Recent advances in dermatology have made it possible to achieve a “facelift” without doing surgery. This is sometimes referred to as a “liquid facelift” because it is achieved by injecting “liquid” filler substances into the face in combination with “liquid” botulinum toxin. Satisfaction surveys show that greater than 90% of patients who undergo a “liquid facelift” are happy with results. This high percentage of satisfied patients means that as general awareness of this treatment becomes more widespread, the number of such procedures performed will no doubt increase dramatically.
The term “facelift” used herein is not meant to imply that one can achieve the same results with a “liquid facelift” as with a traditional surgical facelift. Rather it refers to a procedure that when performed correctly on properly selected patients, creates a more youthful appearance and gives the perception of having had a “lift”.
BOTULINUM TOXIN “LIFT”:
Botulinum toxin (i.e., Botox Cosmetic®, Dysport®, Xeomin®, etc.), when injected strategically into specific areas of the face, can elevate the corners of the mouth and elevate the eyebrows giving the appearance of a “lift”. The botulinum toxin is injected into muscles that push the eyebrows and mouth down thereby weakening these “depressor” muscles and thus allowing the “elevator” muscles to dominate, The resultant appearance, in appropriately selected patients with proper technique, is that of having a “lift”. In selected patients botulinum toxin can also achieve a “neck lift”. To maintain the botulinum toxin “lift” requires repeated treatments at 3 to 6 month intervals.
EPIPHANY OF THE INJECTABLE FILLER LIFT:
Whereas the specific “lifting” properties of properly administered Botox has been known for at least 10 years, the lifting properties of “filler injections” has only been widely appreciated by cosmetic savvy patients within the last two or three years, and is now gaining more widespread recognition in the general public.
TYPES OF FILLERS AND TIMELINE:
The number procedures involving facial filler injections has progressively increased since the FDA approval of Restylane® in December 2003. Restylane® has at least two advantages over prior fillers, namely
• It is a natural substance (hyaluronic acid) and
• mistakes can be dissolved through the use of the enzyme hyalouronidase.
Approval of Restylane® in 2003 was followed by FDA approval of a number of other hyaluronic acid fillers whose trade names include Juvederm® (2006), Perlane® (2007), Belotero® (2011), and Voluma® (2013). In 2010, the FDA approved fillers that were mixtures of Xylocaine® and hyaluronic acid; the addition of Xylocaine® increased the popularity of these fillers by diminishing the pain of injections.
In addition to the hyaluronic acid fillers, at least two other types of fillers are widely used.
• Radiesse® is another popular filler. It is composed of calcium hydroxylapatite and its FDA approval came in 2006 for correction of moderate to severe facial wrinkles and folds (such as nasolabial folds).
• Sculptra® is injectable poly-L-lactic acid that was initially FDA approved in 2004 for treatment for facial lipoatrophy in HIV patients. In 2009, Sculptra was approved for use in non-HIV patients for correction of nasolabial folds and other facial wrinkles.
A recent study showed that both Sculptra® and Radiesse® are more likely to cause complications than hyaluronic acid fillers (JAMA Facial Plast Surg. 2013 May;15(3):226-31. doi: 10.1001/jamafacial.2013.798). In that study the complication rate for hyaluronic acid fillers was 2 per 1000 treatments. The complication rate for Sculptra® was three times higher and the complication rate for Radiesse® was 13 times higher. Moreover, both Sculptra® and Radiesse® have the additional disadvantage that neither can be dissolved easily if injection mistakes occur (whereas hyaluronic acid fillers can be dissolved with hyaluronidase).
