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)
- Radiesse (Hydroxyappetite)
- Sculptra (Poly lactic acid)
- Silikon 1000 (silicone oil)
- 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.
Turning the Frown Upside Down
Many patients present with aging changes around the mouth that causes the corners of the mouth to turn down which makes us look older and sad. Injectable fillers can be placed in the corners of the mouth to actually uplift the down-turned appearance, giving the patient a more youthful and happy appearance. Dr. Niamtu numbs the area first to make the procedure painless. In addition, a small amount of Botox or Dysport can be injected in the muscles that make the frown. Relaxing these muscles in addition to the filler can turn a frown upside down.
The patient shown above has down-turned corners of the mouth. The left side (L) is shown immediately after filler injection and the right side (R) has not been treated. The arrows show the down-turned right side and the improved left side.
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.
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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).
Tear Trough Injection
The tear trough is the depression under the eyes that occurs from various aging changes in the skin, muscle and fat around the eye and cheek. This depression makes patients look older and tired and also can contribute to dark circles under the eyes.
Severe cases may require surgical intervention, but many patients can benefit from filler injection to plump up the tear trough depression and rejuvenate the lower eyelids and upper midface. Cheek implants can also improve this region. Tear trough injections are performed by first numbing the region with a small injection and then filling the depression with one of the available injectable fillers. The procedure takes only minutes and can last up to a year or longer. It is also reversible if desired.
Filling Facial Depressions, Dents and Acne Scars
Injectable fillers can be very versatile for filling aging defects on the face and neck. Many patients have jowls and in reality need a facelift, but may not be able to undergo a procedure for various reasons.
Many of these patients can benefit from filling the hollow regions around the jowl (pre jowl sulcus) which improves the appearance of the jowls at the border of the jaw. The image below shows a patient that had one syringe of filler injected in the pre jowl sulcus before and after treatment. Note the improvement of the appearance of the jowls.
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.
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Silicone injection to depressed acne scars before and immediately after injection.
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.
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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.
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The above images shows earlobe enhancement before and immediately after 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
The following are some of the articles published in the scientific literature by Dr. Niamtu on injectable fillers.
Niamtu, J
New Lip and Wrinkle Fillers Pg. 17-27
In: Minimally Invasive Cosmetic Surgery
Oral and Maxillofacial Surgery Clinics of North America
2005, 17:1, Saunders, Philadelphia
Perioral soft tissue rejuvenation techniques
Compendium Journal
Volume 22, number 11 pg 729-36, 2003
Niamtu, J
Fat transfer gun used as a precision injection device for injectable soft tissue fillers.
J Oral Maxillofac Surg. 2002 Jul;60(7):838-9.
Niamtu, J
Minimally Invasive Cosmetic Surgery
Oral and Maxillofacial Surgery Clinics of North America
2005, 17:1, Saunders, Philadelphia
Niamtu, J
Simple technique for lip and nasolabial fold
anesthesia for injectable fillers
Dermatol Surg 2005;31:1330-1332
Niamtu, J
The use of Restylane in cosmetic facial surgery
J Oral Maxillofac Surg 64:317-325, 2006
Niamtu, J
Reply: Foreign body reaction to hyaluronic acid: an adverse outcome of lip augmentation.
J Oral Maxillofac Surg 64: 1299, 2006
Niamtu, J
Rejuvenation of the Lip and Perioral Areas In:Bell WH, Guerrero CA (eds): DIstraction Osteogenesis of the Facial Skeleton BC Decker, Ontario, Canada 2007
Niamtu, J
Facial Aging and Regional Enhancement with Injectable Fillers.
Cosmet Dermatol. 2007;20(suppl 2):14-20
Niamtu, J
Accurate and Anatomic Midface Filler Injection by Using Cheek Implants as an Injection Template.
Dermatol Surg 2008;34:93-96
Niamtu, J
Experience and Evaluation of a New, Saline-Filled Implant for Cosmetic Lip Augmentation.
Am Journ of Cosmet Surg 2008;24(4):183-191
Niamtu, J
Vo-lip-tuous: Injectable Lip Fillers
Plast Surg Prod 2008;18(3):28-32
Injectable fillers in cosmetic facial surgery. In: Fonseca R, Barber HD, Matheson JD. (eds) Oral & Maxillofacial Surgery.
Saunders Elsevier, St. Louis pp 629-651, 2009
Niamtu, J
Interspeicalty Battles: Who Should Perform Cosmetic Facial Surgery?
Cosmet Dermatol 2009;22:341-342
Niamtu, J
When good fillers go bad
Plast Surg Pract 2009;(28): 16-20
Niamtu, J
Injection gun used for precision device for fat transfer. In Shiffman (ed).Autologous Fat Transfer. Heidleburg: Springer, 2010, 397-400.
Dr. Niamtu named to faculty of Progressive Aesthetic Learning Essential to Technical Expertise
P.A.L.E.T.T.E .
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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.
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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
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