How To Prevent The Challenging Filler Face David J. Goldberg, MD Skin - PDF document

How To Prevent The Challenging Filler Face David J. Goldberg, MD Skin Laser & Surgery Specialists of NY and NJ 1 Facial Fillers • Perhaps the most versatile non ‐ surgical means of facial rejuvenation • Several million treatments performed every year • Expanding indications, anatomic areas, and product development 2 Fillers Can Induce Collagen, Elastin and Proteogylcan Formation • Tensile Strength (Collagen) • Structural Support (Collagen) • Elasticity (Elastin) • Hydration (Proteoglycan) • Swelling Pressure (Proteoglycan) 3

Collagen Formation • HA • Biostimulation (The Others) 4 PLLA Neocollagenesis 30 mo 12 mo Hematoxylin ‐ eosin stain, 400x, Hematoxylin ‐ eosin stain, 400x, shows PLLA microparticles with adjacent shows lack of PLLA microparticles and the aggregation of giant cells, histiocytes, and abundance of collagen fibers collagen fibers 5 Vleggaar D. Dermatol Surg . 2005;31(11 pt 2):1511 ‐ 1518. Reprinted with permission from the author. 5 CaHA Neocollagenesis Canine histology 40–60x, collagen matrix stained with picosirius red 1 4 wk 16 wk 32 wk 78 wk Thick section light microscopy at 1 mo and 6 mo postinjection 2 1 mo 6 mo Top, with permission from Coleman K et al. Neocollagenesis after injection of calcium hydroxylapatite composition in a canine model. Dermatol Surg . 2008;34:S53 ‐ S55. Bottom, from Marmur ES et al. Clinical, histologic and electron microscopic findings after injection of a calcium hydroxylapatite filler. J Cosmet Laser Ther . 2004;6(4):223 ‐ 226. 6 Reprinted by permission of Taylor & Francis Ltd (www.tandfonline.com) 6

PMMA ‐ Collagen Neocollagenesis 3 mo 10 y At 3 mo, microspheres are At 10 y, histology shows mature completely encapsulated and connective tissue, active fibroblasts, surrounded by fibroblasts microencapsulation of each microsphere (40x) and collagen fibers (40x) Lemperle G et al. ArteFill permanent injectable for soft tissue augmentation: I. Mechanism of action and injection techniques. 7 Aesthet Plast Surg . 2010;34(3):264 ‐ 272. With permission of Springer. 7 Elastin and Proteoglycan • 20 Middle Aged Women • Injected with CaHA • Biopsy before and 6 months later Goldberg DJ, et al Dermatol Surg: 2019 8 Proteoglycan: Alcian Blue Staining 6 months Before 9

Elastin: Immunohistochemistry Staining 6 months Before 10 Van Gieson Stain for Elastic Fibers Before 6 months 11 So Why are There So Many Filler Mistakes and Unfortunate Results? • Many injectors received no formal training • Filler treatments can be deceptively difficult to execute properly and master • Use of products that carry higher risk • Poor or basic understanding of facial anatomy, dynamics, and aesthetics 12

What Do I See in My Practice? • I regularly see bad filler outcomes • These are usually due to poor technique • Can these mistakes be fixed/addressed? 13 Want To Focus on Good Technique • Not on Biofilms • Not on Necrosis • Not on Nodules 14 15

16 17 Common Filler Mistakes: General Mistakes • Injecting too much volume in each setting • Especially true in lips and tear trough • Not staging treatments when necessary • Choosing the wrong product 18

Staging Treatments Leads to Better Outcomes • More natural results can be achieved by staging multiple treatments • Less bruising, swelling, patient anxiety • Facilitates more natural expansion of tissue • Allows you to address minor asymmetries • Most over ‐ injected patients are injected in one session 19 Common Filler Mistakes: Lip Augmentation • Injecting filler too far inside lip • Using permanent filler • Creating nodules and irregularity • Not paying attention to lip shape and balance • Injecting philtral columns inaccurately 20 Lip Augmentation Mistake: Injecting filler too far inward • The most common technical error on lips • Lip loses shape and definition • Creates anterior projection • Abnormal look when smiling • Creates visible filler outside of the lip with a ‘puffy’ look 21

Lip Augmentation Mistake: Injecting filler too far inward • The most common technical error • Lip loses shape and definition • Creates anterior projection • Abnormal look when smiling • Creates visible filler outside of the lip with a ‘puffy’ look 22 Lip Augmentation Mistake: Using Permanent Filler • Most common are silicone and bio ‐ gel • Inflammatory response of silicone • Filler walls off, creating an implant look (i.e. no true tissue integration) • Only surgery can fix 23 Lip Augmentation Mistake: Using Permanent Filler • Patient comes in with previous unknown filler treatment • Reports long ‐ standing bumps and nodules 24