BASIC CONCEPT OF HOW THE LIQUID FACELIFT WORKS:
When Restylane® was approved in 2003 and for several years after, fillers were primarily used by injecting the lines or wrinkles themselves. Although many filler injections are still made into lines and wrinkles, the “liquid facelift” is based on different concept wherein fillers are injected into the cheek and temple areas to improve sagginess and wrinkles around the jaw and chin area (without necessarily injecting fillers into the jaw or chin itself). The apparent reason for the tightening effect in the lower face with the upper face injections is that the skin and the underlying fibrous tissue in the temples and cheeks are all connected to the skin and fibrous tissue in the lower face. It is the same concept as taking a wrinkly balloon and filling it with water (or in this case filler) to make the surface of the balloon smooth and taught. Moreover, loss of fat in the face is part of the aging process. So restoring volume by putting filler where the fat in the cheeks and temples used to be has the resultant effect of a more youthful appearance to the face. In other words, the visual perception of having had a “lift” is in fact partially or perhaps largely due to the volume replacement by the filler.
FIVE ADVANTAGES OF THE LIQUID FACELIFT OVER A TRADITIONAL FACELIFT:
Five advantages of the liquid facelift over a traditional facelift include
1) much shorter procedure time,
2) in an office setting,
3) with lower anesthetic risk,
4) with less downtime, and
5) with lower cost.
Without complications, a liquid facelift typically takes an hour or less to perform in a dermatologist’s office, has a downtime of two to three days, and is performed only with topical numbing in combination with the Xylocaine® in the filler. In addition, the liquid facelift is less expensive than a traditional surgical facelift.
The typical cost for a “liquid facelift” is difficult to estimate because it depends largely on how many syringes of filler are used. As an example, if filler syringes are $750 each and only two syringes are used plus $500 of botulinum toxin then the cost would be $2000. However, if six syringes of filler are used plus $500 of botulinum toxin, then the cost would be $5000.
POTENTIAL LONG TERM COST DISADVANTAGE:
One of disadvantages of the liquid facelift is that the botulinum toxin has to be repeated every two to three months and the filler has to be repeated every 6 to 9 months. With repeated liquid facelifts, the long term cost could easily exceed that of a traditional facelift. However, it should be noted that plastic surgeons often administer Botox and fillers on an ongoing basis to their patients who have had traditional facelifts. Thus, the true cost of a traditional facelift often ends up being far greater than the cost of the surgical procedure.
CONTRAINDICATIONS TO FILLER INJECTIONS
Filler injections should NOT be performed in patients who have
• unrealistic expectations,
• inflamed skin from such conditions as cysts, pimples, rashes, or hives, etc.,
• skin infections,
• a proclivity to excessive scarring (keloids) and/or thick scarring (hypertrophic scars),
• a bleeding disorder, including alcoholic liver disease,
• severe allergies or a history of acute allergic reactions (i.e., anaphylaxis, also known as anaphylactic shock which is the body’s potentially fatal allergic reaction),
• allergies to lidocaine (Xylocaine®) (because most modern day hyaluronic acid fillers contain lidocaine), or
• allergies to bacteria (because most modern day hyaluronic acid fillers are derived from bacteria fermentation).
RELATIVE CONTRAINDICATIONS AND PRECAUTIONS TO TAKE PRIOR TO FILLER INJECTIONS:
• Patients who have advanced skin “droopiness” and skin laxity often benefit very little if at all from fillers without a concomitant surgical facelift.
• Patients with multiple dilated facial blood vessels (telangiectasias) often have worsening in appearance of these telangiectasias with filler injections. However, this problem can usually be ameliorated by the concomitant use of a vascular laser or an intense pulsed light device to diminish the presence and size of these visible blood vessels. Nevertheless, these patients should be forewarned of the potential worsening of the appearance of their facial blood vessels.
• Patients taking substances known to cause prolonged bleeding should typically make adjustments before having a filler treatment. These patients may be divided into at least two groups, namely
o those who are self administering these substances and
o those who are taking these substances under the directions of a physician.
Those who are self administering these substances on an ongoing basis, or who have had recently ingested one or more of these substances, should be told to stop the over-the-counter administration of these substances at least two weeks prior to treatment. Such substances include
o nonsteroidal anti-inflammatory drugs (i.e., NSAIDs such as Naproxyn and Advil), and
o herbal supplements such as
vitamin E supplements,
St John’s Wort,
gingko biloba, and
Those who are taking substances to cause prolonged bleeding time under the direction of a physician typically are taking one or more of the following agents:
• warfarin (Coumadin®),
• dipyridamole, or
For these types of patients who are prescribed medicines to prolong bleeding times under the direction of a physician, consultation with their physician is mandatory. In some cases, the patient may wish to proceed even after he/she is properly informed of the significant bruising that is likely to occur and likely to persist for several weeks following treatment.
