Fillers (Soft Tissue Augmentation)

Softening of facial lines and the restoration of volume and fullness in the face often can be achieved non-surgically with injectable fillers. Most fillers are commercial FDA approved products that come prepackaged, such as Restylane® and Juvederm®. As an alternative, fat from your own body can be used as a filler and can last long term. The decision on which filler to use depends on the area we decide to treat and other factors discussed in greater detail below.

Injectable fillers can:

• Plump thin lips
• Enhance shallow contours
• Soften facial creases and wrinkles
• Improve the appearance of recessed scars

Soft tissue fillers do not stop the aging process. However, results can be significant and can turn back the clock. Non-surgical rejuvenation treatments such as injectable fillers cannot achieve the same results as surgery, but may help delay the time at which a surgical procedure becomes appropriate.

If facial aging has caused the skin and soft tissue of the face to droop or sag significantly, you might instead consider more effective surgical alternatives that can give you a greater improvement, such as the Brow Lift, or Eyelid Lift.

Although tissue augmentation is a quick, in-office procedure that can produce a marked improvement in restoring facial fullness and a more youthful appearance, effective and safe use requires a physician, physician assistant, or registered nurse with specialized training and a thorough understanding of facial anatomy to recommend and inject an appropriate filler.

Choosing a plastic surgeon to treat your face with injectable fillers means that your treatment will be performed by someone who not only has training in injection therapy, but in all types of non-surgical and surgical facial rejuvenation.

There are several important factors to choosing a surgeon, including recommendations from friends, personality, physician training and board certification, and experience.

Personality: It is important to develop a good relationship with your surgeon so that communication is easy and trust can be developed. You should feel that you are in good hands. Bedside manner is important.

Referral from Friends: Many prospective patients find confidence if they have a close friend or other trusted individual who has already undergone a successful procedure by a certain doctor. This is often a good first step in making a decision. In fact, most of our patients are referred to us by friends who were very satisfied with their results. However, not all patients know someone who has had surgery.

Training and Certification: In years past, only plastic surgeons performed Cosmetic Surgery. However, in recent years doctors from many different specialties are more commonly performing cosmetic surgery procedures. Only a surgeon who has been certified by the American Board of Plastic Surgery has received the most extensive training in cosmetic surgery. There are many Boards, and it is easy for patients to become confused or assume that when a doctor says they are “Board Certified,” it all means the same thing. BE CAREFUL! Learn more about the significance of Board Certification here.

Experience: Finally, consider the physician's experience—the most important factor in making a decision. As with all professions, expertise is directly proportional to experience, meaning the total number of procedures performed. Medical literature illustrates that biggest predictor of success in surgery is volume, in other words, the number of times that a person has performed a procedure.

If the doctor is recommending a specific procedure, how many has he performed? Also, how often does he do this procedure? While board certifications and training are important, a surgeon's experience with the procedure itself is more important. Don't hesitate to ask pointed questions about recommended procedures.

While not as involved as surgical cosmetic procedures, soft tissue augmentation is a medical procedure. You should do it for yourself, not to fulfill someone else’s desires or to try to fit any sort of ideal image.

Tissue fillers may be a good option for you if:

• Are noticing vertical lines around your lips
• Feel that your lips are getting thinner
• Have deeper lines between your nose and mouth (smile lines)
• Have deeper lines at the corners of the mouth that make the mouth turn down (marionette lines)
• Are looking sad, tired, or angry even when you are not
• Have a contour irregularity or dent on the nose
• Have acne scarring on the cheeks
• Have noticed that your cheeks are not as full as before
• Have grooves or shadows under the eyes
• You have a positive outlook and specific, but realistic goals in mind for the improvement of your appearance

Because every case is unique, the only way to accurately determine which procedure is best for you is to consult with Dr. Alexander.

To ensure the most natural looking results, it's imperative for a surgeon to recommend the procedure which most appropriately matches your needs and to offer realistic expectations for outcomes. When you meet with Dr. Alexander, you should expect a full discussion of the options for your face, which is unique.

A good surgeon goes through a series of examinations and observations that are individual and depend upon your specific situation and goals, but also factor in the surgeon's expertise, training and experience.

The success and safety of your procedure depends on your complete candidness during your consultation. You’ll be asked a number of questions about your health, desires and lifestyle.

Be prepared to discuss

• Why you want the procedure, your expectations and desired outcome
• The options available to you for facial rejuvenation
• Medical conditions, drug allergies and medical treatments
• Use of current medications, vitamins, herbal supplements, alcohol, tobacco and drugs
• Past treatment with injectable fillers, facial shaping or Botox® therapy or other facial rejuvenation procedures
• Previous surgeries

We may also:

• Examine and measure your face
• Take digital photographs for computer imaging
• Discuss your options and recommend a course of treatment
• Discuss likely outcomes of soft tissue fillers and any risks or potential complications

Your initial treatment will include a complete consultation. Subsequent follow-up procedures may take only a few minutes.

