However, now the State of Virginia is apparently banning physicians from being able to provide these important medical skin care options to their patients.  There have been rumors of the DEA or officials from the State Board of Pharmacy, raiding doctors’ offices in Virginia, prohibiting and fining them for selling these skincare products in their offices!  There have been additional rumors as to how this all got started since Dermatologists and Plastic Surgeons have always been able to provide these products to their patients in Virginia and other states.  There are rumors that a jealous Dermatologist in Southern Virginia “informed” the State Board of Pharmacy that her neighboring competing Dermatologist was selling these products without a Pharmacy License.  The other rumors are that local Virginia pharmacists complained to the Virginia Board of Pharmacy about physicians taking business and profits away from them by selling these products in their offices rather than prescribing them to their patients.  These are all rumors that have been floating around over the last few weeks but the fact is that the practice of dispensing facial cosmeceuticals like Obagi, SkinMedica, NeoCutis and Image containing Retin-A and Hydroquinone, have changed in Virginia and may do so elsewhere as well. 

What the Virginia Pharmacy Board is now apparently saying and demanding is that physicians selling these products should have a “pharmacy license.”  While the actual license and its cost are not the major debating factor, the procedures that are required for a physician to take prior to being given a Pharmacy License are complex, tedious and unwarranted and not needed in the vast majority of states other than Virginia.   The other disturbing part of this news is that the various vendors selling and supplying these products to Dermatologists and Plastic Surgeons have apparently known about such suffocating laws but not informed their physician clients, thereby placing the physicians at risk with the Virginia Board of Pharmacy and DEA.  These are all very concerning new developments and while the entire story is not clear yet, the fact is patients will not be able to get the care and treatment they have been used to getting for many years and might elect to get their products from unknown and unsafe online sources rather than their trusted local Dermatologist or Plastic Surgeon.  The vast majority of physicians will elect not to jump through the complex and silly hoops set forth by the Virginia Board of Pharmacy and will elect not to provide these important products to their patients.  This is troubling indeed!

I appreciate your tough position and concern.  Hydrelle and its complications have been a huge problem.  I continue to get emails, phone calls and messages on my website blog from excellent experienced doctors like yourself as well as patients.  The company has been in denial for the most part although their CEO did admit some issue to me during a phone call.  What I hear from other doctors is that the company representatives continue to sound surprised when an experienced doctor calls them with concerns. 

My own patients are mostly fine and have moved past this as I stopped injecting Hydrelle many months ago and went back to Juvederm and Restylane, especially now that they come with added lidocaine. 

I am treating a patient who had Hydrelle injected in another state and then moved to DC and now is under my care. 

I will post this message and the main empirical protocol I came up with for treating Hydrelle complications on my website for others to see as well since I get these emails very often and it may be helpful for others in similar situations to see what seems to work.

• Hydrelle complications follow in the acute and delayed category
• The acute Hydrelle complication is usually swelling and redness.
  • Oral antibiotics  help reduce the inflammation
  • Oral steroids may be useful but have risks
  • Hyaluronidase injections to dissolve the Hydrelle are useful
  • The delayed reactions seem to occur at 4-6 weeks after injections
    • The presentation may be lumps or initial swelling
    • As some point lumps seem to appear.  These may appear little by little and not all at once.
    • Oral antibiotics are useful
    • Oral steroids may be useful but also have risks
    • Hyaluronidase injections are important to dissolve the Hydrelle molecules
    • Kenalog injections may be useful, especially at the beginning.  These may leave divots or depressions and should be used conservatively. 
    • Aspiration of sterile abscesses may be needed at some point as the lumps are often granulomas or sterile abscesses. 
    • The Hyaluronidase injections can also cause a sensitivity reaction that is does dependent.  Take that into account
    • The Hyaluronidase injections may be needed once a week or even more for several weeks
    • Steroid injections may be needed as well but I don’t do them more than once every 2-3 weeks usually.  Be careful with this.

