A ^Retired Plastic Surgeon's Notebook

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.

Thanks for reading!  Dr. Lisa Lynn Sowder

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