By Pamela Jacobs
Dr. David Rapaport continues the discussion on anti-aging cosmetic treatments and facial muscle relaxers versus fillers... New York Resident: In the last issue, we talked about popular muscle relaxers including Botox and Dysport, which differ greatly from facial fillers. Can you tell me what the fillers are used for?
Dr. Rapaport: Facial fillers play a more important role in restoring youthfulness to the aging face. In looking at the aging face, one of the most significant things you see is a loss of fat. People age differently based on genetics; but what’s universal about the human face as it ages is this loss of fat combined with a loss of skin elasticity. We see it most dramatically around the eye, particularly the lower lid area, which becomes hollow, as well as the area referred to as the tear trough, in the inner lower eyelid area. As the skin of the cheek loses fat, it essentially collapses, and that is what leads to smile lines, or nasolabial folds. Some people have significant hollowness on the sides of their temples. The easiest way to see this is to look at the extremes—if you look at a child or teenager, what you see in their face is lots of fullness; if you then look at the elderly face, you’re looking at a very empty face with loose skin.
This is why facial fillers acquire a more critical role as we age and that role is much more significant than muscle relaxers. In the last few years I’ve seen a dramatic rise in the use of facial fillers, in both women and men, generally speaking from the 30’s on up. Fortunately, now with improvements in technology we have injectables available, which are extremely safe and reliable.
NYR: What exactly are the fillers, and how do they work?
DR: The most important agents we use today—and indeed, the most popular in the world—are the hyaluronic acid fillers (HA fillers). HA fillers are various forms of replication of material found throughout the body, which is hyaluronic acid. It’s what lubricates our joints and fills up a lot of the soft tissue matrix in our body. What scientists have been able to do in the last few years is clone these materials in the laboratory, so there are no contaminants, skin tests are not needed, and allergies are rare. This is in contrast to the days when the main filler we had was cow collagen, and there were significant allergies to it. The HA products use a variety of sugar molecules and that’s basically what gives them their longevity. The different companies that make them are obviously in competition, but the products are different in certain characteristics—what they all have in common is that they’re safe, and they will last a predictable amount of time, typically 6 to 12 months, and then gradually fade without leaving any damage behind. You don’t end up being any worse, any “emptier,” after the filler wears off.
NYR: Tell me about the different fillers available?
DR: The most common of the HA products is Restylane—made by the same company that makes Dysport, a popular muscle relaxer—which is clear in color and has been FDA approved since 2003. It’s the product I use the most, and is the most sold facial filler in the world. It comes by the vial, which is 1.1 cc. It’s used in the cheeks, lower lids, smile lines, marionette lines (the lines that appear in the lower lip area on the sides), and it’s a safe for lips. It’s very versatile and can be used anywhere; patients with very mild amounts of fat loss can benefit from only one syringe divided between the two smile lines, while there are other patients who benefit from multiple syringes.
Another safe injectable is Juvaderm. It is more gel-like, less stiff than Restylane, and the different characteristics of these two products can be used in different ways. For the nasolabial folds, I prefer the stiffness of Restylane, as it is less likely to be moved out of its position by the action of smiling, which could potentially happen with Juvaderm. I find Juvaderm to be an excellent product and usually my first choice when I’m injecting lips, because it’s softness as a gel creates a more natural enhancement of the lip area. The other area where I usually prefer Juvaderm is in the marionette areas or the general hollowness of the lower lip. The hollowness in the area tends to be very subtle. In the cheek I want something a little firmer, more robust. What’s important is that product use can be tailored depending on individual needs.
Another filler is Radiesse, based on hydroxyapatite, a calcium-based product found in coral. It is a white, pasty product, and injects smoothly. I like to use it in deeper injections, typically on the bone. In the cheek area, if someone has a weak bony structure, I lean towards Radiesse. When people talk about a nonsurgical rhinoplasty, often they’re referring to Radiesse, an excellent product to inject if someone has had too much of the bump of the nose removed, or in someone with a flat nose who wants to create a stronger nasal bridge. In the past, the only remedy was to put an implant in, and risk complications. It can also be used in areas of weakness of the face, such as the upper lip and chin area. Some doctors prefer Radiesse in the nasolabial folds. Fillers can also be great on the hands—my favorite being Radiesse.
Another product worth mentioning is Sculptra, or l-polylactic acid. It’s a powder that gets mixed with sterile water and injected which stimulates the production of collagen. Rather than the fillers acting similarly to plaster, Sculptra stimulates you to form your own collagen. In about three weeks the body starts to form collagen continuing for 4 to 6 months, with results lasting 2 to 3 years. Powerful results are seen in the cheeks, and it’s particularly useful for someone who isn’t in a hurry to see results. If you want the most gradual, longest-lasting change possible, Sculptra can be an excellent choice.
