Fillers, Lip and Wrinkle

There have been so many advances made in the field of facial fillers that they are now one of the most popular cosmetic procedures performed.

Who does the injections?

In many offices nurses, interns or other staff perform filler injections.  It is important for our patients to realize that Dr. Niamtu personally does 100% of the filler treatments.

History of Fillers

For over a century, various substances have been injected to plump lips and wrinkles. For the past 25 years, there was basically only one choice in our country that was FDA approved and that was collagen. Collagen was manufactured from cows and since it was an animal product it required allergy testing. Patients used to have to come in for an allergy test and then come back in a month for the actual treatment. The other problem with older fillers such as collagen was the fact that they just did not last long. Some patients only retained the collagen fillers for a number of weeks or several months at best. In the past 100 years, everything from wax to fat to plastic has been injected into the facial tissues and some fillers proved reactive or dangerous.

New Injectable Fillers

A virtual revolution is going on with the development of fillers. Many different products have been used safely and effectively for many years in Europe, Canada, and Australia. These fillers have been passing FDA scrutiny and many have been cleared for use in the USA. Each coming year will bring the introduction of new fillers.

What Filler is the Best?

There is no easy answer for this question as each filler has different advantages and disadvantages. Contemporary cosmetic surgeons use multiple fillers to assist the various problems associated with facial aging. It is rare that any contemporary surgeon uses only a single filler. In reality it is important to separate the marketing and media hype from the true clinical science of injectable facial fillers. It seems that each time a new filler is FDA approved, it is hyped as "the best and longest lasting filler in history", that is until the next month when the next filler comes out. In reality, they are all good for specific indications. Sometimes they are like "Coke" and Pepsi" in that they are made of the same ingredients and do the same thing. Some patients or doctors simply like one better than the other.

All doctors and patients want fillers to last long. As filler science progresses the longevity of fillers is increasing. Although we want things to last long, sometimes it is a good thing that they go away. What looks good or is in style today may not look good or be in style in 5 years. Due to this, fillers that will eventually be absorbed by the body may be preferable.

The contemporary cosmetic surgeon is somewhat of a "filler bartender" and has multiple filler choices specially tailored for specific applications.

Common FDA Approved Injectable Facial Fillers used by Dr. Niamtu

• Juvederm, Juvederm Ultra, Juvederm Ultra Plus (Stabilized Hyaluronic Acid)
• Restylane, Perlane (Stabilized Hyaluronic Acid)
• Cosmoplast (Human collagen)
• Cosmoderm (Human collagen)
• Evolence (porcine collagen)
• Radiesse (Hydroxyappetite)
• Sculptra (Poly lactic acid)
• Silikon 1000 (silicone oil)
• Artefil (Collagen and plastic microspheres)
• Prevelle Silk
• Elevess
• Hydrelle
• Autogenous fat

 

Contemporary Injectors must be "filler bartenders" and have expertise with all new fillers to suit the needs, wants and desires of discriminating patients.

Not every filler is for every patient and various fillers have various indications and work better for certain patients.  Choosing the correct filler is decided by the patient's aging, desires and budget.

What Can Fillers Do?

Many patients misunderstand fillers and sometime confuse them with Botox. Fillers are substances that are injected under the skin or lips to plump up the tissues. For the lips, fillers can provide an increase in lip size as well as enhancing the definition. They can also plump out "lipstick lines" that develop in many female patients.

For skin wrinkling, fillers are usually used for nasolabial folds (laugh lines) or bigger, deeper wrinkles. Fillers can also be used to augment facial anatomy to make bigger cheeks, chin or to fill in defects and scars.

How Are Fillers Administered?

Fillers are injected through small needles. Dr. Niamtu goes to great lengths to make this procedure painless. All patients are first treated with numbing cream on the areas to be injected, then several small dental injections of local anesthetic are given to totally numb the lips and related areas for a truly painless procedure.  Many surgeons do not take the time to properly their patients and Dr. Niamtu has had many patients switch to his practice because of his painless injection technique.

Dr. Niamtu has written numerous journal articles and textbook chapters on filler technique and local anesthesia techniques for painless filler injection. They can be seen by clicking on Plastic Surgery Products: Voluptuous Lips or on Dr. Niamtu's Online Library.

The filler is then injected in the lips, wrinkles or folds. The actual injection only takes minutes. Ice is placed on the lips immediately after the injections. The lips generally swell somewhat but most patients are able to return to work the next day. Rarely, some patients experience more significant swelling. For this reason, a first time filler patient may want to be treated on a Friday. It is also a good idea to refrain from aspirin or drugs that delay clotting for 1-2 weeks to decrease bruising when injecting fillers.

Dr. Niamtu recommends having the patient return in two weeks to check the result and make sure everything is symmetric. Occasionally a touch up may be performed at the follow up appointment. It is important to view filler injection as a sculpting process and in some cases multiple appointments are required to provide that special result that patients desire.