• Are you certified by the American Board of Plastic Surgery?
• Were you specifically trained in the field of plastic surgery?
• How many years of plastic surgery training have you had?
• Is the office-based surgical facility accredited by a nationally- or state-recognized accrediting agency?
• Am I a good candidate for this procedure?
• What will be expected of me to get the best results?
• Where and how will you perform my procedure?
• How long of a recovery period can I expect?
• What are the risks and complications associated with my procedure?
• How are complications handled?
• How can I expect my skin to look over time?
• What are my options if I am dissatisfied with the cosmetic outcome of my procedure?
• Do you have before-and-after photos I can look at for this procedure and what results are reasonable for me?

Collagen is a natural protein that supports the skin. Although it was once widely used, Collagen is no longer being manufactured for use by itself (see Artefill® below).

Hyaluronic Acid is a natural substance found in our bodies. It is well suited to plump thin lips and fill facial creases such as nasolabial folds. It may also be appropriate for some surface wrinkles and concave scars. The results may last 6-8 months or longer, and after several treatments, results build on themselves and treatments last even longer. Examples are Restylane®, Juvaderm®, and Perlane®.

Hydroxylapatite is a mineral-like compound found naturally in human bones, suspended in a gel-like formulation. It is the heaviest of facial fillers and is recommended to fill deeper creases such as nasolabial folds, marionette lines and frown lines, as well as to enhance fullness of the cheeks and other facial contours. An example is Radiesse®.

Human fat, harvested from your own body, can be reinjected to enhance facial fullness, fill deep creases and to build up shallow contours. Fat injection requires a more extensive procedure than other injectable fillers because it uses liposuction techniques to extract the fat prior to injection. This procedure can be done with local anesthesia. Approximately 30-40% of the transferred fat will “take” and remain permanently. Fat can sometimes be stored for your own future treatment. However, the duration of results from preserved fat is not as favorable as fat used at the same time it is harvested.

PMMA fillers (polymethylmethacrylate) contain 20% tiny PMMA microspheres suspended in 80% purified collagen gel. An FDA-approved PMMA filler is recommended for the correction of facial wrinkles known as smile lines.
Treatment results last up to a year or more. An example is Artefill®.

Silikon 1000 is a silicone oil that has been used as an injectable for decades. It is not FDA approved for wrinkles or soft tissue augmentation, therefore its use for this purpose is considered “off label.” When used in small amounts, problems are very rare. Complications tend to occur when large amounts of this filler are used and the body sees the filler as a foreign body. This is true of any type of filler when used in too large a quantity.

A note about the FDA and injectable fillers:
The U.S. Food and Drug Administration reviews and approves pharmaceutical fillers in the same manner as medical devices. However, some fillers may be used on an “off-label” basis, meaning they are approved medical treatments but not directly reviewed for a specific application. The options discussed in this website are among the current fillers preferred by plastic surgeons. Some are available for general use, others are not; regulatory status may be subject to change.

Anesthesia—General: The patient is asleep, requiring that the airway be protected, either by a standard breathing tube, or by a laryngeal mask (LMA), an inflatable mask that goes in the back of the throat but doesn’t go down the trachea. Through the airway, an anesthesiologist gives gases to put the patient asleep. Drugs may also be given through the iv.
Anesthesia—Local: The surgical area is numbed up with an injection, but the patient is awake. Sometimes a patient will be given an oral medication, like Valium, to help with relaxation.
Anesthesia— Sedation (Twilight): The patient is made sleepy with medications given through an iv. The level of sedation can be adjusted, from barely sleepy to very sleepy. Sometimes sedation is given by the surgeon, but most of the time it is administered by an M.D. Anesthesiologist.
Botox: An injectable solution that temporarily weakens facial muscles that cause unwanted wrinkles, such as frown lines. Botox is not a filler, but a muscle relaxer.
Collagen: A natural protein used as an injectable filler for soft tissue augmentation.
Cupid's bow: The middle portion of the lip, which has the upturn.
Hyaluronic acid: A natural substance found in the body used as a filler.
Hydroxylapatite: A mineral-like compound found naturally in human bone used as a filler.
Injectable fillers: Substances used to restore volume and a more youthful appearance.
Liposuction: Also called lipoplasty or suction lipectomy, a procedure that vacuums out fat from beneath the skin’s surface to reduce fullness.
PMMA: A widely used implant material formed into tiny microspheres and suspended in a collagen gel for use as a wrinkle filler.
Soft tissue augmentation: The use of injectable fillers to restore volume and your youthful appearance.
Vermillion: The red pigment of your lips.

Cost is always an important consideration in elective procedures. However, when choosing a plastic surgeon, remember that the surgeon’s experience and your comfort are just as important as the final cost.

A quote will be provided to you after your consult with Dr. Alexander.