I typically mix 1cc of Hyaluronidase (150u-200u/cc) with 1cc of 2% Lidocaine with epinephrine with 0.5cc of K40 steroid to make a 2.5cc mixture.  I use a 27g needle with a 3cc syringe.

• I inject deep to avoid damage to skin
• I often leave the kenalog out for subsequent injections

Frequent follow up is necessary

It’s a tough problem but it is fixable completely or near completely with lots of time and attention.  The Hyaluronidase is not cheap.  Your patients need to know this was not due to your error but rather as a result of the product. 

*** These are treatments that have worked for me.  They have not been scientifically studied.  You should do what you feel is right and feel comfortable doing and not take these suggestions as “advice.”

You should also report adverse reactions to the FDA by filling out the online form:

https://www.accessdata.fda.gov/scripts/medwatch/medwatch-online.htm

Good luck.

______________________________________________________________________

Dear Dr. Naderi,

I wish I had known about the Hydrelle problems earlier.  I amd now seeing a patient whom I injected in

January and she just came in the day I was leaving for a conference. I just got back to the office so it was a total of 12 days since I first saw her. I have been injecting fat and fillers for many years and this is the

first time I have had any problems. The hard masses reminded me of a patient seen during training that

had silicon injections to the face in another country and eventually needed expanders and excision for

reconstruction. Needless to say this patient has been daily in my mind and made my time away not so enjoyable as I wondered how she would be when I returned. Since I would be away I did not want to inject with anything as I could not see her if any further problems developed. I treated her with the Dermsound that has

an untrasonic feature and did some massage of the areas with this and gave her one of the new Opal clarisonic home devices that have ultrasound for her home use.

I called your office today to try to get some idea of how to treat this patient as the Coapt company could

offer no specific treatment, could not direct me to where to get any hyaluronic acid or how to use it and told

me they had rare complaints such as mine.  I have always been so careful with patients and ” to do no harm” .

I thank your office for letting me know where I could get hyaluronic acid but would like to know how I should

go about injecting it and how much and how often. Some of the areas are 2 cm by 3cm and others 0.5to 0.7 cm.

Do I combine with Kenalog and if so what type of combination and how often to inject?

I did some added ultrasound today and she will continue with the home Opal device. The areas remain hard

but a bit less noticable until touched.

I would appreciate any help with this case and thank you for your efforts with Coapt. I have 12 boxes of the

stuff and I am not using it on anyone else.

Dr.  M.

Allergan has introduced the long awaited formulation of Juvederm with lidocaine for added patient comfort. Juvederm is now available in Ultra, Ultra Plus and XC variations.

Medicis also released Restylane with Lidocaine as well as a 2.2cc syringe of Restylane.

These safer HA fillers, now with lidocaine allow for more patient comfort during injections.

For lip injections, patients can now try without dental block numbing. However, patients who still choose to undergo dental blocks for total lip numbness should probably stick with the older, less expensive Juvederm or Restylane formulation without added lidocaine as there is no point spending extra money on the cost of the new formulation if a dental block is to be done prior to the injections anyway.

The larger syringe of Restylane allows for a more cost effective volume restoration of the laugh lines or facial wrinkles and sagging cheeks. While some doctors may simply charge twice the amount of a 1cc syringe, we have chosen to offer the 2.2cc syringe at asignificant discount to help patients achieve their desired and needed volume restoration without worrying about cost.

These added versions of Restylane and Juvederm have been long awaited. While no medical substance or drug is 100% safe, Restylane and Juvederm have had very good track records in the US over the last few years.

The only thing that doctors can do right now is report the issues to Coapt and Anika.  Unfortunately the doctors all tell me that the Coapt representatives act as if their case is the first case.

