Managing Expectations: Facial plastic surgeons emphasize the limits of injectable fillers

For Dr. Gladstone, ensuring clear communication with the patient goes beyond simply describing the fillers and their use. Fundamentally, it includes an overall philosophy of facial rejuvenation. Recounting an experience with a patient who was focused only on correcting her smile lines, despite his suggestion that she could benefit from a more global volumization of her face, he said he reluctantly followed her lead and only used a filler to correct her smile lines. “She was disappointed because her overall appearance, in terms of rejuvenation, was very small, and yet she had spent several hundred dollars,” he said. “That taught me to really communicate to the patient that it is not just about filling lines, as well as the need to make sure all questions are answered.”

Personalized Fillers

Along with identifying which particular filler is appropriate for each patient’s need, Dr. Gladstone also stressed the importance of making sure that the patient is appropriate for the filler. Because these are elective procedures, he is cautious about performing them on patients with serious acute illnesses or infections but makes this decision on a case-by-case basis.

“Obviously, we use fillers for HIV associated with lipoatrophy, and the patients are fine,” he said; however, he cautioned that patients who are immunocompromised are at a higher risk of infection. In addition, Dr. Gladstone does not perform cosmetic procedures on pregnant women. “Although the risks to the fetus are probably low,” he said, “I don’t know for sure, and therefore I take a conservative approach.”

Certain patients also need to be aware of their increased risk. Lisa Danielle Grunebaum, MD, assistant professor of otolaryngology/facial plastic and reconstructive surgery and co-director of the University of Miami Miller School of Medicine’s Cosmetic Medicine Group in Miami, Fla., said these patients include those with severe or complicated medical problems, including autoimmune and rheumatologic disorders, elderly patients, those on blood thinners and possibly those who have undergone previous facial surgery.

This last group, she said, may be at increased risk of more serious complications. “I believe that patients who have undergone previous facial surgery, such as rhinoplasty, may be at greater risk for necrosis due to possible interruption of collateral blood supply,” she added.

Other serious risks, however rare, include delayed complications such as granulomas and infection. Recent reports suggest that the development of biofilms may be an underlying cause of these rare complications (Plast Reconstr Surg. 2010;125(4):1250-1256). Although associated more with long-term fillers, biofilms can be seen with almost any filler, according to Rod J. Rohrich, MD, professor and chairman of plastic surgery at the University of Texas Southwestern Medical Center in Dallas. Dr. Rohrich stressed the importance of informing patients that, if they occur, it takes anywhere from weeks to months for biofilms to resolve completely.

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Discussing Cost

Because cosmetic procedures are elective, the role of cost in a patient’s decision of which inflatable filler to use may be an important factor in discussing the overall cost-benefit ratio of each filler.