Doctors seeing more patients for cosmetic facial work

By: TAMMIE SMITH | Richmond Times-Dispatch
Published: September 30, 2012
RICHMOND, Va. –Katherine Will is a fan of Botox and dermal fillers such as Juvederm. She points to her crease-free forehead as one reason.

“I used to have huge wrinkles, and they are gone,” she said recently, two days after getting a Botox treatment. “It’s also preventative. If you get rid of the wrinkles now, they are not going to be so entrenched when you get older.

“The Juvederm, as I get older, because I’m 49, I can see that my skin is thinning, and some of it’s starting to droop,” Will said during a break in treatment at the Midlothian office of Dr. Joe Niamtu III, an oral and maxillofacial surgeon whose practice is mainly cosmetic facial procedures.

“The Juvederm or Restylane… it tends to lift it up a little bit, and I don’t have these caves right here,” Will said, pointing to areas of her face. “It kind of smoothes it so it’s more of an even flesh. Trying to keep young,” she said, laughing.

She’s hardly by herself.

Last year, cosmetic patients had more than 5.6 million Botox or Dysport (another brand of botulinum toxin type A) procedures and more than 1.8 million soft-tissue filler procedures, according to figures from the American Society of Plastic Surgeons.

Soft-tissue filler procedures — using products such as Juvederm and Radiesse, as well as using the patient’s own fat — were up 7 percent over the previous year, compared to 5 percent for Botox and Dysport procedures.

Doctors have close to a decade or more of clinical experience with some of the products, time enough to refine how they use them to get the best results.

In addition, more is known about how the face ages.

“There is no question that the most important new development over the past five years has been the recognition of the role of volume loss and facial fat atrophy” in facial aging, said Dr. Lewis T. Ladocsi of Richmond Plastic Surgeons.

“We now understand that the facial aging … is the result of three categories of problems … surface damage due to environmental exposure, sagging of facial skin and soft tissues, and facial hollowing due to volume loss from the atrophy of facial fat. As a result of this new understanding, a variety of products have been developed to provide a nonsurgical way to restore a youthful facial contour,” Ladocsi said.

Explained another way, it used to be thought that by just tightening the skin, pulling and lifting, you could make a face look younger. But you can only tighten so much before it starts to look strange.

“Fillers are for volumizing the face,” said Dr. Nadia P. Blanchet, a plastic and reconstructive surgeon whose office is in the Stony Point Professional Park.

“Most facial rejuvenation surgeries are excising skin and reshaping. It is usually some combination; I don’t ever do a facelift now without doing fat-grafting at the same time, because if you just pull the skin, the patients look tighter but not necessarily younger. But if you tighten and fill — I use fat because they are under anesthesia already — then they look more natural,” Blanchet said.

The dermal filler market is full and getting more crowded.

The U.S. Food and Drug Administration website lists more than a dozen products — from collagen products approved for the market in the 1980s to Belotero Balance, the latest hyaluronic acid gel product brought to the market. It was approved in November.

The FDA data lists Restylane, approved in 2003, as the first hyaluronic acid product approved in the U.S. Before then, fillers were made from animal-based materials and patients had to undergo allergy testing before they could get injections.

Two of the first soft-tissue cosmetic fillers to the market in the 1980s were Zyderm and Zyplast, made from purified cow collagen.

Patients had to wait about a month for allergy test results, Niamtu said.

“That was a big drawback. Now with these nonanimal fillers, allergies are pretty much unheard of,” he said.

The most popular soft-tissue ones are made with hyaluronic acid (Juvederm, Perlane, Restylane), poly-L-lactic acid (Sculptra) and hydroxylapatite (Radiesse). Hyaluronic acid can be found in the skin, umbilical cord and fluid in joints. Poly-L-lactic acid is a synthetic material used in resorbable stitches. Calcium hydroxylapatite is a mineral found in bone and teeth.

Most were used in other medical applications before companies ventured into the lucrative cosmetic products markets.

One of the latest developments, Blanchet said, is dilution of the fillers to treat some areas, such as under the eyes or in the lines in the skin of the face, instead of using laser resurfacing.

Sally Partlow, 42, is seeing Blanchet for a more serious reason — breast reconstruction after undergoing a bilateral mastectomy for breast cancer. Weeks of worry and crying left her with under-eye circles. Blanchet offered the dermal filler as a morale booster.

“Oh, wow,” said Partlow, of Goochland County, a married mother of three teen and pre-teens, as she looked into a mirror. Almost immediately, the results were apparent.

“You can go as superficial as you need to and get a more natural effect, because it doesn’t lump,” Blanchet said.

Before, “I would inject it in the hollows under the eyes, where the skin is thin, and squeeze,” Blanchet said. “Sometimes it did OK. Sometimes you would have a lump of visible filler, then you would melt the lump — because many of the fillers are dissolvable — and then there would be a dent. So then I would just go really deep, which wasn’t really the area that needed to be filled. Now that it’s diluted, I don’t have the filler visibility issues. It’s really neat to be able to put the filler where it needs to go visually, and I just don’t worry about lumping. That’s been nice,” Blanchet said.

If patients have a change of heart and don’t like the results, doctors can inject an enzyme that immediately dissolves the filler.

Most want to know, however, how long the results will last.

Blanchet said she’s had Perlane in soft under-eye areas for up to two years.

“How long the filler lasts depends on the filler, but it also depends on where you put it,” Blanchet said.

“So if you inject it around the mouth, the mouth is constantly moving, it doesn’t last very long. But in the cheeks, that’s a static area. The chin is a static area. I’ve had it last for a long, long time” in those locations.

Some people call soft-tissue fillers a “liquid face lift,” but fillers don’t compare to surgery when it comes to permanence. Cost comparisons have to factor in because repeat procedures of filler are needed.

Niamtu said patients generally need at least two syringes of filler, which average about $500 a syringe, to get the results they are after.

Will, pleased with her youthful look, put the cost, of Botox in particular, in perspective:

“The way I figure it, if you get your hair highlighted once a month and pay $100, that lasts about a month. But yet you do this every year, and it comes out about equal. It’s just an initial payment in one lump as opposed to doing it every single month.”

For all of that, she said people generally don’t notice.

“I find people really are into their own selves. I will go home and look in the mirror and I will notice. People will ask, ‘Is that a new shirt?’ They can be that far off. But I notice, and that’s what’s important.”


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