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

Injectable fillers are not surgery, but plastic surgeons use injectable fillers every day for facial rejuvenation and enhancement.  Dr. Bass discusses the history of fillers and shares where we’ve come since the beginning of the modern era of injectable fillers.  Starting with Restylane and Juvederm along with newer FDA approved injectable fillers, there is a growing role for correction at all stages of facial aging.  The progressive volume loss that occurs in the face with aging is mostly treated with injectable fillers. What specific features are treated with fillers?  What is the role of liquid facelift and non-surgical rhinoplasty?  Will I look distorted or unnatural?  How should I select which filler to use?  What should I look for in an injectable provider?  Let Dr. Bass’s common-sense perspective empower you to get the most from injectable fillers and understand the playing field.



Doreen Wu (00:01):
Welcome back to Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I’m your co-host Doreen Wu. 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 “get your fill: exploring the double edged sword of injectable fillers in facial rejuvenation.”This episode is focused on injectable fillers, Dr. Bass, you’re a plastic surgeon, injecting filler is not surgery per se. Why do you do it? Why is it so important?

Dr. Lawrence Bass (00:38):
It’s important for a number of reasons. Dorian, first of all, we always want to have the full rainbow of possibilities, both surgical, and non-surgical that address? All of the aging changes of the face and aging changes that take place at all the different stages of aging for people who have aged enough to have surgery, injectable fillers, give us a more complete correction and help correct things that surgery doesn’t address for the very large number of people who don’t yet need surgical rejuvenation, injectable fillers provide correction for many, many of the early aging changes that we see in the face. Finally, it’s better overall to maintain appearance rather than letting appearance deteriorate and then try to restore it with a big surgery.

Doreen Wu (01:35):
Ah, I see injectable fillers are a minimally invasive procedure that helps combat aging and can provide many benefits. It makes sense by injecting fillers is a part of your beautification toolbox. So where did the concept of injectable fillers originate?

Dr. Lawrence Bass (01:52):
People have injected all manner of materials in the body for most of the 20th century. Uh, and even before that, in order to try to augment appearance, but in the modern era of fillers, this really started in the 1980s with injected bovine collagen collagen that came from cows and was processed and purified for injection in the face. More recently, uh, in the early 2000s, we saw the modern era of fillers start, uh, with injected fillers that were more durable and that had a whole range of physical characteristics to allow us to target different individual facial features. Um, so that’s really the modern era. And I’m talking here about fillers that are FDA approved for use as cosmetic injectable agents in the face for various indications. There are non-absorbable materials that have always been injected. Uh, however FDA has not cleared those materials for that sort of use in the United States. And there are significant safety issues and problems associated with many of these products.

Doreen Wu (03:21):
What were the facial features that were targeted? What did these fillers let us do?

Dr. Lawrence Bass (03:26):
So the initial use of fillers like collagen was for nasolabial folds and marionette lines, the folds between the cheek and the upper lip and between the chin and the lower lip. Um, and also for lips both to adjust size to chase lipstick bleed lines and to accent the Vermilion border. So those were the big collagen uses. And those in fact were the same uses that the early generation of modern fillers was applied to. And that early generation of modern fillers were materials like Restylane and Juvederm.

Doreen Wu (04:09):
That sounds like a good thing, but does that really make a big difference?

Dr. Lawrence Bass (04:14):
So lips have always been a big deal even before aging changes take place. It’s a very popular area to make the lip bigger or more curvy, or to try to balance the size between the upper and lower lip. However, there are early aging changes, uh, that do start to show that we are not any longer in our youthful state, things like the nasolabial fold and Marionette line. And so adjusting those features, you know, if you’re 80 years old, that’s a drop in the bucket because there are all kinds of things going on in the facial area and elsewhere on the body that show that you’re aging. But if you’re in your thirties or your forties, these small areas may be the only things that are starting to give a hint that you’re no longer in your twenties. So correcting those things actually ends up being a big deal.

Dr. Lawrence Bass (05:14):
Uh, however, uh, there’s, there’s a whole story to this and volume in the face. In fact, we start losing fat in our face in our mid to late twenties at 25, we have the baby face, but that fat loss starts. And by the mid thirties, we typically have a more sculpted and angular look. And that may be the best looking face that we have actually in our thirties, not in our twenties, however, fat loss continues. And that eventually becomes too much of a good thing. At some point, you start to look hollow, folds start to deepen, and eventually things start sagging. That’s the, the role of injectable fillers to restore some of that volume loss. Um, in addition, when we get in our late fifties, sixties and beyond, we start losing muscle and bone volume as well, which just accelerates the volume loss, aging changes in the face.

Doreen Wu (06:23):
And where has it gone from there? What progress has been made with fillers?