NYR: These fillers are temporary. Are there permanent options, such as silicone injections?
DR: Here’s what’s wrong: I advise in the strongest of terms against injecting any liquid silicone directly into the face. As opposed to silicone breast implants which are safe, directly injecting silicone into the face is not FDA approved, nor is it safe, those few doctors who do choose to use it are using it off-label by finding an unrelated loophole. The biggest problem with injecting liquid silicone is that it can act unpredictably. The body can eventually start to react, causing lumps. It has also been seen to migrate unpredictably, after years of being fine. The other problem with injecting permanent products into the face is that the face itself is not a permanent structure. I could give you an injection today that will look absolutely perfect, but if that filler is still there in five years, chances are you will have lost fat around it as part of the aging process, so that what looked good five years ago will now look like a piece of linguine under your skin.
NYR: How much is too much? You often see celebrities looking unnaturally enhanced…
DR: The images that often come to mind are those of people who are ridiculously overfilled and unnatural looking. The consumer needs to understand that a person doesn’t get overfilled with one or two well-placed syringes. Remember: it takes two to tango. You generally have a patient who is shooting for something totally unrealistic, who may have a distorted self-image, and you often have a doctor with a distorted image as well, or, more cynically, one who is just looking to make as much money as possible and will inject as much as possible. Those cases are the rare exception. Most people, many whom you may know, look great and you’d never know they were injected. I had Restylane injected into my face for the first time this year and I had a total of 3 cc’s, and there’s no way anyone would know that without me telling them. I practice what I preach; the products are very safe. And as long as you keep your goals realistic and you go to a good doctor, you won’t look ridiculous.
For lips, it’s especially important to be very conservative and use limited amounts and it’s important to remember that the lips swell, so they may well look overdone for anywhere from three to seven plus days, so you need the right timing—and the right sense of humor—as you might look like Goldie Hawn in “The First Wives Club” that night.
Another great feature of the HA fillers is that there is a product called hyaluronidase, which will directly dissolve HA. In the case where someone feels they’ve been over-injected, it’s possible to reverse the process and dissolve the filler.
NYR: Can any doctor perform these injections?
DR: You should be going to a plastic surgeon or a dermatologist who has experience and a good aesthetic eye.
Be careful to not go to someone where this isn’t a serious part of their practice. If your dentist, gynecologist or internist is offering you injections—I can’t say they don’t have a terrific aesthetic eye and amazing hands—but ask how many have they done and the extent of their training. A weekend course or an hour of training isn’t enough. You want someone who has performed hundreds of injections, so you can benefit from their experience.
NYR: What’s the process from the time a patient comes to you to the administering of the product?
DR: First, I hand the patient a mirror and ask what he or she doesn’t like. Dialogue is very important. On some patients I’ll use an anesthetic cream for 20 minutes, but the most important thing is to use gentle technique, and it’s very helpful to apply ice prior to injecting to reduce discomfort. A session can take anywhere from ten minutes to 40 minutes depending on how much product is being used. I like to inject while listening to music. I find this advances the aesthetic process and helps the patient relax.
NYR: Do fillers now replace the need for a facelift?
DR: These products can be great around the cheeks, nasolabial folds, lips, marionette lines, and mouth—the area where they have limited role is the jowls, and almost no role is the neck. So for problems in these areas, such as the turkey gobble complaints or loose jowls or wrinkly neck, there’s no amount of filler that will fix that. A lower facelift can greatly improve that problem.
NYR: Are fat injections a good alternative?
DR: Fat is absolutely a legitimate filler in the face, but it is not the product that I turn to first for the face. As opposed to Restylane, where I can reliably say that when I inject it into your face you’re going to get a result that will last six to 12 months or more, with fat, I can’t guarantee results anywhere near as closely. Often you just don’t have lasting results. And if the fat doesn’t “take” evenly, you get lumps, which do not go away. The overwhelming majority of doctors performing facial injections are turning to the shelf for fillers, as opposed to fat, despite the fact that the fat on the body is free—that’s because of the reliability of the products. It could be exciting for the future, as better technology develops.
David Rapaport, M.D. is a board certified plastic surgeon on Fifth Avenue in Manhattan who has been practicing for over 20 years. Dr. Rapaport will be serving as the monthly cosmetic surgery consultant for NY Resident. For more information visit drrapaport.com/
Coming next month: All about liposuction…