Seattle Plastic Surgeon blogs about fillers she does not like and does not use.
I’ve written many blogs on the miracles of fillers for facial aging. I think they are the best thing for facial maintenance since sunscreen.
Facial silicone gone bad. Really, really bad.
The fillers I really like and use a lot are Voluma, Juvederm, Restylane, and Perlane which are all hyaluronic acid (HA) fillers. The thing I love about HA fillers is their ease of use, safety, and their reversibility when a rare patient (1 every five years or so) does not like the result. The HA fillers can be reversed by injecting an enzyme which dissolves the filler within 24 hours.
I also use fat as a facial filler in some cases. The thing I like about fat is that there is usually an abundant supply and it is often very, very long lasting and sometimes permanent.
There are other fillers out there. Here’s my list of fillers that I just don’t like or use. Full disclosure here: this is based solely on my (sometimes very limited) experience, hearsay, prejudice and my risk adverse nature. Some of my colleagues use these regularly and successfully but these fillers just give me the creeps.
Collagen: It is sooooo yesteryear. Even when it was the only legit filler out there, I didn’t like it. Patients needed a skin test 30 days prior to using Collagen. The results were fleeting and even a detail freak like me had trouble getting a nice smooth result. Oh, it also had to be refrigerated and shelf life was very limited. Oh, one more thing, it comes from cows.
Radiesse: This is used quite a bit in the Seattle area but it gives me the creeps. It’s made of teeny, tiny spheres of calcium hydroxylapatite and provides a scaffold for connective tissue growth. It is quite thick and can fill in deep creases nicely but can also result in nodule formation. Radiesse lasts 1 -2 years which is great (unless you are one of the unlucky ones who develops nodules). I used it a few times years ago in a a few employees who volunteered (really, they did) to be my training subjects. All three of them bruised really, really badly and I felt like a worm until their bruising resolved. I don’t have a cajones to try it again.
ArteFill: Yikes. This is a scary one. This is a permanent filler which is made up of teeny, tiny spheres of polymethylmethacrylate. They elicit a “foreign body response” which walls off the little spheres with collagen. It also requires a skin test 30 days before injection because the sphere are carried in liquid collagen. My training subjects this time were two pals of mine. Both had negative skin tests. My first patient did fine and is still my pal. The second patient, who was from out of state, had to delay her injection because a family illness prevented her from traveling. Four months later, she had a rip-roaring inflammatory reaction to the little spot on her forearm where I had injected the test dose. It was by the grace of a good and loving God I had not injected her face. She is still one of my very best pals. I have also seen many case reports and a couple of patients with poor results from ArteFill. The only way to get rid of it is to surgically remove it.
Sculptra: Sculptra stimulates dermal fibrosis and thickens the skin. This is filler was first introduced about 10 years ago for use in patients with HIV. The medications that many HIV patients rely upon to stay healthy have the side effect of facial wasting. This filler is made of poly-L-lactic acid, the same chemical that a common suture, Vicryl, is made of. I use Vicryl a lot. It is easy to sew with. It provides strength and support for a couple of months while an incision heals and then the body absorbs sit. But once in awhile, a patient has an inflammatory reaction to the suture. I have had maybe a dozen patients over 20 + years of practice who have “spit” every single stitch. There are many case reports of disfiguring inflammatory reactions to Sculptra and all I have to do is think of one of my Vicryl “allergic” patients and I break out into a cold sweat. Am I a wimp or what?
Silicone: This is the Queen Mother of Bad Fillers (in my humble opinion). It has been used for decades and is responsible for the permanent disfiguration of many, many patients. I will never forget a lecture I attended when I was a surgery resident on the treatment of a bizarre condition called Romberg’s disease. This disease causes profound atrophy of facial fat. Way back when, these patients were injected with medical grade silicone and initially it was beneficial. But fast forward 10, 20 even 30 years and many of these patients went on to develop severe inflammatory reactions that were more disfiguring than the original disease. I know of a plastic surgeon in Hawaii who used this stuff on his wife’s lips. Yikes.