Dr. Lawrence Bass (06:28):
So, as I said, you know, some of the earliest areas that show deepening or aging change or things like the nasolabial fold or Marionette, however, as those changes amplify, and as time goes on, as I just described, there are many, many other areas of the face that start to show obvious visible signs of volume loss. One of those areas is the cheek, which is really several components, the malar eminence or the, the curvy upper portion of the cheek, the arching that goes back from there and the area under the cheek, which can become increasingly hollow. So restoring volume in that area with fillers is something that’s very popular these days and has evolved beyond the nasolabial and Marionette applications, uh, treating the lower eyelids. What in medical terms is called the infraocular hollow is another area that makes the eye look tired and worn, uh, and accents, the appearance of any bulging fat as well.

Dr. Lawrence Bass (07:38):
Uh, there are indications for the jawline. One was just approved in the last week by FDA, uh, because the jaw line, which is sharply defined and straight, typically when we’re young starts to become saggy and baggy and uneven as we age, and this can be corrected nicely with injectable filler. Another area is the temples, which hollow as we age, we never want them to be convex, but if they become more than slightly concave or neutral, ideally then that starts to look like an aging change. And when you think of someone at the extreme of age well into their eighties or nineties, that hollowing shows very clearly. That’s what we’re trying to blunt in the aging face. People will also accent or boost the brow or the chin and will make very nicely controlled, very small shaping changes in the nose that might be difficult to achieve with surgery.

Dr. Lawrence Bass (08:44):
So those are just a few examples of the things that are being done with fillers. There are some other applications, skin remodeling applications with fillers that stimulate collagen production, and that’s being used in some face neck and body areas. And there are body shaping applications that are really developmental at this point. Um, and there are a lot of tantalizing potential applications to accent, body shapes, but currently in the United States, there’s no product that’s approved for this. And so caution applies, and we’ve all heard horror stories about people using non-medical materials to augment body shapes with disastrous consequences,

Doreen Wu (09:31):
Right? It’s so amazing that this many different applications for fillers currently, and I’m sure there are many more to come in the years. Can you break it down for me now? What is the overall role?

Dr. Lawrence Bass (09:43):
When we think about facial aging, there are three big categories or pathways. Um, one is loose skin and that’s in the very early stages, energy devices and mostly surgical lifting, whether it’s mini lifting or, uh, the formal facelift neck lift, there are skin surface changes like wrinkles, age spots, and so forth. And this is typically treated with energy based devices or chemical peeling. So these are things like radiofrequency microneedling, laser resurfacing, and so forth. The third big category is what we’ve been talking about, volume loss and volume loss applications, which occur early and continue to gather momentum as we age. So we see it over almost every stage of facial aging. Those volume loss problems are largely treated in 2022 with injectable fillers. When we need small volumes or just one or two areas, it’s almost universally injectable fillers. If we need a large volume or many, many areas treated, then this is sometimes done instead with fat grafting, which is a surgical procedure with bruising, swelling, recovery. And that’s done in the operating room.

Doreen Wu (11:19):
We’ve all seen those people who have so much filler in their faces that they look puffy and distorted, or possibly even like a chipmunk. How much is too much? How do I avoid getting in trouble with fillers?

Dr. Lawrence Bass (11:31):
This is something we talk about a lot in plastic surgery, in many, many areas. It’s always a case of not doing too much. And it’s an American sentiment. That more is better, but when it comes to plastic surgery, that’s certainly not true. The goal is an artistic, natural looking restoration of your appearance, or perhaps a slight enhancement or augmentation of your appearance rather than something that’s heavy handed, which is always going to be obvious and unnatural. So this is the Goldilocks principle, not too much, not too little, just right. And, um, this is where the skill of the injector is really critical. It’s like painting with a paint set. If you give a child a paint set, you’ll get a painting. If you give a master artist like Rembrandt, a paint set, you’ll get a masterpiece because the skill is different. The paint is the same.

Dr. Lawrence Bass (12:34):
It’s not the fault of the paint. It’s the fault of the people applying it. So it needs to be artistically applied, uh, and you need to follow the guidance of the provider, the experienced injector who’s doing it. And that’s an important thing to realize also about filler. Filler is highly dependent on the skill of the injector. It is not easy to inject and get an artistic result. An example is something like the liquid facelift also, uh, not a term I’m in love with, but it’s something you hear bandied about and on the internet liquid facelift describes using injectable fillers to restore facial volume, which is a good thing to the extent that you’ve lost volume, but also to reduce laxity in the face. Now you heard me say before that laxity is mostly about lifting surgery and occasionally energy based devices while adding volume helps you with laxity as well.

Dr. Lawrence Bass (13:40):
And if you only have mild laxity, restoring some volume in the face may be a good thing. And you land up looking like yourself, the way you used to taking that mild amount of laxity out of the face and all as well. But if you have enough laxity where you really need lifting surgery, and you’re trying to chase that with filler, what you can end up with is pumping someone up like a balloon, which looks distorting and unnatural because you’re chasing laxity with a modality, which is not well suited to do that. So that’s a mistake. And it’s an example of doing too much

Doreen Wu (14:24):
With so many products on the market, which one is the best.