PRECAUTIONS TO TAKE AFTER TO FILLER INJECTIONS:
Patients should be advised to stay out of the sun as long as bruising persists, and vigorous exercise should be avoided for the first 24 hours to avoid raising blood pressure.
See the FDA list of side effects at http://www.fda.gov/medicaldevices/productsandmedicalprocedures/cosmeticdevices/wrinklefillers/default.htm #Materials and http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm049349.htm
Most side effects associated with dermal fillers happen shortly after the treatment session and most go away in less than two weeks. In some cases the side effects are not immediately apparent and do not present themselves until weeks, months or years after injection. Any injectable dermal filler may cause long-term side effects, permanent side effects, or both.
Side effects that are anticipated in almost every “liquid facelift” include the following:
• needle marks,
• injection pain, and
• tenderness or soreness for 24 – 48 hours afterwards,
• itching, and/or
Additional common side effects after treatment are
• a lumpy skin surface and/or
• an initial imbalance between the two sides (asymmetry) from putting in
o too much filler (overcorrection) or
o putting in too little filler (undercorrection).
These types of common side effects are usually corrected on a follow-up visit as follows:
o Lumpy skin areas and overcorrected areas are typically treated by performing massage and/or injecting a substance that dissolves the excess filler (i.e., hyaluronidase).
oUndercorrected areas are typically treated by injecting additional filler into them.
HYALURONIC ACID FILLERS HAVE LOWER COMPLICATION RATES AND CAN BE DISSOLVED
The “side effects” listed above should not be confused with the “complications” that are discussed below. Whereas “side effects” are the anticipated unpleasantries that occur to some degree in many if not most filler treatments, “complications”, on the other hand, are the more substantial unwanted and undesired occurrences associated with filler injections that are uncommon. As noted in the above referenced study on filler complications (JAMA Facial Plast Surg. 2013 May;15(3):226-31. doi: 10.1001/jamafacial.2013.798), the overall complication rate for filler injections is low. In that study complication rates were 0.2%, 0.6%, and 2.6% for hyaluronic acid, poly-L-lactic acid (Sculptra®), and calcium hydroxylapatite (Radiesse®), respectively. In other words, although the complication rate was low for all three types of fillers, the complication rate was three times lower for hyaluronic acid fillers vsSculptra® and the complication rate for was 13 times lower for hyaluronic acid fillers vsRadiesse® . Moreover, both Sculptra® and Radiesse® have the additional disadvantage that neither can be dissolved easily if injection mistakes occur (whereas hyaluronic acid fillers can be dissolved with hyaluronidase).
COMPLICATIONS – “LESS SERIOUS” AND “MORE SERIOUS”
Complications may be divided into two general categories subjectively described as “serious” and “less serious”. Of course, from the patient’s perspective, any complication is “serious”. The most serious complications include
• instances when a filler substance is inadvertently injected into an artery or into a vein,
• a severe allergic reaction resulting in life threatening anaphylactic shock,
• serious infections, and
• worsening in appearance.
Less serious complications include
• skin discoloration such as
o pigmentation from the filler itself such as the “Tyndall effect” with hyaluronic acid fillers,
o tattooing the epidermis in the case of Radiesse®, and
o reactive skin pigmentation that may persist (particularly in darker skinned individuals) as a result of inflammation caused by an immune reaction to the filler substance,
• raised lumps and bumps in or under the skin referred to as “nodules” or “granulomas”,
• acne type eruptions,
• localized infections that are cured with a single outpatient course of antibiotics,
• Migration (i.e., movement) of the filler material from the site of injection to another location,
• open or draining wounds from a sore at the injection site caused by leakage or rupture of the filler material at the injection site or through the skin as a result of tissue reaction or infection,
• triggering a herpes virus flare, and
• allergic reactions other than anaphylaxis.