So there is my personal rogue gallery of “no thanks” fillers. All of these (I think) are still in the good graces of the F.D.A. but you won’t find them on my shelf.
Hey, thanks for reading. That was a slog, wasn’t it? Dr. Lisa Lynn Sowder
Seattle Plastic Surgeon knows how to make the Grinch look a little less grinchy.
It’s those glabellar frown lines and nasolabial folds that make this Grinch look soooo grinchy.
Take a look at the Grinch. What is it that makes him look so old and cranky? It’s his glabellar from lines between his eyes that make him look like he’s having a pretty bad day and it’s his nasolabial folds (those creases that go from the sides of the nose to the corners of the mouth) that make him look a billion years old. All he needs to do to work himself up into a really bad mood is to look in the mirror every morning. No wonder he has such a bad attitude.
If the Grinch were to come into my office, here is what I would recommend:
His forehead creases would be softened and smoothed out with Botox. He looks like he needs a pretty large dose, maybe 60 units. The injection would sting but would be quick and he would see a remarkable improvement within 3 days or so. Also, he would feel so much more relaxed. If he wanted to scowl at his poor little dog, he would be unable to! Smile, yes but scowl, no. This amount of Botox would set him back $900 and would last at least 3 months. If he kept coming back for treatment, his dose would likely drop considerably.
His nasolabial folds could be filled in with one of the hyaluronic facial fillers that I inject almost every day of the week. They are terrific for treating the area around the mouth that is such a problem in some people and is hard to treat with other methods. Even a full face lift doesn’t help this area very much. I would use 2 or 3 syringes to get as full of correction as possible. It’s been my experience that patients who opt for just partial correction (to keep the cost down) are not nearly as satisfied as those who just go for it. Three syringes of a filler such as Juvederm would set him back about $1600. Juvederm lasts at least six months and I have many patients who have had nice lasting improvement for up to two years.
Do what about the redemption of his rotten soul? I’ll leave that up to the transcendent love and forgiveness of Whoville. But he’s got to save his face for me.
Maybe the Franchise Model Just Doesn’t Work for Something as Personal as Plastic Surgery?
I got word yesterday of the closure and pending bankruptcy of “Lifestyle Lift”. You have to be living in a cave not to recognize this name and their pitch for a “one hour face lift under local anesthesia” and their very pretty spokeswoman, Debby Boone.
Years ago, I was approached by the Seattle Lifestyle Lift with the offer of a part time job which I graciously turned down. I cannot do a decent facelift in anything under three hours and I seriously doubt that even the speediest of surgeons can do much of anything in just an hour with the patient squirming away with only local anesthesia on board. Also, I was turned off by their one facelift fits everyone approach. Facelift, like just about every surgery a plastic surgeon does, is highly individualized. That’s one of the many things I love about my work. I never do exactly the same operation twice. (Well, I take that back. I did do breast implant surgery on a lovely set of identical twins about ten years ago.)
I just don’t think a franchise is a great business model for surgery in general and plastic surgery in particular.
I will not miss seeing their ads and I am sure Ms. Boone will find another gig.
Seattle Plastic Surgeon is happy to add Voluma to her toolbox.
Those who know me well know that I take a long hard look at new technology, products, procedures, etc. I think that new is not enough. It has to be better, safer, easier or less expensive that the technology, product or procedure it is gunning to replace. I’m always so tickled when something new really does turn out to live up to its claims.
My very brave first Voluma patient. Before injection on the left and after injection on the right. Note how her fuller cheekbones enhance her entire face. Oh, the eye makeup doesn’t hurt either.
Voluma is the new thing that floats my boat. Here’s why. Voluma is another hyaluronic acid (HA) filler, similar to other HA fillers such as Restylane, Juvederm, Prevelle, Perlane, etc. What makes it different is that it was developed for deep injection onto the bone or in the fatty layer of the mid face. Voluma allows for nonsurgical enhancement of the cheekbone area which in turn can improve the contour of the lower eyelids and also the nasolabial folds.
