Dermal Fillers

Dermal fillers

I would like fillers to my face but I am put off by images that I have seen in the media

There are many practitioners carrying out fillers and the amount of training and knowledge that they hold clearly varies as evidenced by the bizarre appearances of some people after filler treatment. Filler like all aesthetic treatments is aimed at enhancing your appearance not making you look unnatural and unappealing. Excess filler in the cheeks can give someone an appearance of abnormally large cheekbones which completely unbalances the face and is aesthetically very unappealing. Similarly attempts to get rid of lines in the lower part of the face by pumping in more and more filler are futile. This again will unbalance the face giving a hamster‑like appearance. Excessive filler in the lips can convert a soft smile into hideous grimace or a pleasant curvature of the lips into a ridiculous pout. In my opinion these results are a combination of a lack of understanding of facial ageing and facial form as well as excessive filling. In my clinic I will always advise you when I feel there is sufficient filler in your face.

What causes a trout pout?

Trout pout is caused by excessive use of filler along the rim of the upper and lower lips in an attempt to turn the lips out and eradicate lines in the skin of the upper lip. There are ways of achieving these goals without using excessive amounts of fillers but the location of the filler is critical and the amount used should not be excessive. If small amounts which give a good volume to the lips do not achieve the goal there is no point in putting further filler in. In this situations there are other strategies, sometimes surgical, which need to be considered.

I would like to have filler but I am worried that my lips will be too big

In my clinic I use techniques that I have fine-tuned over the years to ensure that the result you get will be determined by your aims and will be natural. I will always advise you when I feel that we are close to the optimum amount of filler that can be put in your lips without them looking unnatural. Furthermore I carry out my filler treatments in an unrushed manner and you will have a mirror in your hand and be able to monitor progress as we go. I use a small amount at a time and get you to check the appearance as we go along. In this way you will have full control over the size of your lips backed by my experience.

I would like to have filler but I have an important event coming up, how long before I am fully recovered?

This is a common question that patients ask me. Filler treatments normally take 24 to 48 hours to settle but sometimes can take longer particularly if there is bruising as this can lead to more swelling. For this reason if you have an important event such as a wedding I would strongly advise you to have your filler treatment at least one to two weeks in advance of this.

How long do fillers last?

The duration of the commonly used fillers such as Juvederm and Restylane depends on the thickness of the filler. For fillers used deeply to add volume to the mid-face and support the cheeks, the filler can last on average a year. In this location my experience is that the effect disappears after this time. For fillers that are used around the mouth and in the lips I use Juvederm 3 and this lasts on average six months.

In the lips themselves my experience is that a little less filler is required at subsequent treatments.  We know from the scientific papers published on the subject that this is not because the filler lasts any longer, however the filler may stimulate some collagen formation in the lips. This effect can also be found in some patients who have filler to the nose for highlighting the aesthetic areas eg the tip or to smooth the profile. In this area my experience is that Juvederm 3 can last up to 12 months which is six months more than it would typically last in other areas of the face. Again I have found that less filler is required at subsequent treatments in the nose. The much thinner fillers that are used for the skin have a different role. These are to firm up the skin and essentially make it better at retaining water. For these fillers the average duration is around six weeks. In my experience I have not noted any effect longer than this.

As we get older a number of changes take place in the face. These changes are influenced by genetic factors, gravity and lifestyle. Our understanding of how these factors work together to age the face has altered dramatically. This in turn has altered the way in which we approach the ageing face.

We now understand that loose skin is an end-product of this process rather than the fundamental cause. The face and neck are supported by two important arches – the first is an arch of bone and soft tissue that extends from the temples, around the eye and to the side of the nose. This arch is important in supporting the cheeks. The second arch is the lower jaw which is important in supporting the lower mouth area and the neck.

Over time bone thins in these areas and fat is also lost. The skin is no longer as well supported and the cheeks start to sag forwards and downwards, deepening the fold that runs from the nose to the corner of the mouth (nasolabial fold). This same migration of the cheek leads to jowls disrupting the line of the jaw and giving the face a rectangular appearance instead of a more youthful almond shape. The cheek also pulls away from the lower eyelid area creating a groove between the two.

Sagging of the muscles in the neck and accumulation of fat under the chin starts to obliterate the normal tight contours of this region and excess skin can develop folds, which are both unsightly and ageing. Similarly, folds and lines develop in front of the ears.  These changes can also affect younger individuals after weight loss in the face.

The result is that you who may feel young and fit but you have the outward appearance that is older and tired. My patients are not typically looking for a radical change in their appearance, rather they are looking to set the clock back to when they were happier with their face, in a way that looks natural and restores that energetic look.

Fillers are used to combat the effects of facial ageing and can also be used to enhance certain features of the face, for example the lips.

In the past a variety of different fillers have been used and broadly these can be separated into two categories – permanent or non-permanent. Permanent artificial fillers are no longer recommended for use and indeed I have not used them in my practice as I have always felt that they carry too high a risk of complications. Your own fat (fat transfer or lipofilling) is in my view the gold standard of restoring volume and enhancing the face.