LESS SERIOUS COMPLICATIONS:
• Filler injections may be complicated by at least three types of skin discoloration.
o Localized persistent darkening of the skin at or near the injection site usually occurs only in darker skinned individuals and is the result of the inflammatory reaction to the filler substance. The medical term that is used is termed post-inflammatory hyperpigmentation or PIH.
o Another type of discoloration is caused by the filler itself. For example, Radiesse® is white in color and if a portion of the injection is inadvertently deposited too close to the skin surface a white “tattoo” can result.
o The Tyndall effect is a complication specific to hyaluronic acid wherein the filler appears as a blue discoloration under the skin in instances where the filler is injected too close to the surface. Named after the 19th-century British physicist John Tyndall, it is the phenomenon by which an invisible beam of light becomes visible when it passes through nonhomogeneous material — in this case, the zone of the skin that contains boluses of filler. Light beams penetrating the skin surface are dispersed in many different directions; this physical process is known as light scattering or Rayleigh scattering, after the 19th-century British Nobel laureate Lord John Rayleigh. The filler material in the skin scatters blue light about 10 times more strongly than red light. The blue light then traces a visible path back to the skin surface. The result is a bluish appearance of the filler in the skin and. The bluish appearance of the sky, which is in reality colorless, is another example of the Tyndall effect (i.e., stronger scattering of blue light than red light). Another example of the Tyndall effect is the red color of the sun at sunrise and sunset because there is more scattering of blue light away from an observer’s eyes when the sun is low in the sky. The Tyndall effect associated with hyaluronic acid fillers is typically treated by dissolving the filler via injections of an enzyme (i.e., hyaluronidase) and then re-injecting the filler deeper in the skin (deeper injection avoids having the Tyndall effect in the first place.)
• Raised lumps and bumps in or under the skin referred to as “nodules” or “granulomas”, form in a very small percentage of patients. The above referenced study showed that this complication is seen less often with hyaluronic acid fillers and are more common with stimulatory products such as poly-L-lactic acid (Sculptra®) and calcium hydroxylapatite (Radiesse®). These are thought to be either an infectious process or an inflammatory response to the filler. Everyone has some form of tissue reaction to all fillers and in some patients the reaction is worse than desired. In these patients whose tissue reaction to the filler is higher than normal, bumps can form and these bumps are referred to as “nodules” or “granulomas”. In other patients, the reaction can appear as persistent redness and/or acne. In some instances these bumps harden and become “permanent”; in some instances the only way to get rid of these “granuloma” bumps in is to cut them out. In other cases injecting steroids may work to make them disappear. For nodules that form as a reaction to hyaluronic acid fillers, hyaluronidase injections are the initial treatment of choice.
• Localized skin infections although rare, typically show up as new redness, swelling, or pain within a few days of treatment at a time when post injection pain, swelling, and redness should be gone. The infection may also appear as red, painful, or tender nodules. Infectious complications that are seen following treatment with injectable fillers have been postulated to be a result of the “biofilm” concept which holds that the nodules and granulomas that form after filler injections are in some instances reactions to certain bacteria that protect themselves by producing a protective film around them that in turn glues itself to the filler thereby preventing destruction of these bacteria by usual natural body processes.
• Abscesses may either be sterile reactive process to the filler material or in some cases may represent a bacterial infection. In some cases the abscess may have already begun to drain and present as an open draining sore. A culture of the abscess will distinguish between these two possibilities. An abscess at a single site suggests contamination was introduced during the injection, whereas the appearance of multiple abscesses indicates the patient was injected with filler material that may likely have been contaminated prior to injection. Drainage of the abscess and prompt treatment with antibiotics is usually curative.
• In patients with a history of facial herpes simplex outbreaks, a filler injection may trigger a flare-up. A prescription antiviral medicine that is usually taken before, during, and after having a filler injection is usually successful in preventing the herpes outbreak.
• Allergic reactions, such as rash, hives, swelling, or flu-like symptoms are rare.