Other procedures that can enhance this area include fat transfer, cheek implants and vertical face lifts. Of course, these all have down time whereas our Voluma patient on the left went to work about 10 minutes after her injection. And she said it hardly hurt although maybe she was just being nice.
Voluma lasts about 2 years, much longer than the other HA fillers.
The cost for this new filler is twice that of the standard HA fillers but often less can be used because it is so “volumizing”. A little bit goes a long way.
So this is another tool in my toolbox and one that I think I will pull out often. Oh, and by the way, the makers or Voluma do not pay me to promote their product. In fact, no one pays me anything to promote their products. I prefer it that way and you should too!
Seattle Plastic Surgeon discusses the promotion of stem cell face lifts by ethically challenged physicians.
Pssstttt …. I’ve got a Stem Cell Face Lift for sale.
Recently I have had several inquiries about “stem cell face lifts” and whether or not I perform them. There must be someone out there promoting this as the latest and greatest fountain of youth. That someone is probably deceptively promoting him or herself as a plastic surgeon with a magic wand.
A little background on stem cells: These are little baby cells that can differentiate into almost any adult tissue. Research on stem cells is one of the hottest areas of biology and with good reason. Figuring out how to turn on the right genes in a population of stem cells could lead to tissue and organ engineering and amazing advances in the treatment of human disease and injury.
Adult fat tissue has a lot of stem cells. Cool, huh? Who would have thought that Mother Nature would pack away these tiny powerhouses of potential in our blubber? Stem cells can be isolated from fat tissue in the laboratory using very sophisticated equipment . This equipment is not something available to physicians working in a clinical setting. Stem cells are not being isolated from fat and injected into human faces.
So what’s the deal? Fat transfer for facial rejuvenation has been around for 20 + years and is becoming more and more popular as we understand the aging process better and also get better with the very fussy techniques required for successful fat transfer. I’ve been doing fat transfer for facial rejuvenation for 15 years. Fat transfer does something that is very obvious: it plumps up a deflated face and makes it more youthful appearing. It also does something else that has been observed by those of us who do fat transfer: it improves the qualityof the overlying skin. And this qualitative improvement is likely the effect of stem cells that come along for the ride with the fat. So the “stem cell face lift” practitioners are doing fat transfer but are promoting it as something new and unique. It’s a little like calling a jelly donut a new type of fruit serving.
Seattle Plastic Surgeon shares a very quick history of Botox.
My very first Botox patient. I injected her scowl lines and was met with great success.
I remember, years ago, hearing about doctors injecting each other with Botox to reduce their scowl lines and thinking: how crazy is that?????
But the anecdotal reports kept coming in and in 1992 a Canadian ophthalmologist, Dr. Jean Carruthers and her husband, Alastair, published their finding that Botox is effective in treating moderate of severe glabellar frown lines (those nasty vertical scowl creases right between the eyes). Dr. Carruthers got the idea to try this because Botox had been used for years by ophthalmologists to treat involuntary squinting. She and other astute opthalmologists noticed that the areas injected with Botox would loose their wrinkles.
Botox quickly became one of the most widely researched pharaceuticals in the world with more than 2500 articles in scientific and medical journals written about it. Ten years after the paper by Drs. Carruthers and Carruthers, the FDA approved Botox for cosmetic use and well, the rest is history. Botox is now approved for 25 unique indications in 85 countries. In 2011, according to the American Society fo Plastic Surgeons’ procedural statistics, 5.6 million Americans opted for Botox treatment. Some days when Botox is flying off my freezer shelf, I feel like I’m the one doing all those injections!
It is the scientific serendipity of the Botox story that I find so interesting. It makes me wonder what other discovery is just an astute observation away from being the NEXT BIG THING.
Do you have a child with severe acne??? An ounce of treatment now is worth a ton of scar revisions later.