Filler injection to plump the lips.

In the lips, the filler is used to enhance the natural lip outline and definition that is lost with aging. It is also used to plump the lips to actually make them bigger and to show more of the red lip. Careful attention to detail allows very natural enhancement. Patients that have been overdone are quite obvious. Many factors go into making an esthetic lip. Just making lips bigger is not the answer and can look quite fake. For most patients a single syringe of filler is adequate to plump both lips.

The above image shows the two most common areas of the lips to be enhanced.  The left picture shows a technique to outline the lips. This is done to provide definition for those patients that do not need or want larger lips.  The picture on the right shows the deep fill method and is used for patients that want more "air in the tire" of fuller lips.  Dr. Niamtu may use either of these techniques or frequently combine them depending on the amount of aging and desired augmentation.

I Hate Needles!

Dr. Niamtu has developed a technique to inject lip fillers without using sharp needles.  This technique was published in the journal Dermatologic Surgery in January 2010 and involves using a small blunt device that is known as a cannula.  The cannula is inserted in the lips through a small puncture and since it is blunt, swelling and bruising are rare.  By using the cannula, Dr. Niamtu is able to avoid multiple sharp needle punctures and this technique cuts the treatment time to less than a minute for most lips.  The following pictures are before and immediately after injection with the Niamtu Micro Cannula technique and are evidence of the immediate result without swelling and bruising.

  

click above to enlarge

How can you predict what your lips may look like with filler?

One way to get a idea of how your lips may appear when plumped with an injectable filler is to use your fingers and roll out the upper and lower lip as shown below.  This simulates the addition of volume augmentation with fillers.

For nasolabial folds (laugh lines) the filler is injected to plump the fold. Patients must understand that the fold will not be totally eliminated (actually adults would look unnatural without any smile lines). Instead of being eliminated, the fold is blunted. The fold is actually a valley of tissue and the filler fills in the valley making it less pronounced. For most patients with moderate to deep nasolabial folds (smile lines) a syringe of filler for each side is needed.

How can you predict what your smile lines may look like with filler?

Fillers won't make the smile lines (nasolabial folds) disappear, but will improve the appearance of the lines and folds. To get an idea of what to expect when injecting the folds with a filler, place your index finger above the fold and press on the skin. This will cause the fold to plump out, similar to what the filler does. Younger patients may only need a single syringe of filler for both folds, but patients with deeper folds will more than likely require a syringe for each fold. The biggest problem with nasolabial folds is under treatment or not using enough filler. A patient is better off saving up for two syringes than under treating the folds with a single syringe.

Filler injection of the nasolabial fold (smile line).

Surgical Lip lift

In today's fast paced field of cosmetic facial surgery lip enhancement is one of the hottest and most requested options. The most common lip augmentation procedures include injectable fillers, lip implants and unknown to many patients, subcutaneous lip lift.  This procedure is also called "subnasal lip lift".

What is a "Lip Lift"?

A subcutaneous lip lift is a procedure where excess skin and muscle are removed from the upper lip, just under the nose.  This procedure is done for two reasons; first to shorten the aging lip and secondly to roll out the upper lip to provide pout.

Young patients have shorter, fuller and more pouty lips and as we age, the lip elongates and loses volume and pout.  In addition, upper lip excess can cover the front teeth in some patients giving them a "denture smile" where the teeth are hidden while speaking and smiling.  A surgically shortened lip can provide a more youthful and cosmetic show of teeth.

Who is a candidate for Lip Lift?

This procedure is most commonly performed on patients with an excessively long upper lip from heredity or aging.  The lip must be at least 18 mm long from the bottom of the nose for the patient to be a candidate for this procedure.  Most patients requesting lip lift are those who are aging and losing normal lip form and function, younger patients with long lips or any patient who has lack of normal incisor (upper teeth) show when smiling or speaking.

How is the procedure performed?

This procedure is about 30 minutes long and can easily be performed with local anesthesia or IV sedation if the patient wishes.  The lip is measured and marked and a "mustache" or Bull Horn" configuration of excess tissue is removed.  The can include skin or skin an muscle.  The incision is closed with very fine sutures and the patient is asked to refrain from excessive oral function for several days.
This must be done in a very precise and controlled way or the procedure will not be effective and the scar will be noticealbe.  When performed correctly with normal healing, the procedure heals in about 7-10 days and by 30 days the scar is usually hardly preceptible.  If the scar is visible it can easily be lasered to hide it.

The image below shows the area of skin to be excised in yellow and the right image shows a typical lip lift scar 3 weeks after the procedure.

The image below shows a patient before and afer subcutaneous lip lift by Dr. Joe Niamtu.  Note the shortened lip with improve pout as well as the increased amount of upper tooth show consistent with a more youthful lip.