• Migration (i.e., movement) of the filler material from the site of injection to another location appears most often in the literature in relationship to lip and to eyelid injections. Most commentators appear to believe that technique plays a major role here. However, it appears that well designed peer reviewed studies on this phenomenon are lacking. Nevertheless, it may be prudent to use hyaluronic acid fillers in areas where migration appears to be more common because there is a mechanism to dissolve the unwanted hyaluronic acid filler, and this is not an option with other types of fillers.
MORE SERIOUS COMPLICATIONS:
As note above, the most serious complications of filler injections include
• instances when a filler substance is inadvertently injected into a blood vessel,
• a severe allergic reaction resulting in life threatening anaphylactic shock,
• serious infections, and
• worsening in appearance.
Injection Of The Filler Into A Blood Vessel
The blockage of blood flow from filler injection can be due to trauma to the blood vessel wall, inadvertent injection of the filler into the blood vessel, or a direct pressure effect of the filling agent on the blood vessel causing blockage of the blood vessel channel. Furthermore, the mere swelling of the injection process may push on the blood vessel wall to the point of closure. Injection of filler into a blood vessel can clog up the blood vessel and prevent blood flow through it. Stoppage of blood flow in this manner has caused blindness, stroke, and death of skin tissue with subsequent scarring. Intense pain or a dull ache persistent ache immediately on injection accompanied by blanching are the first signs of intra-arterial injection and venous obstruction frequently manifests with a delayed spotty, purplish appearance. Pain is typical but may be masked because of anesthesia. Skin changes progress predictably to the appearance of purplish-red mottling and then hemorrhagic blisters. Ultimately, the skin and underlying tissue dies with resultant scarring. At the first sign blood vessel blockage, the injection should immediately be stopped, and an attempt should be made to aspirate the filler. When the filler causing the blood stoppage is hyaluronic acid, hyaluronidase should be administered immediately in an attempt to dissolve the filler and open up the blood vessel. Other treatments include aggressive massage, warm compresses, the application of 2% nitroglycerin paste to the affected area, and administration of aspirin. Oral prednisone is also a consideration if swelling is believed to be pushing a vessel closed. The patient should be followed daily until significant improvement is noted and referred for a second opinion if needed.
Severe Allergic Reaction Resulting In Life Threatening Anaphylactic Shock
A severe allergic reaction with life threatening anaphylactic shock is extremely rare but is theoretically possible if the patient is allergic either to the lidocaine (Xylocaine®) in the filler, or is allergic to certain bacteria (because most modern day hyaluronic acid fillers are derived from bacteria fermentation). This type of allergic reaction is a true 911 emergency and should be recognized and treated immediately.
Most infections following filler treatment will typically resolve with a single course of antibiotics. Typically these infections present as increasing pain, swelling, and/or redness within in a few days after surgery at a time when the post injection sequelae should be improving. Close patient monitoring is crucial in these patients so that any worsening is immediately recognized and treated appropriately. In such situations, a low threshold to consult an infectious disease specialist is warranted.
Worsening Of Patient Appearance After Filler Injection
Worsening of patient appearance after filler injection will be regarded by the patient as a major complication and should be addressed promptly. Minor imbalances in symmetry that are corrected on a follow-up visit are common and the patient should be forewarned prior to treatment. Unanticipated major imbalances in appearance are more easily dealt with when hyaluronic acid fillers have been used because hyaluronidase injections can dissolve the excess filler.
LIQUID FACELIFT SUMMARY
“Liquid facelifts” offer many advantages over a traditional surgical facelift in properly selected patients. Satisfaction surveys show that greater than 90% of patients who undergo a “liquid facelift” are happy with results. This high percentage of satisfied patients means that as general awareness of this treatment becomes more widespread, the number of such procedures performed will no doubt increase dramatically. The fact that three fourths of this document is devoted to contraindications, risks, side effects, and complications serves to emphasize that the “liquid facelift” should not simply be considered as another “cosmetic treatment”, but rather a serious undertaking that should be carefully considered by prospective patients.
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