For most fillers cost may include:

• Filler costs
• Prescriptions for medication
• Anesthesia fees

For fat transfers costs may include:

• Surgeon’s fee
• Operating Room and Supplies
• Anesthesia fees
• Prescriptions for medication
• Medical tests

Except for fat transfer, which is a surgical procedure, little is required prior to your procedure. Artefill® patients must have a simple allergy injection test four weeks prior to being treated.

Medications are administered for your comfort during the procedure. Some fillers can be done with no anesthesia. Some patients choose to use ice or a topical anesthesia. Others prefer to have the area blocked with a local injection. Fat transfers can be done with local anesthesia or IV sedation.

We will recommend the best choice for you based on your personality, your desires, and the complexity of your procedure.

INJECTABLE FILLERS
The procedure typically takes a few minutes depending on the individual and other variables.

Step 1
Dr. Alexander or Joanna, his Physician Assistant, will carefully evaluate your facial appearance and skin tone, and examine the areas of your face to be augmented with injectable fillers.

Step 2
Strategic points on your face may be marked as guides to the appropriate injection sites for the filler.

Step 3
The injection sites will be cleansed with an antibacterial agent and icing or a topical numbing agent may be offered to make more sensitive patients comfortable.
In some cases, the filler itself will contain an anesthetic agent. In other cases local anesthetic may be administered to the treatment site.

Step 4
Injection takes only a few moments per site and a few minutes for a course of treatment.

Step 5
Following injection, any markings will be cleansed and icing may be offered to alleviate any temporary, minor discomfort. Makeup may be carefully re-applied so long as care is taken not to apply pressure to the treatment area.

Filling wrinkles or recessed scars involves multiple injections. In some cases where deeper injection of fillers is required, a local anesthetic may be used prior to treatment.

Common sites for deeper tissue fillers are the nasolabial folds and marionette lines, or to enhance fullness in the cheeks. Soft tissue augmentation of the lips requires multiple injections to distribute the filler for enhanced lip fullness and to raise or define a Cupid’s bow or vermillion border.

FAT TRANSFER AS FILLER
The procedure typically takes about 30-45 minutes depending on the individual face and other surgical variables.

There are four basic steps to cheek fat transfer surgery.

Step 1 - Marking
Dr. Alexander will make careful marks on your face prior to beginning the procedure.

Step 2 - Collecting the fat
Tumescent fluid is placed in the hip or abdomen. Fat is suctioned with a syringe, and the tiny incision is closed with a suture.

Step 3 - Preparing the fat
The fat is washed in saline and separated, then placed into an injection syringe.

Step 4 - Placing the fat
Using a special injection syringe, the fat is injected into the soft tissue of the cheeks in several lines and layers, plumping up the cheek tissue. No dressing is required.

Pain
Pain after receiving fillers is usually minimal. Pain pills can be provided, but are usually not required. Significant pain is extremely rare and may be the sign of a serious complication, so your physician should be notified.

Important facts about the safety and risks of fillers
We will explain in detail the risks associated with this procedure. You will be asked to sign consent forms to ensure that you fully understand the procedure you will undergo and any risks and potential complications.

Complications from fillers are uncommon.
The risks vary depending on the specific filler used and the relative permanence of the filler substance and include:

• Fillers derived from non-human sources may require a pre-treatment allergy test
• Bruising
• Infection (extremely rare)
• Lumpiness
• Asymmetry
• Skin sensitivity

An improved appearance is visible almost immediately, although minor swelling or bruising may appear at the injection sites. With some fillers, a slightly “over-filled” appearance may be initially present. These conditions will resolve within a few hours, or at most a few days. The duration may be as long as a few weeks with injection of one’s own harvested fat.

You will be given specific instructions that include:

• How to care for the procedure site
• Medications to apply or take orally to aid healing and reduce the potential for infection
• Specific concerns to look for at the surgical site or in overall health
• When to return to the office

The results of soft tissue augmentation with many injectable fillers are not permanent. The continued aging of your face and variables in the absorption of fillers will affect how long your results last.

Should you choose not to repeat treatment, your appearance should return to its original condition. Plumped lips will lose volume and improved wrinkles, creases and scars will reappear in time. Even the results of permanent fillers can change over time as the face continues to age.

In general our patients are very pleased with their soft tissue fillers. The practice of medicine and surgery is not an exact science. Although good results are expected, there is no guarantee. Small revisions are occasionally necessary.

Continuing a Skin Care program can help maintain your result and help keep your skin young and healthy. We offer a complimentary facial after your procedure to introduce you to our Aesthetician, Leanne, and our Physician Assistant, Joanna, in our excellent Skin Care Clinic.

Life-long sun protection will help to maintain your rejuvenated appearance by minimizing photo-aging or sun damage. In addition, a healthy lifestyle will also help extend the results of your rejuvenated, more youthful appearance.