Dr. Lawrence Bass (14:28):
So that’s a loaded question. And the manufacturers of course, would say their product is the best each manufacturer. In reality, the FDA approved fillers in the United States are extremely safe products. There’s tons of data, both data leading up to the FDA approval and data in clinical use since then, because there are many, many injections a year just in the United States alone. Well, over a million, the original group of fillers, uh, were basic hyaluronic acid fillers. These are absorbable. The treatments have to be repeated, uh, but they were good at covering all the bases because that’s all that was out there. Wrestling in Juvederm. Most of the filler manufacturers have next generation products, which were really different lines of hyaluronic acid fillers, or in a few cases, other materials that were on the European market and that showed particularly useful properties. And so what’s really happening with fillers now is products are coming on the market in the United States, FDA approved for specific indications.

Dr. Lawrence Bass (15:51):
So they’ve been tinkered to have exactly the physical properties that will be good for superficial fill or fill under thin skin or heavier applications like cheek and jawline. Finally, there are what are called active dermal matrix products. So all of the fillers when they’re injected stimulate a little collagen production, but there are two fillers in particular Radiesse and Sculptra, which stimulates significantly more collagen production in the skin when they’re injected. So these products, in addition to having a filler or volumizing property also structure and densify the skin because our skin thins and has less collagen as we age. And so this brings the skin back towards a more youthful state. So use of these products, as I mentioned in areas like neck, hands and face for these purposes in some of which is off label, not specifically FDA approved, but these properties and the fillers are an additional benefit for those particular individual fillers really picking which filler you should be using is, is all about working with your doctor because they’re the one who’s going to be injecting it.

Dr. Lawrence Bass (17:24):
They know what works well in their hands for a given particular indication, whether it’s the cheek or the temple or the eyelid. And so each provider knows what they can get a good result with. And it’s also partly a product of what your response to previous filler treatments was like. So if you’re working with your provider over time, which is always a better idea than jumping around from provider to provider, they can judge how you responded previously. You can give feedback on how well the feature was corrected, or if you had any other issue that you liked or did not like about that treatment. And you can adjust from there. And that’s really the best way to pick because all of these fillers absorb and you do the treatments over and over, it’s reasonable to tinker with your provider to really find what the right filler is rather than bank on, uh, reputation on the internet that this filler is great for X, Y, or Z. In reality, all of these fillers are really variations on a theme. So they’re little fine tuning as I said, in the physical properties from filler to filler, like the difference between vanilla ice cream and French vanilla ice cream, they’re kind of the same, but not exactly. So providers, doctors who are experienced injectors use these fillers for their exact characteristics to just customize the result you get. And again, that’s really about the artist more than it’s about the paint

Doreen Wu (19:06):
Before we close Dr. Bass, can you give us some final thoughts on dermal fillers?

Dr. Lawrence Bass (19:11):
Sure. Um, there are a lot of issues with fillers and again, this is very popular, a lot of treatments being done. So it’s important to get the most out of it because it’s something you’re doing over and over. It’s important to do the right amount, uh, because when you do the right amount, you’re most likely to get a good correction of the feature you don’t like. You’re unlikely to get an unnatural result or a problem. You have to do the treatment often enough, but not too often. If you do it often enough, you’ll maintain the result well, but you won’t traumatize the tissues by, by over injecting them. This is one of the big three mainstays of facial aging. So it’s really an essential part of everybody’s beauty plan. As they try to maintain their appearance or enhance their appearance with aging, your provider can tell you when you’re doing too much, or when you’re pushing too hard on a feature, that’s really exceeding the ability of the fillers reasonably to provide a result. And remember, it’s technically very demanding to inject fillers. It takes a lot of skill and experience as well as a lot of understanding of the aesthetics of the face. So in my opinion, it really matters to have an experienced injector. Overall fillers are the second most popular non-surgical treatment in the United States with about 1.3 million injections of filler in 2020, which is the last year for which statistics were available from the aesthetic society. So this is a big part of what we do now in treatment of facial beauty.

Doreen Wu (21:04):
Thank you for sharing all of these insights, Dr. Bass. It sounds like injectable fillers in the hands of an experienced injector can be very helpful in sting off the early signs of aging and postponing the need for a facelift. I hope our listeners found this episode equally interesting and informative. This is Doreen Wu, thanking you for joining Dr. Bass and me for this discussion of injectable fillers and its role in nonsurgical, facial maintenance and rejuvenation. Be sure to tune in next time for our episode on neuromodulators, another injectable commonly used for facial rejuvenation.

Speaker 3 (21:40):
Thank you for joining us in this episode of the Park Avenue Plastic Surgery Class podcast with Dr. Lawrence Bass Park Avenue plastic surgeon, educator, and technology innovator. The commentary in this podcast represents opinion. This podcast does not present medical advice, but rather general information about plastic surgery that does not necessarily relate to the specific conditions of any individual patient. No doctor patient-relationship is established by listening to or participating in this podcast, consult your physician to advise you about your individual healthcare. If you enjoyed this episode, please share it with your friends and be sure to subscribe to our podcast on Apple Podcasts, Google, Spotify, Stitcher, or wherever you listen to podcasts.

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