There will generally be two patient cohorts requesting facial fillers: those who have lost volume with increasing age and or weight loss who require re-volumization and those who are younger and have a “normal” volume but wish to enhance areas that may be naturally deficient for them. Within these two groups, there may be patients who seek unnatural and overdone filler. When considering whether to undertake this type of treatment, the surgeon must consider whether they wish to have an association with creation of unnatural or bizarre looks, as this would not be in keeping with the principles of plastic and reconstructive surgery and will likely be a poor advertisement for the surgeon’s practice. Patients who do want excessive amounts of filler may actually be very satisfied with this, in spite of the perceived odd looks generated. The complication rate may be higher, but not drastically so by injecting higher volumes of filler. The risk of malpractice claim could be altered but usually when patients know what they want, and a reversible filler is used, then this risk remains relatively low. The product will be able to achieve the goal of creating an unnatural look, hence the need for an objective and common sense approach by the injector. In many countries, medical practitioners are not the sole people performing the injections and a range of other people including beauticians, hairdressers, etc., may be injecting. Nonmedical practitioners may have different principles upon which they operate.1–3
One of the known stigmatizing side effects of HIV antiviral medication is lipoatrophy which can be present at a number of different body sites, but is often most obvious in the malar region giving patients a gaunt, aged appearance. Options for managing this include injectable fillers as well as cheek implants. Fillers may be temporary or permanent. Poly-L-lactic acid sold as Sculptra has FDA approval specifically for this indication. It is a synthetic polymer, which is biocompatible and nonallergenic. It typically requires reinjection at 24 months. The other temporary injectable that has FDA approval for HIV-associated lipoatrophy is calcium hydroxyapatite, sold as Radiesse. This was classically the treatment of choice in this scenario. It is a calcium mineral compound made with human bone. It, too, is biocompatible and nonallergenic. It needs reinjection around 12 months. Low G (more viscous) hyaluronic acid fillers are better suited to superficial placement for treating fine lines and as lip volume fillers, rather than deep volumizers. High G hyaluronic acid fillers like Juvéderm Voluma may be suitable for this purpose, but will need more regular reinjection than Sculptra or Radiesse, typically less than 12 months. Polyether ether ketone (PEEK sold by Synthes) and polyethylene (sold as Medpor) are both materials used to manufacture solid cheek implants. These may be an alternative to the injectable solution for some patients with HIV. Autologous fat has a role in volumizing the cheeks and other areas of the face; however, the problem for many slim HIV-positive patients such as this patient is that their stores of fat elsewhere are poor for harvest. This is not consistently the case though as the antiviral medications used in HIV (nucleoside reverse transcriptase inhibitors), such as zidovudine and stavudine, can also lead to truncal lipohypertrophy.1–3
3. Homicz MR, Watson D. Review of injectable materials for soft tissue augmentation. Facial Plast Surg 2004;20(1):21–29
4. Lamb JP, Surek CC. Facial Volumization: An Anatomic Approach. Thieme; 2017 Hyaluronic acid filler is very popular for facial rejuvenation procedures. Since its FDA approval in 2003, its use has supplanted collagen as the synthetic filler of choice. There are many advantages of using hyaluronic acid as a filler, but injections can be painful, so topical and or injectable local anesthetic agents should be used. Most products also contain lidocaine within the syringe, although for more sensitive areas this alone is not enough to remove pain completely. There is no species specificity and therefore no immunological activity, meaning that skin tests are not required. However, after injection, patients can apply ice packs for the first 24 hours and take antihistamines or anti-inflammatories to settle local reactions and swelling. Hyaluronic acid is a normal component of ground substance responsible for dermal hydration, so it absorbs water following injection resulting in further expansion. Injections initially last for 6 to 9 months and subsequent injections actually last longer with lesser volumes usually required. Hyaluronic acid fillers are readily available, reliable to use, and have the added benefit of being reversible if placed incorrectly. This is achieved by injection of hyaluronidase at the previously injected site.1–3
Sculptra is a synthetic polymer that would be a good option in this case. It is biodegradable, biocompatible, immunologically inert, and does not require a skin test. It contains Poly-L-lactic acid, which initiates a foreign body reaction and is ultimately replaced with collagen. Therefore, it is not a filler per se, but rather a product that induces volumization by the formation of collagen. Sculptra requires injection with a needle of at least 26 gauge given its viscous nature, and may be combined with local anesthetic. It can provide longer-lasting rhytid correction than hyaluronic acid, although it takes more time to achieve this result. When using this type of filler, patients must be advised that the results will develop over time and this contrasts with other injectables such as hyaluronic acid which can give a rapid-onset change in appearance. This forms part of the initial consultation assessing patients’ aims and objectives and setting realistic goals. The limiting factor in this case is the lack of preparation time, as it must be reconstituted at least 2 hours before injection and preferably overnight.1,2