Filling Facial Depressions, Dents and Acne Scars

Long lasting or permanent fillers (injectable silicone) can be used to elevate facial irregularities such as depressions or scars from acne, trauma or surgically induced depressions.  The case below shows a patient that sustained a facial depression from a fall and was treated with a single injection of silicone.

click to enlarge

click to enlarge

Fillers can also be used to fill in the lines that are underneath the lower eyelids called the "tear troughs". This area makes patients look hollow and by injecting fillers, it plumps out the depression and improves the "dark circle" look. Other uses include plumping the earlobes and "nonsurgical rhinoplasty"

Injectable fillers can be used on most any area of the face and neck where augmentation is required. The above case shows augmentation of the nasal bridge to normalize the nose. This type of filler injection has been called Non Surgical Nose Job. Although temporary, it can mask cosmetic defects of the nose that would otherwise require surgery.

Filler "rhinoplasty" to masquerade a nasal hump

FIllers can also be used in some areas that are not as well known like the earlobes. As we age, our earlobes lose their youthful volume and also become wrinkled. A simple filler injection can restore youthfulness to aging earlobes.

The above images shows earlobe enhancement with injectable fillers.

How Long Does the Filler Last?

There is no correct answer to this question as each patient metabolizes fillers differently. Research has shown fillers such as Restylane and Juvederm last up to 12 months. Radiesse has been shown to last over a year and silicone and Artefil are permanent. Fillers may not last as long in areas of increased movement such around the mouth. Different fillers will last different periods of time in different patients. One thing for sure is that the newer fillers last considerably longer than the first generation of fillers.

When Good Fillers Go Bad!

From time to time all injectors will over correct an area or experience an asymmetry. With the common hyaluronic acid fillers such as Juvederm, Restylane, and Prevell Silk it is possible to reverse or dissolve the unwanted filler with a product called hyaluronidase. This product is marketed as Amphidase or Vitrase and is a safe and effective way to dissolve unwanted filler in 24 to 48 hours. Dr. Niamtu has treated numerous local and out of town patients to reverse filler mistakes from other offices in patients that either got too much filler or got filler in a place they did not want it. The injections are simple and the effect is rapid, usually in 1-2 days. There are no significant risks and no recovery.

Click here to learn more about dissolving unwanted filler

Dr. Niamtu has had the honor of training under some of the true pioneers in facial fillers. Pictured below are Drs. Jean and Alastair Carruthers, Dr. Arnold Kline, and Dr. Richard Glogau.

Drs. Klein, J. Carruthers, A. Carruthers and Glogau.

Dr. Niamtu is a Certified Restylane Trainer and a clinical investigator and lecturer for Juvederm and teaches filler techniques internationally.

Dr. Niamtu demonstrating contemporary filler techniques at the Niamtu Cosmetic Surgery Course

Surgical Lip Lift

Surgical enhancement of the lip is a less common but valuable procedure, especially for those patients with upper lips that have lost their shape and lengthened with aging. This procedure is called a subnasal lift. With this procedure a small section of skin is removed from the upper lip where it meets the nose. This scar is hidden in the nostrils and the purpose of this lift is to shorten and "roll up" the long and flat upper lip. The procedure can be performed with local anesthesia, takes about 30 minutes and has about a week recovery. This procedure will also allow patients to show more of their front teeth, which can be a problem with longer lips in older patients.

The above picture shows shortening of a elongated lip after the subnasal lift.

The above picture shows the patient showing more teeth after the subnasal lift.

Dr. Niamtu named to faculty of Progressive Aesthetic Learning Essential to Technical Expertise

P.A.L.E.T.T.E .

click to enlarge

The PALETTE faculty is made up of well known filler experts across the USA and has to goal to teach safe and effective filler techniques to doctors from multispecialties.

Dr. Niamtu named to teaching faculty of Aesthetic Health Dimensions Editorial Review Board

In September of 2008, Dr. Niamtu had the honor of being appointed to the Editorial Review Board of Aesthetic Health Dimensions. This group is composed of well known plastic surgeons and dermatologists who are leaders in the teaching and development of facial fillers.

Click to enlarge image

Click on above to enlarge

Dr. Niamtu is a physician member of the Medicis Aesthetics Advisory Council

Dr. Niamtu Co-AuthorsInjection Technique Teaching DVD Sponsored by the University of South Florida

Click on image to enlarge

Dr. Niamtu is a member of the Evolence Education Faculty and lectures and teaches on this new filler

To learn more about lip and wrinkle fillers, click below to see my blog entry on the subject.

Dr. Joe's Blog on Lip and Wrinkle FIllers

click on the link below to view filler discounts and promotions

http://www.lovethatface.com/discountspromotions/discounts-and-promotions.aspx