SAUL R. BERGER   M.D.
818.990.4545
PLASTIC, COSMETIC AND RECONSTRUCTIVE SURGERY
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Guide to Injectable Therapies for the Face – The Basics

(including fillers, wrinkle relaxers (ex. Botox) and Kybella)

 

Over the last 15 years there has been tremendous growth in the area of injection therapies for rejuvenation and the consumer has a remarkable array of choices for looking their best.  Naturally, with more options comes the “burden” of having to sort through what is available, and to determine what is best for each individual.  This guide will provide you with a basic understanding of these treatments, and assist you in starting your journey toward the best results.

Presently, there are three main classes of injectables that are FDA-approved in the U.S. and have a reputable track record of results:  Neurotoxins, Fillers and Fat Dissolvers.  Each category is so distinctly different from the others that it is important to understand the role of each one and recognize that they are not interchangeable.

Neurotoxins are agents that are injected in an area specifically to decrease muscle contraction that causes wrinkles or asymmetry.  The muscle relaxation and smoothing effect will persist for up to four months.  At the time of this writing, three such medications were approved for use in the U.S.: Botox, Dysport, and Xeomin.  While these medications are slightly different on a molecular level, patients would find it difficult to distinguish them when receiving a treatment or assessing their effect.  These neurotoxins act at the cellular level by reducing the ability of the target facial muscles to receive the signal to contract and wrinkle the skin.  Once the effect wears off, muscle function will generally return to baseline.  Neurotoxins can, thus, be thought of as muscle “relaxers” or wrinkle “smoothers” of the face or neck.

Fillers are agents that are used to add volume to areas of the face, whether on a “fine” level such as filling individual wrinkles, or on a larger scale such as adding cheek volume.  Fillers can be subdivided into categories based upon their chemical composition.  They are primarily composed of molecules that are designed to be similar to molecules found in the human body so as to make them highly compatible.  A very popular class of fillers are made of hyaluronic acid (“HA”), which is a widely found class of molecules in the human body.  Examples of HAs include Restylane, Restylane Refyne, Restylane Defyne, Restylane Silk, Juvederm Ultra, Juvederm Ultra Plus, Voluma, Belotero and Volbella.  Another successful category of fillers is comprised of calcium hydroxyapatite (CaOH), a molecule like that found in human bone tissue.  The popular filler composed of CaOH is called Radiesse.  A unique filler that some categorize separately from the other fillers is Sculptra.  This is an agent composed of poly-L-lactic acid (PLLA) which, when injected into an area, causes the body to produce its own collagen thereby adding volume.  Based on its mechanism of action, many consider this Sculptr to be a collagen “stimulator” rather than a filler per se.  In contrast to the classic fillers, Sculptra volume will increase over time, while other fillers will gradually decline over time.  In general, how long a filler will last depends on a number of factors including the type of filler, where it is placed, and the individual.  Fillers placed in areas of greater movement, for example, tend to dissipate a bit faster because of movement in the area.  Also, certain fillers that are prepared in a special way so as to create more chemical bonds between its molecules are also designed to slow the breakdown.

Currently, there is one injectable on the market that is used to dissolve fat: Kybella.  This is a specific chemical that is devised to “melt” fat from the area of the neck and below the chin while avoiding an effect on the skin and other tissues in the area.  Chemically, it is a component that is found in human bile, which aids in the digestion of fat in the intestine.  The effect of Kybella is quite rapid, and can be seen within four to six weeks. It is common for several treatments to be needed for a full correction of neck fat.

When the FDA approves an agent for use in the medical field, they do so with specific “indications,” or guidelines in which the agent “should” be used.  These specific guidelines are called “on label” use.  In the case of the injectables, they can be used effectively in other ways, termed “off-label,” provided it does not violate safety or ethical guidelines.  This kind of flexibility works in the patient’s favor by offering more ways for these therapies to make people look their best, but demands that the physician be well-versed on the agent and its safe administration.

Given the ever-increasing choice of injectable agents available nowadays, it is no wonder that many patients are confused as to how to move forward.  It is essential that patients receive the best guidance from an expert, ideally a physician with aesthetic expertise.  Because these injectables can be ordered and administered by any licensed physician, regardless of whether he or she has expertise in facial anatomy and aesthetics, patients may not realize their best results.  Also, injectables are often administered by allied providers whose background and training may be insufficient to provide expert treatments.  Certainly, common sense should make anyone reading this guide question whether he/she should trust receiving these treatments at an urgent care center or so-called medical spa!

There are several keys to successful treatment with injectables.  Here is a brief guide:

  • Be sure to get a consultation with an expert, such as a plastic surgeon or physician trained in both facial anatomy and aesthetics. Formulating a solid plan is absolutely essential for the best and most natural results.  A great plan with an expert will set you up for the best enhancements, the most natural results, realistic expectations of what can be achieved, and the most efficient use of your money and time.  A flawed plan can compromise any of these aspects resulting in possible disappointment or higher cost.  I strongly advise against shopping for the best price on these procedures, as that can ironically result in much higher expenses over time as more frequent and less effective treatments add up!  It is not always necessary to pay a fortune to see a physician who has a focus in injectable treatments.  Also, do not assume that an injection plan that works for your friend or family member will be ideal for you; generally, that is not the case!
  • Once you are ready to move forward, be sure to prepare for the treatment. It is best to attend the visit with washed skin that has no other topicals applied such as makeup.  It is important to avoid medications that contribute to bruising or bleeding, such as aspirin, ibuprofen (Advil), Coumadin, persantine, and the like.  Also, be sure that you are not planning on attending any important events within the few days following your treatment as it is possible to have mild bruising and swelling that will take a short time to disappear.
  • For the most part, the majority of injection treatments do not require specific follow up care. However, this is not true for all treatments.  Sculptra, for example, requires a specific, albeit easy, follow up routine for about five days.  Most fillers will benefit from ice for the first day or two, but this is not essential.
  • The best results depend on follow up and collaboration with your doctor. Specifically in the case of the neurotoxins (Botox, Dysport, Xeomin), treatment is required at about four months apart.  While it is understandable to want a treatment that is “permanent,” none of the neurotoxins achieve a permanent effect.  In my view, this is not a criticism that should be a “deal breaker.”  Excellent treatment requires only three visits per year, and all of the agents have an amazing record of both safety and effectiveness.  Three visits in a year are a frequency that is far less than many people need for hair styling, manicure, massage, or acupuncture.

Although every individual benefits from a customized plan, there are a two general concepts to consider as you embark on these exciting therapies.  First, the best results often come from blending the treatments rather than using one therapy alone.  For example, using Botox for smoothing and Restylane or Juvederm for filling can give much better overall results that either agent alone.  In addition, the injectable therapies often work beautifully with other aesthetic treatments such as laser treatments or physician-grade skin care regimens.  Second, always remember that filler results depend on the volume given, and many great candidates for fillers do not realize their best results because the volume given was too low.  Most of the research studies conducted on fillers before they are approved by the FDA treated patients with multiple syringes.

Stay tuned for more detailed information about these non-surgical therapies at our web site!