Left: Before a bazillion procedures. Right: After a bazillion procedures.
I have two children in high school and I often am asked for advice regarding acne. I am not a dermatologist nor do I play one on T.V. so do not expect any advice as to the latest therapies for acne. I do have advice, however, on whether or not one should seek therapy. So here goes.
If the zits are small and superficial, there will likely be no lasting damage and whether or not to seek anything other than over-the-counter treatment is really a matter of how much the zits bother your child. BUT if the zits are deep (so called cystic acne), your child needs to get treatment YESTERDAY.
The problem with cystic acne is that it causes inflammation deep under the skin and can result in very bad scarring that can be devastating and permanent. And it’s not just the scarring that is an issue. The inflammation can also cause atrophy of the fatty layer under the skin and cause sinking in of the face.
The example on the right shows both superficial scarring and also some deeper scarring and atrophy. This is a mild case. If this were a man, he probably would not have sought treatment but this is a young, beautiful, fine featured woman and this post acne scarring affects her self esteem and also results in her spending a lot of time every morning trying to cover this up.
She an I got to know each other very, very well over about two years of procedures that included fat grafting, skin resurfacing, excisional scar revision and filler injection. It was a long process but worth it for both of us. She can now get on with her day without the prolonged fussing with cover-up and I just loved the bright smile on her face at her last visit.
Not all plastic surgeons are well suited to treat these patients because it involves a lot of patience (which I for some reason have in abundance) and a lot of hand holding.
But the real message here is that if you know someone with deep, cystic acne who is not under the care of a dermatologist, do what you can to get them proper care. What seems like just a minor, cosmetic issue can be a major, difficult to treat problem later.
Fill ‘er up even if it means saving up some hard earned $$$.
Seattle Plastic Surgeon, Dr. Lisa Lynn Sowder blogs about patient satisfaction with HA fillers such as Restylane, Perlane, Prevelle and Juvederm.
I’ve been using these fabulous new facial fillers for many years now and have come to really, really love the way they rejuvenate the face without looking fake or tight or overdone.
Here is one thing I have learned over the years: patient satisfaction is directly proportional to how full their tank is filled. The tank is your face and the fuel is the filler.
Some patients will get to full with one syringe and some will require a half dozen. It just depends on how many creases a patient has, how deep the creases are and how much fullness would benefit the patient. And I am not talking freak show fullenss here. This is Seattle. I’m from Spokane. I don’t do freak show.
The big issue, of course, is the cost and these magical fillers are pricey. Many patients are reluctant to spend the money ($2800 for 6 syringes!) especially considering that these fillers are temporary. But …….. it has also been my experience that these temporary fillers can often last 18 – 24 months even though they are advertised as lasting 6 months. And ……….. patient’s who fill ‘er up usually need much less volume for subsequent “maintenance” injections.
“Fill ‘er up” patients are almost always thrilled and I know they will be back for more. The patients who settle for just partial correction are rarely impressed and often don’t come back for repeat injections.
So if you need a lot to “fill ‘er up”, save up and let me really do it right! Thanks for reading! Dr. Lisa Lynn Sowder
Lower face in the upright position.Lower face in the supine position.
Seattle Plastic Surgeon explains why she always marks her patients in the upright postion.
Plastic surgeons always, always, always do our preoperative markings with patients in the upright position. It doesn’t matter if we’re operating on a face, a chest or an abdomen. Most people understand the effect that position has on breasts and bellys but have never really thought about the effect that position has on the face.
Take a look at these photos posted on the Real Self website by a lady with questions about facial surgery. Look at how much improvement she gets with her jaw line and her nasolabial folds (the creases that run from the nose to the corner of the mouth) when she lies down. Also look how her square face assumes a more oval shape. Wild, huh?
These photos also illustrate why we sit patients up during or near completion of a face lift. A face that looks great supine on the operating room table may need a little tweaking once gravity is added to the equation.
@lisalynnsowder