Non-permanent fillers exist in a large number of brands, but the vast majority are based on hyaluronic acid which is a gel that already exists in your tissues. Hyaluronic acid has biological properties of holding water and signalling other cells. It may also have a role in increasing the production of useful components of the skin. I commonly use the Juvederm range. Absorbable fillers typically last from 6 weeks to 12 months depending on the thickness used.

When my patients are seeking a long term solution or require large amounts of filler, I will usually recommend that we use their own fat, but for patients who are looking for an immediate response that will last around 6 to 12 months then Juvederm fillers provide a good alternative.

The filler is introduced around the arch extending from the temples to the nose and this has the pleasing effect of restoring cheekbones and supporting the cheeks. It can also lighten the nasolabial fold that extends between the nose and the corner of the mouth. A filler can also be placed along the jaw line to give a firmer more youthful appearance to the jaw and this tends to help lines in this area and support the tissues of the neck.

The commonest area that I treat with fillers is the lips. In young patients who want bigger lips filler that is introduced step by step in small quantities can produce a very pleasing natural look. Many patients have an asymmetry between the lips, for example the upper lip may be much thinner than the lower lip. Fillers are very good at addressing this asymmetry and improving the balance of the lips.

In older patients the lip increases in length and turns in which hides the red part (vermillion). Filler introduced within the lip can turn the lip out to a degree, again without giving an unnatural look. For the skin of the upper lip, which can often have multiple lines in it a combination of very small amounts of filler with regular Botox can have a pleasing rejuvenating effect whilst enlarging the upper lip but keeping its natural shape.

In the lower lip volume can be added as for the upper lip and lines similarly treated. The corners of the mouth can be improved by using filler to support the outer part of the lips.

The two areas that we commonly present to the world around us are our faces and our hands. Like the face the hands also age with loss of volume and thinning on the back of the hands so that veins and tendons become visible. The skin also thins and develops a degree of translucency. This can give the hands an aged look and patients sometimes seek treatment for this area. Fillers can be used to increase the volume in these areas and also thinner fillers such as Juvederm Hydrate can be used to thicken the skin and give it a firmer feel and appearance. As an alternative your own fat can also be used.

Treatment with fillers is carried out usually as part of a general treatment plan but in some patients it is their only treatment. I carry filler treatment out in my Outpatient Clinic and the procedure typically takes around 30 minutes. The first time I see you at your initial consultation I will take your full medical history and assess the areas that you would like treated. After this we will make a treatment plan for you and arrange your first treatment.

Local anaesthetic spray is applied to the areas that are to be treated. This is particularly effective for the lips and has made the procedure much more comfortable and more accurate because there is no swelling from local anaesthetic injections. As a result any volume increase is due to the filler and this allows me to accurately assess how much to put into a given area. I typically use Juvederm which has local anaesthetic mixed in with it.

When I treat the lips I use a very fine needle and you will be given a mirror to follow your treatment. Most patients have an asymmetry to their lips and I start with the side that requires the most treatment and introduce small amounts of filler to that area first. I then ask you to sit up and look at the result and carry on in this manner until we have achieved a good correction for you. Once one side is completed I move to the other side of the lip and repeat the process. We then carry out any balancing of this filler to the lower lip if needed and any treatment to the areas surrounding the lips for support. A small amount of Vitamin K lotion is applied afterwards which is soothing.

Treatment to other areas of the face and hands is carried out in the same way. At all times you are involved in the process and can see the results at each stage. Over the years I have found this is the best way for my patients to achieve their aims with minimal risk of overfilling or an unnatural look. When you want to use your fat own transfer as a filler the process takes longer and details of this can be seen on my fat transfer page.

With all my patients I start off with a full medical history and assessment. It is important that you let me know of any medical conditions that affect you. It is very useful to have information about previous filler that you have had. I carry out a full assessment of your face looking at all aspects of facial aging and will advise you of any adjunctive treatments that may be beneficial in addition. It is very useful if you bring photographs of yourself from your late teens through late 20s and 30s so that I can see how your face has changed. These do not have to be professional quality as long as they give a clear shot of the face.

After your treatment I recommend that you take things gently for three to five days and should avoid any contact sports. You should expect swelling to reach a peak at 24 to 48 hours and then to subside. You can speed this process up to a degree by applying cold packs wrapped in some cloth to prevent ice burns. Artificial fillers often give a sensation of lumpiness inside the tissues although this is not generally visible. This tends to subside to a degree as time goes on but you can sometimes feel some persistent fullness in an area that has been treated. Bruising can occur and although I make every effort to avoid this, if it does occur you can again apply cool packs. You can apply makeup a few hours after having fillers. If you are having extensive filler work done however I recommend that you wait for 12 to 24 hours.

Showering and Bathing

There is no problem in showering and bathing your face after treatment with fillers. When you are washing your face you should be gentle for the first few days to avoid moving filler around.

If you have filler to your hands I would advise you to elevate your hands for the first night on pillows by your side to prevent excessive swelling. If swelling does occur and persists you can use a sling intermittently for each hand.

Following your filler treatment I recommend that you come to see me for a follow-up appointment at two to three weeks so that I can assess your results and ensure that we have a plan tailored to you for future treatments.