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Steven J. Pearlman, MD, FACS Dual Board Certified in Facial Plastic Surgery

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Facial Fillers

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What Do Facial Fillers Fix?

Facial fillers replace skin substances that, when lost, cause wrinkles. The skin thins by loss of collagen and fluid. In youth, the skin remains plump from a natural sugar called hyaluronic acid that attracts and binds to the body’s water. Fillers are substances that are injected to fill in wrinkles and facial depressions that may come with age. With the advent of choices for facial fillers, we can choose the best for the specific problem and longevity.

There are now so many fillers available, we prefer to categorize them by their ideal usage. Fillers can be used to treat three conditions:

1. Superficial fine lines

2. Facial folds and crevasses

3. Facial volume loss

We all want fillers to last as long as possible, but don’t want bumps from over-injecting. Gradual, precise and pointed is our method. The most superficial lines, those that appear “etched” into the skin require the thinnest fillers. As the need for more volume replacement increases, fillers are placed deeper and can be thicker. Medium thickness fillers are used for actual folds in the skin and deeper crevasses, such as the naso-labial folds. Naso-labial folds run from the corner of nose to the corner of the mouth. Medium depth fillers also may be very effective for melo-labial folds that run downward from the corners of the mouth to the jaw; otherwise referred to as “marionette” lines. These thicker fillers are also longer lasting than the thin, superficial fillers.

Since there are a number of available fillers for fine and deep wrinkles, both may be used in the same patient, and in conjunction with one another. We often layer fillers in the same areas in order to plump folds and fill the lines that may lie in the depths of those folds.

The thickest fillers are more for volume enhancement for the face that needs to be “plumped up.” As the face ages, the cheeks get hollow in addition to droopy. Patients may need lifting as well as volume. In younger patients, however, facelifts can often be delayed by filling the cheeks. This can actually give a small lift as well and is called the “Liquid Facelift.” Of course, nothing substitutes for a beautiful and professional facelift if it’s a means to elevating jowls or excess skin under the neck. But we can go a long way in making you look more refreshed by starting with fillers.

There are a number of options for facial volume restoration. The most natural technique is using one’s own fat. The fat is re-injected immediately after removing it from elsewhere in the body. This technique is called lipo-transfer. However, we now use it less than we did a few years ago because lipo-transfer is similar to a surgical procedure in preparation and healing time. Plus there are a number of facial fillers available that can restore facial volume that may last for up to a year or more. These are Sculptra, Radiesse, and the thinker Hyaluronic Acid products; Perlane and Juvederm Ultra Plus.

There are many types of injectable fillers available today. The most popular fillers are made from hyaluronic acid (Restylane, Juvederm). Hyaluronic acid is a clear gel that already exists in the human body. It attracts water, hydrating your skin. Hyaluronic acid fillers have been safely used in Canada and Europe since 1996. Unlike many other fillers, Hyaluronic Acid is non-animal-based and poses no risk of animal disease transmission or allergic reaction.

The hottest new application for Restylane is to fill dark circles under the eyes. Often, dark circles are the result of fat bulging in the lower eyelid that is exaggerated by a hollow area called the “tear trough.” By placing Restylane into this tear-trough, there is less shadow and therefore improvement in dark circles, making you look more rested and smooth.

We also use Radiesse, a non-surgical facial contouring filler that delivers an immediate, longer lasting result. Radiesse may be thought of as a longer lasting filler for deep facial folds and may even be used for volume enhancement. Radiesse appears to last even longer than hyaluronic acid fillers for treatment of naso-labial folds and marionette lines. Radiesse provides immediate visual improvement common with other fillers, along with the benefit of long-lasting results. This is because Radiesse is made of very tiny, smooth calcium hydroxylapatite (CaHA) microspheres. These particles stimulate your own collagen to grow. microspheres (particles) form a scaffold through which your body’s own collagen grows.

Common fillers:

Superficial Fillers (for fine lines and wrinkles):

  • Collagen: bovine-derived and requires an allergy test
  • Cosmoderm: human-derived, no allergy testing required
  • Juvederm

Medium Depth Fillers (Medium wrinkles):

  • Collagen
  • Cosmoplast
  • Restylane, Juveder and Radiesse

Deep Fillers (Deep wrinkles):

  • Perlane; thicker form of Restylane
  • Juvederm Ultra Plus
  • Radiesse; calcium hydroxyapetite granules. May last longer than hyaluronic acid.
  • Artefill; PMMA (Teflon) beads in collagen, currently not available in the U.S. Long-term filler also still pending extended long-term testing.

Large Volume Fillers – (When patients require a larger quantity of facial volume enhancement):

  • Fat lipotransfer; Spinning the patient’s own fat in a centrifuge and then depositing very small amounts with each of multiple passes. A patient’s fat is the most “natural” filler and the fat has a much better longevity. There is more swelling than with other fillers, but the results are smooth, natural, and often long lasting.
  • Sculptra; poly-lactic acid. Patients retain long lasting facial volume enhancement after two to four injections spaced a month apart. Sculptra is a true volume filler for the face. It can restore youthful fullness to the cheeks, temples, and anywhere in the face there has been considerable loss of youthful fat. Collagen and hyaluronic acid products are best used for lines, folds and wrinkles. When you desire true restoration of fullness, Sculptra may be the ideal substance.
  • Radiesse, Perlane or Juvederm Ultra Plus



Answers to frequently asked questions about the procedure

Q: Can Plastic Surgery Help my Eyes Look Less Tired?

Eyelids can look "tired" from a number of reasons. The more common ones are bags under the lower eyelids, excess skin of the upper and/or lower eyelids and drooping of the eyebrows. You don't have any of these.

Your eyelids slant downward towards the sides; the corner where the upper and lower eyelids meet (called the canthus) is lower towards your ears than near your nose. There are a number of surgical techniques that can be used to raise the lateral canthus. Sometimes, there may be some hollowness of the bone of the eye socket as well. This is also treatable. Seek out a surgeon who is versed in this procedure for a more definitive discussion.

Q: How long does a rhinoplasty last and at what point will you need to do additional maintenance?

A: A rhinoplasty will last for the rest of your life. However, even a nose that has undergone a rhinoplasty ages like the rest of your face and body. As we age, the nose begins to droop. After a rhinoplasty they will age from where they were after the procedure. The procedures we do for an aging nose is often more subtler than a formal rhinoplasty.

Q: What is a "mini lift"?

A mini-facelift of today was the maxi-facelift of 2 decades ago. Mini or maxi, best to discuss with your doctor.  There are many definitions of what a mini-facelift is. For some it's a shorter incision, for other doctors its less work on the muscle called the SMAS. The technique depends more on the doctor's skill and your anatomy. For a patient in their early 40's, you often don't need the same deep plane facelift that someone in their 50's or above might need. Most of these procedures address your jowls.

Q: If I were to have a rhinoplasty and septoplasty, would I go to a facial plastic surgeon, ENT or Plastic surgeon?

A: Performing both a quality septoplasty and rhinoplasty is dependent on the individual's training and experience. Generally, facial plastic surgeons start with ENT training before they move on to facial plastic surgery. Although they are not formally trained, many plastic surgeons can also be experience and qualified to perform septoplasty procedures. The main focal point should be how much training they have received and how much experience do they have performing the procedures together and separately. There are subtle signs that could indicate if the proposed surgeon is right for you:

  • Did the surgeon look inside my nose? (As surprising as it sounds, in a number of my revision consults, patients often say that their original surgeon never looked inside their nose.)
  • Do they have specialized instruments to tackle the procedure? (A special headlight, nasal instruments, etc.)
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