PEER-REVIEW | FACIAL REJUVENATION | In general, all fillers create some form of histological
reaction that generally evolves over time. This inflammatory reaction is of particular concern for the semi-permanent and permanent fillers as its persistence may lead to a more chronic inflammatory process. More severe granulomatous reactions can also occur and have even been reported with more biologic products, such as the HAs. Granulomas can often be treated with simple excision. Improper injection technique can also lead to
complications. If a filler is inappropriately injected at the incorrect skin depth, location or volume, a myriad of unwanted skin changes can occur, including palpable bumps, contour deformities, and superficial beading. These unwanted changes may resolve slowly. Serious complications are rare, but can include anaphylactic reactions, skin necrosis, blindness, and death.
Surgery The most common complications associated with surgical procedure are: ■ Alopecia ■ Haematoma ■ Hypertophic scars ■ Infections ■ Skin loss close to the incision border ■ Minimal skin loss ■ Mobility disorders caused by the marginal mandibular nerve paresis
commonly associated with patient anticoagulation
owing to concurrent and/or recent use of aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), or blood- thinning medications. In addition, the use of large-bore needles and injection into highly vascular areas, such as the lip, can also increase the risk of bleeding. Infectious complications are rare; however, patients
with susceptibility to infection or a history of herpes simplex infections may be candidates for prophylactic antiviral and/or antibacterial therapy. Acute allergic reactions are a serious concern for fillers
containing bovine and other xenogenic components. To minimise this risk, product recommendations for allergies and allergy testing should be followed. Patients who have had a prior hypersensitivity reaction to a specific filler should not be treated with that filler again. Given the availability of injectable human collagen, allergy testing prior to bovine collagen injection is now predominately only of historical interest. Post-injection pain is common and can be reduced
using the smallest needle possible for injection. For less viscous fillers, this may be a 30-gauge or 32-gauge needle; more viscous fillers may require a 27-gauge needle (e.g. calcium hydroxylapatite), or even a 25-gauge needle (poly-L-lactic acid) to avoid clumping or clogging. Topical or regional anaesthesia, including nerve blocks, can be used when required. Some injectables may contain small amounts of lidocaine as part of their injection carrier. Caution is advised when using local injectable anaesthesia as this may alter and obscure the contour defects.
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■ Seroma ■ Severe and prolonged oedema ■ Superficial cutaneous necrosis.
Key points
■ In 2011 there was a decrease in surgical procedure requests compared with 2010
■ Combination treatment with dermal fillers and neurotoxins makes it possible to achieve aesthetic results similar to more invasive procedures
■ The liquid facelift is a cost-effective treatment and can has minimum intervals of 8–12 months
Costs Aesthetic surgery, particularly the use of biodegradable dermal fillers, is a growing field. According to the American Association of Plastic Surgeons more than 244 000 surgical rhinoplasties, and 119 000 facelifts were performed in 2011, representing an increase of 1% and 9%, respectively, over those performed the previous year. The average cost of these procedures exceeds $8000 per rhinoplasty and $12 000–15 000 per facelift. During the same period, the real growth in cosmetic procedures was in dermal injections and this trend was even higher in 2012. Botulinum toxin injections increased by more than 150% and HA treatments are growing each year with a cost which is approximately $500–$1500 per treatment area.
Conclusions Injectable facial fillers offer an excellent option in the treatment of facial ageing, wrinkling, and contour defects. They are a viable alternative to surgery for patients seeking a safe, minimally-invasive, and affordable means of maintaining a youthful appearance. It is imperative for the aesthetic surgeon to have a thorough knowledge of all the available products and their properties. This knowledge will enable optimal pairing of facial filler with specific defects and consequently, maximum efficacy and patient satisfaction6
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