Lip Augmentation Mistake: Using Permanent Filler • Unknown soft material expressed • Culture negative • Patient healed without incident 25 Lip Augmentation Mistake: Creating Nodules & Irregularity • Patient treated previously with ‘micro ‐ droplet’ silicone and HA filler • Her injector once treated her during an active HSV ‐ 1 outbreak 26 Lip Augmentation Mistake: Creating Nodules & Irregularity • What are the problems here? • Use of permanent filler and HA • Poor technique – not properly distributing filler  How to address?  Firm massage  Carefully placed hyaluronidase  HA filler injected unevenly (to blend with the silicone) 27

Lip Augmentation Mistake: Creating Nodules & Irregularity • Patient treated with an unknown filler substance • This was the result of one treatment session (i.e. a massive amount of product) 28 Lip Augmentation Mistake: Creating Nodules & Irregularity • What is the cause here? • Too much filler at once, creating a ‘tissue expander’ effect  How did I address this?  Firm massage  Large amounts of hyaluronidase (multiple sessions)  A small amount of HA (to fill in the massive skin excess)  Recommended surgical excision of excess skin 29 Lip Augmentation Mistake: Not paying attention to lip shape/balance • Injectors often create imbalance between upper/lower lip • Border of lip and definition often ignored • Usually straightforward solution 30

Lip Augmentation Mistake: Not paying attention to lip shape/balance • An entire syringe of HA was injected into her upper lip • 150U hyaluronidase dissolved all of the filler 31 Lip Augmentation Mistake: Injecting Philtral Columns Poorly • Augmenting or creating philtral columns can improve lip balance • Attributes of a beautiful philtrum • A slight diagonal tilt (15 degrees) • Slightly narrow inter ‐ philtral distance • More fullness inferiorly • Many injectors create fat philtral columns in a wide, vertical orientation 32 Lip Augmentation Mistake: Injecting Philtral Columns Poorly • Too wide • Asymmetric • Too vertically oriented • Can this be fixed?  Good separation  Symmetric  Slight inward orientation & curvature 33

Common Filler Mistakes: Tear Trough • Using the wrong filler • Placing filler too far inferiorly • Placing filler too superficially • Ignoring the lateral component 34 Tear Trough Mistake: Using the Wrong Filler • Higher concentration HA fillers can lead to long ‐ term edema • Highly resistant to enzyme degradation • Tissue expander effect • Calcium ‐ based fillers should never be used • Create visible white nodules 35 Tear Trough Mistake: Placing Filler Too Far Inferiorly • Typically due to two causes • Cannula use by an inexperienced injector • Inferior approach to the tear trough • Avoided by using needles and entering perpendicular to the skin overlying the tear trough 36

Tear Trough Mistake: Placing Filler Too Superficially • More commonly seen in patients treated with cannulas • Inexperienced users place filler in wrong tissue plane • This cosmetic deformity is more prominent in patients with poor skin elasticity • Almost always requires enzyme degradation • Can create a ‘tissue expander’ effect After cannula treatment Post ‐ enzyme treatment Re ‐ treated with HA 37 Master the needle, then the cannula • Injecting in the correct plane (i.e. supra ‐ periosteal) is critical • Much easier to stay in correct plane with needle • Though it is easy to learn cannula technique, you MUST understand anatomic planes to be successful 38 Tear Trough Mistake: Ignoring the Lateral Component • Technically, the tear trough is only medial • Continues laterally as palpebromalar groove • Many injectors ignore the palpebromalar groove since it is often less prominent • Lateral correction is necessary in >90% of patients treated, and is often more important than medial 39

The Midface is the Among the Most Complex Areas of the Face • Anatomic variability is incredibly high among patients • Must pay attention to adjacent areas to maintain balance • Lower cheeks • Temples • Parotid/pre ‐ auricular region • Underlying bony anatomy impacts outcomes greatly 40 Common Filler Mistakes: Mid ‐ face Augmentation • Too much emphasis on the medial cheek • Reliance on a ‘cookbook’ approach • Not paying attention to the lower cheeks and temples 41 Mid ‐ face Mistake: Too much emphasis on the medial cheek • Too much attention paid to medial cheek by inexperienced injectors • Can worsen tear trough and decrease size of eyes • Creates a ‘fat face’ look that can be difficult to correct 42