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Fear of Fillers?

Filler, when injected tastefully and in the right areas can be a game changer to fix asymmetry of the face, plump the lips and even help an aging face look fresh and youthful! Fear of an occlusion from filler is common and understood when the worst case scenario can result is necrosis or blindness. However, if you are with an experienced injector who knows how to first minimize the risks, second treat the problem quickly and properly and third re-vascularize the area, the experience is worth it!

First, its best to clear up what "filler" is. A variety of injectable filling agents are available for the treatment of contouring defects or deep lines in soft tissue. Unlike permeant silicon, temporary fillers are biodegradable and include hyaluronic acid (HA), collagen, calcium hydroxylapatite, and poly-L-lactic acid (PLLA). The most common type of filler used in aesthetics to treat an aging face are from the HA group.

Each type of temporary filler works in a different way. For example, Radiaesse is a calcium hydroxylapatiten suspended in an aqueous gel (the same gel used in artificial tears) that after injection stimulate local production of collagen over time. The gel suspension is eventually absorbed, and the calcium excreted by your body. Sculptra, on the other hand, does not technically "fill" the skin. Once injected, PLLA induces a subclinical inflammatory response that stimulates fibroblast proliferation and collagen formation, leading to a progressive increase in volume of the dermis. PLLA is gradually broken down over the course of 9 to 24 months resulting in the appearance of tighter smoother more plumped skin.

Now let's discuss the most commonly used HA fillers. Some common trade names familiar to you include the Juvéderm's Voluma and Volbella, Restylane and Revanesse collections. A shared feature of these collections is the chemically treated hyaluronic acid altered through cross-linking so that the molecules resist rapid breakdown in the body to stay "plump". In contrast, naturally occurring or uncross-linked hyaluronic acid is degraded in skin within a few days. The great news about HA fillers is that the products can be dissolved by the hyaluronidase reversal agent to correct a "bad filler job" or treat an occlusion. What differs about these fillers are where each comes from, it's concentration, consistency, and flow.

Hylaform, one of the original HA fillers comes from the rooster comb whereas most other newer fillers are derived from the fermentation of Streptococcus equi bacteria. Concentration of HA will vary according to the type and purpose of the filler from each collection. HA fillers also vary in gel hardness (G'). A higher G prime will be needed to provide a more structured support for the jaw, cheek or chin and a lower G' prime for a a softer look most often used for the lips. Additionally, under the microscope molecules of brands vary in shape and the ability to absorb water which has a great effect on the amount of swelling seen after injection. Revanesse Lips+ and Versa+ is a smooth molecular gel containing a numbing agent to help minimize the discomfort of injection resulting in a reduced amount of swelling post injection and preferred at the Med Spa at Clinical Edge for most purposes. Revanesse is a 100% HA filler that when administered does not feel "lumpy" like some other fillers on the market. Furthermore, the product is easily dissolvable by the hyaluronidase reversal agent and has a low adverse event profile.

When a more severe deficit is needing correction due to HIV-associated lipoatrophy or deep hypertrophic scars, HA filler may not be enough to get the job done. This type of deficit would most likely require calcium hydroxylapatite like Radiesse or poly-L-lactic acid also known as Sculptra or permeant silicon. None of these products are reversable by hyaluronidase and may require surgical intervention if an occlusion is suspected. A well-trained injector will recommend the most appropriate filler type and avoid injecting into high risk areas such as the bridge of the nose, under the eye, and yes even those "11's" are high risk. Now days there are other modalities such as lasers, PDO threads and protein rich fibrin that can achieve the same or better results with little to no risk. Another way to avoid complications is to reduce the number of sharp sticks by using a blunt cannula whenever possible. If an occlusion is suspected, immediate intervention with massage and hyaluronidase injections are necessary to avoid irreversible effects. Superior injectors will follow up daily and offer revascularization by protein rich plasma (PRP) or protein rich fibrin (PRF) derived from the client's own blood to speed recovery and optimize the best results.

Below is an example of an occlusion that was recognized early on with proper follow up. Treatment: day 1 injection of 5 units of hyaluronidase 150u/1ml; day 2 another 5units; day 4 revascularization with client's own PRF. This client is an example of being in good hands with the proper processes in place for excellent cosmetic results in just a few days time!

Carruthers, J. and Humphrey. S. Injectable Soft Tissue Fillers: Temporary Agents. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. (Accessed on February 14, 2023.)

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