or they ask for injections and until the point that they don't see those lip lines. But then that upper lip looks a little bit like planet of the apes. It's very rubbery, it's very thick, it's very distorted and distracting. And so that's where feedback from the practitioner who's trying to give the best result is really important cuz you can get lost in what you are asking for.

How would you deal with a patient who says, well I just wanna have one syringe today and I'll, I'll see how I like it and then I can come back again if I want to have more?

If I feel that they need more than that one syringe, then I just don't do the injection because my goal is not to inject a syringe. My goal is a happy patient and I know they won't be happy. How about you Josh?

So what I do is I, I remember once a long time ago in Egypt, I took a taxi to visit the pyramids and I paid the taxi. He wanted a certain amount of money in advance, so I paid. And then when we got there, he said it was for both ways, but then he wouldn't take me back to the city <laugh> until I paid again. So I don't,

You were stuck.

I was stuck without paying again. So I don't do it where I put one syringe on one side of the face and say, you see now you have to have it on the other side. So you have to have more than one. Sometimes I'll say to the patient, if that's what you want, I can split the syringe, do half on this side, half on that side. But you have to recognize that I think you need two or three syringes.

(11:50)
So we kind of agree that we make that decision as soon as the first syringe is in place so that people can have a better idea of how it works. But it is really important, just like when the refrigerator needs to be fixed, I don't know anything about fixing refrigerators, so I don't try to figure out and tell the refrigerator repairman what piece of equipment they need to put in the refrigerator. I think it's important with fillers, you have to choose someone that you trust and then you have to let them guide you because otherwise you won't be happy. And they won't be happy because they can deliver what you needed.

Yeah, exactly. It's, it's that first choice of practitioners. So you don't want to just shop based on price. Cause I think a lot of people focus on the price without really understanding how important that practitioner is, both the aesthetic result but also your safety.

So let's get to the other part of all this, which is there are so many choices. There are so many kinds of fillers and so we hear about them, there's so much marketing. How do we pick? How do decide which fillers to use?

Well, there are a number of different types of fillers, as you mentioned. There's hyaluronic acid, which is probably the most commonly used form of filler. And as far as brand names, RHA, Juvederm, Restylane, Belotero, those are examples. There's also something else, calcium hydroxyapatite. You may know that, they're microspheres, you may know that as Radiesse, and that lasts longer than hyaluronic acid, but it's not reversible. And hyaluronic acid is reversible. There's also something called Sculptra, which is a mouthful, poly l lactic acid or P L L A, which stimulates collagen production. So it doesn't have a lot of volume fill in itself. It's got some that disappears with time. It takes about six weeks for those results. And then there's bellafill or artefill which has little beads of methacrylate that's kind of like a little plastic. It's uh, permanent. And then there's our own fat, which is something that we'll get into in another episode. But that's also something to keep in mind that that's another way of filling in volume. How would you decide?

So like I said a little before, I think it's a question of what's the problem, how deep is the valley? I think there's a song like that. How deep is the valley? How is the valley <laugh>? So if the valley's really not very deep, then a hyaluronic acid product would be really good. It's also depends on where in the face, like for example, the tear trough, which is under eyelid, which is a lot of people have that they think they have fat pockets, which they may have fat pockets, but a lot of times it's a hollowing, or as we age, the cheeks descend somewhat and then the junction between the lower eyelids and the cheek becomes more defined. And that's areas called the tear trough. So in that area you need a very, in my opinion, thin hyaluronic acid product. And that gets put right, little drops, less is more, right onto the bone.

(15:19)
It's very satisfying to see really instant results. That's the thing about fillers in general. Most of them there are like right away results. Yes, you might bruise a little, you might swell a little bit, but in general you get instant results. So, and then deeper ones, deeper creases, deeper wrinkles require deeper products. There's a new product that just came out called Volux, which is in the Juvederm family from Allergan. And that is for contouring along the jawline. There's so many products, because there's so much demand for filling in defects. The world of Instagram has created a great demand for more and more. And so I think how to figure it out, I think instead of trying to drive yourselves crazy as consumers, once again, go to someone you trust and let them help guide you.

You made a really good point with the tear troughs, just put in a little bit. I think a lot of people are looking for a flat contour so that there's no indentation and that actually doesn't look very natural. And with time that hyalurlonic acid, which draws in fluid can create, rather than a concavity or you've got a crease, it can create a convexity. So you've got sort of a little mound and that just looks strange. So going for, as Josh said, less is more is really the way to go with a lot of areas, including tear troughs and lips.

So I think at the end of the day, what you're trying to do is you don't want to look like an inflated balloon and you don't want to look bumpy and you want to look at the risk of sounding repetitive, natural. Really what you want to do is, most people like how they look they just want to look improved. But you can do a lot of things with fillers. We haven't even talked about things like liquid rhinoplasty where you can put a little bit in to non-surgical ways to adjust the nose. There's many, many areas, but at the end of the day you need a trustworthy practitioner, somebody who's really skilled and somebody who can make you happy.

Thank you for joining us. This is Skintuition.