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

“Price can certainly play a role in the decision-making process,” said Sukhjit Johl, MD, senior physician of oculoplastic surgery at The Permanente Medical Group, Inc., in Sacramento, Calif. “But I would not agree to do something if I felt it was harmful or unlikely to accomplish what the patient expects.”

To ensure patients’ understanding of the risks and benefits, Dr. Johl has a thorough discussion with each patient prior to any procedure to make sure the patient has a realistic idea of how much filler volume will be required to achieve the desired result. He uses standardized pictures provided by the manufacturers that show the effects of different volumes of filler for a given patient. For example, manufacturers of Restylane provide pictures showing a patient before and after injection of 1 ml and 2 ml of Restylane in the nasolabial folds, he said.

When two fillers are thought to have a similar benefit, Dr. Gladstone gives the patient the choice. “Usually the filler that doesn’t last as long will cost less,” he said, adding that he encourages the shorter-acting and less expensive filler for patients trying a filler for the first time.

Long-Lasting Results vs. Permanent Problems

It is particularly important to make sure that patients who want longer-lasting fillers, such as polymethyl methacrylate and silicone (permanent fillers) and poly-L-lactic acid (Sculptra), are aware of the potential risk for complications, which include granulomas and infection.

Wendy W. Lee, MD, assistant professor of clinical ophthalmology at the University of Miami’s Miller School of Medicine, emphasized the need to let patients know that complications from these fillers may require surgical excision.

“If overinjected, permanent fillers will be more apparent and not go away completely without surgical excision,” she said. “As well, if a patient has a hypersensitivity reaction or other complication, surgical excision of the permanent filler may need to be performed.”

Dr. Lee also cautioned that one of the difficulties with long-term or permanent fillers is that as the face continues to age, previously injected permanent fillers may become apparent in unwanted ways.

Because of the risk of permanent problems, Dr. Sykes doesn’t use permanent fillers. “There are a lot of people who use them and are successful with them, but I realize that any negativity that you get by overinjecting an area or nodule with a long-term filler is a permanent result, and that is a problem,” he said.

Dr. Sykes prefers to use poly-L-lactic acid, which he calls an intermediate filler; unlike permanent fillers, it won’t introduce the potential for a permanent unwanted result. “I love it,” he said. “I think it is a safe product, and it has nice long-term results with global volumization.”