Bellafill is an example of a permanent filler best used in the nasolabial folds and deep marionette lines. It is also useful to reduce acne scarring. It should be used with caution in thin skin or areas liable to thin with age such as the periorbital and glabellar areas. It is composed of collagen-covered PMMA beads and may require a reinjection. The PMMA beads are permanent but rarely cause granuloma formation. The injected collagen acts as a temporary transport vehicle only and is absorbed during the first 6 weeks post injection. Long-term volume increases are achieved by secondary formation of connective tissue around the beads. First-line treatment of irregularities discovered soon after injection is steroid injection to soften the tissues. Surgical resection is required only in persistent problematic irregularities.1,2
injected? This woman is most likely to have undergone injection of hyaluronic acid (Juvéderm). Injection of this filler too superficially and with too great a volume can lead to a bluish discoloration. This is described as the Tyndall effect, also known as the Tyndall scattering, and is observed when light is reflected by small particles that are in suspension. It is named after the nineteenth century physicist John Tyndall. As this is a temporary filler, the problem will be self-limiting, but could be treated with an injection of hyaluronidase if the patient is not prepared to wait. Alternative approaches described include firm massage to spread the product more widely or a stab excision using an 18-G needle with expression of the filler to drain the excess. The Nd:YAG laser has also been described to treat this problem. As is the case in all treatments for plastic and aesthetic surgery, it is vital to discuss these risks with patients in advance to set their expectations and reduce anxiety about them posttreatment.1,2
product? Fillers are generally placed either in the dermis or just below it when used to fill shallow lines and imperfections. Where volumization is being performed, then placing the injections just above periosteum is frequently advocated. The theory behind placement of injections at this level is that small volumes in this location work like “liquid nails” to help suspend tissues and fill them out from deep within. Injections are typically placed on the zygoma and maxilla for volumization of the cheeks. This often has a positive effect on the nasolabial folds and forms part of the so-called liquid facelift. A further benefit of placing the product deep is that it is less likely to be visible or palpable and this plane is safe and avascular. Where more superficial filler is placed, this is often in the dermis or just deep to it.1–3
There are a number of different approaches to the injection of temporary fillers into the face and these techniques need to be adapted to the situation considering the anatomic area being injected, the intended aim of the injection, and the filler consistency selected. A consistent requirement is to perform plunger aspiration prior to injection to minimize the risk of inadvertent intravascular injection. Placement of filler into the arterial vasculature can create problems with skin necrosis and even blindness due to filler causing an embolic event. The needle used for injection is usually a 30 gauge, but larger needles such as 27 and 25 gauge may be used. Most products are supplied with the “correct” needle. It is also possible to use a cannula instead, and this will require a larger needle to puncture the skin and soft tissues before switching out to the cannula. The benefit of cannula use is that damage to internal structures is reduced and thus intravascular injury is minimized. Injection techniques may be linear deposition, for example, when filling a deep nasolabial fold or enhancing the white roll of the lips. Alternatively, they may involve a fanning or cross-hatching technique to blend filler over a broader area. When injecting deeply, it is sometimes useful to deposit small blobs of filler as part of the volumizing approach (Fig. 105.1).1,2 Fig. 105.1 Injection techniques. A, Linear deposition. B, Fanning. C, Cross-hatching. A
There are two areas of the face, which are associated with a higher risk of blindness where intravascular injection occurs following injectable fillers. These are the glabellar and the nose (a.k.a. liquid rhinoplasty). Liquid rhinoplasty can be helpful as a test prior to or after surgery or used as a definitive treatment instead of surgery. Fillers can be used to augment the nasal tip, adjust the dorsal hump, and address post-rhinoplasty imperfections. The glabella is often first treated with neurotoxins to reduce the dynamic rhytids. However, some patients will also benefit from filler to reduce the static rhytids where there are deep creases. Likewise, the same is true of the transverse forehead rhytids. The malar region is injected as part of a liquid facelift or in isolation to help restore midface volume and cheek projection. The nasolabial and marionette folds are commonly requested sites for treatment. Each of these may be injected directly or indirectly by adding volume more cranially or laterally in the face. The lips can be injected to enhance their appearance. This may be to counteract the appearance of aging or simply to create more lip fullness. Due to the extensive arterial network in the face, each of these areas must still be injected carefully as intravascular injection could result in significant problems.1,2
There are a number of recommendations for patients undergoing facial injectable therapy. For all patients, it is reasonable to consider whether antiviral prophylaxis is warranted. This will be down to the individual circumstances of the patient and if they have a strong history of herpetic outbreak, then 1200 mg of acyclovir should be prescribed the day before treatment and continued for up to 1 week. In patents with active herpetic outbreaks, then injections should be rescheduled. Antibiotics should not be routinely prescribed for facial injections, as there is no clinical need and overuse of antibiotics will affect resistance. Some patients and some surgeons have a preference for ice compression following treatment, but this would only be for the first 24 hours and there is no justification for doing this for a full week. In general, patients should be advised to avoid massaging the areas, which have been injected, as this risks displacement of the product from where it was intended. However, some patients may need some gentle massage if there is a particular lump or imperfection, which you and the patient wish to address. For this reason, discussion of this should be made with the patients at the time of injection with advice to make contact if there are any such concerns. Facial fillers do not necessitate a long downtime; however, avoiding strenuous activity is advisable for the first couple of days. There is no justification to undertake exercise posttreatment.1,2
There are a number of potential complications to consider when injecting facial fillers. Some of these relate to specific products, while others are more broadly applicable. The scenario described indicates that there has been an intravascular injection leading to an embolic event and consequent ischemia in the surrounding skin. This must be treated urgently with hyaluronidase to breakdown the hyaluronic acid and limit further tissue injury. Management of this problem represents an evolving area of research, but current protocols recommend high dose (450–600 units) and pulsed (hourly) injections of hyaluronidase until clinical improvement is observed. Allergic reactions are extremely rare with hyaluronic acid or other fillers and the need for epinephrine use to manage anaphylaxis is therefore also extremely unlikely. Surgical debridement is rarely required and even where necrosis of the skin has occurred, conservative measures will be preferred, as they will reduce the sacrifice of potentially viable tissues that may be debrided if surgery was performed. Cold compress and ice are reasonable for moat patients following injections, but cooling the skin would not be of any specific benefit in this scenario. Other things to consider in this setting include things to help cause vasodilatation and blood flow including nitropaste (nitroglycerin), warm compresses, sildenafil, and aspirin for its antiplatelet action.1 Steroid is indicated following injection with some fillers, such as PMMA where there is scarring and firmness. However, it is not indicated in this scenario.
The treatment goal for lips is to add volume and create shape, while respecting the aesthetic proportions. In younger patients, a volume/shape enhancement is typically desired, while in older patients a volume/shape restoration is desired. There are a number of fillers on the market, which are appropriate for use in the lips. These include Juvéderm Vobella and Restylane Silk as well as Juvéderm Ultra/XC. These all have FDA approval for this use. They are low-molecular-weight hyaluronic acids, i.e., are thinner and less viscous than the other products listed, and so work better in more superficial locations. Lip filler may be placed along the white roll in a retrograde linear deposition fashion to enhance this area. Alternatively, deeper injections in small deposits may be used to help lip eversion and overall fullness. Either way, only small volumes are required to achieve a noticeable effect, and it is advisable to under-correct, rather than overcorrect, as additional top ups may always be considered, where dissolving the product completely is less likely to achieve the desired outcome. Lip injection can be painful and infraorbital nerve blocks can therefore be helpful in addition to the lidocaine contained within these products.1 Juvéderm Volure is an intermediate filler that can be used for both deep volume augmentation in the midface and correction of moderate to severe facial wrinkles and folds. Juvéderm Voluma is a thicker filler that is also indicated for deep volumization. Restylane has a range of products including “Refyne” and “Defyne” which have similar indications to Volure, i.e., correction of moderate to severe facial wrinkles and folds. Restylane Lyft is indicated for deeper volumization and the dorsal hand.1,2 Sculptra is indicated for the correction of shallow to deep nasolabial fold contour deficiencies and other facial wrinkles, as well as correction of lipoatrophy in people with HIV (see Table 105.1).3