Any complaints with a medical device such as a filler should be reported to the FDA by filling out the online 3500 form:

https://www.accessdata.fda.gov/scripts/medwatch/medwatch-online.htm

I will keep you posted after my conversation with the Coapt CEO today.  I appreciate all the phone calls and emails and online posts from doctors and patients throughout the U.S., sharing their frustrations and problems with Hydrelle.

Coapt has been a major company and a good company in the cosmetic surgery industry with some fantastic products on the market.  Also, there are plenty of patients who have been injected with Hydrelle with no complications or problems.  But the ratio and incidence of complications is very alarming and disturbing compared to other FDA approved fillers in the U.S.

As of this morning, we have had 2 doctors from Florida, 1 doctor from Ohio, and one Nurse Practitioner from San Diego as well as 1 doctor from Baltimore tell me about their Hydrelle complications.

They have all had patients with unexpected to severe complications from Hydrelle.  I have even had a patient from Los Angeles tell me that Hydrelle injection resulted in a week long admission to a hospital to deal with the Hydrelle complications.

Apparently Hydrelle complications are affecting patients and doctors all over the United States and Hydrelle has been out on the market for only a few short months.  Doctors and patients alike are suffering as result of this filler.  One doctor injected herself and developed large lumps (granulomas).

Coapt and Anika continue to ignore the Hydrelle problems and refuse to “do the right thing.”  Phone calls and emails from many doctors have been ignored by the makers of Hydrelle.  The FDA is now aware of the growing problem.

Please feel free to share your stories of Hydrelle allergies so that other doctors and patients, who may think their issues are isolated and may be afraid to come forth, can do so and ask for help and guidance in resolving the issues.

Ever since Hydrelle was introduced to the U.S. by Coapt (made by Anika and distributed by Coapt), there have been a significant series of complications that have resulted from the use of Hydrelle:

1) Allergic Reaction
2) Infections
3) Abscess formation
4) Necrotizing Granulomas
5) Scar tissue
6) Delayed onset problems

Most of these problems have been a delayed onset reaction with Hydrelle patients.  Patients who had injections return about 4 weeks later presenting with infections from Hydrelle, Allergy to Hydrelle, Large scar tissue Granulomas from Hydrelle to name a few.

These issues were nearly non existent with other US FDA approved fillers until Hydrelle came along.  Although the complications listed above can occur with any filler the reported numbers in literature are 1 in 3000 to 1 in 10000.

Personally, I have injected thousands of fillers from Restylane to Juvederm to Captique, to Hylaform, to Radiesse to Artefill, to Perlane, to Evolence, to Prevelle and never had even one single complication.  With Hydrelle, I have only injected 5 patients and 3 developed some of the Hydrelle complications listed above!

More significantly, two doctors from Florida and one from Ohio have emailed me, called me, and written feedback on my website about their own identical problems with Hydrelle.  These highly experienced doctors also have never had complications with any of the other fillers.

To make matters worse, Coapt and Anika have refused to remove Hydrelle from the market until further studies are done on Hydrelle.  They have also recently refused to reply to our emails and phone calls. As such, these complications have been reported to the FDA for review.  The online form that must be filled out by doctors can be found here:

https://www.accessdata.fda.gov/scripts/medwatch/medwatch-online.htm

The treatment of Hydrelle complications may include:

1) Oral abtibiotics for Hydrelle complication
2) Oral steroids for Hydrelle complication
3) Hyaluronidase (wydase or Hydase) injections to melt the Hydrelle molecules
4) steroid injections to dissolve the hydrelle granulomas
5) drainage of pus and abscess from Hydrelle complication
6) re injection with Restylane or Juvederm to re inflate the deflated areas after the Hydrelle complication is resolved.

This problem with Hydrelle complications is not over yet.

The introduction of an FDA approved, safe, Hyaluronic Acid filler, with premixed Lidocaine, for patient comfort, was long awaited and exciting news.  Up to that point the Hyaluronic Acid fillers had proved to be the most versatile and safest of all the available fillers.  But unlike Cosmoderm Collagen or Artefill which both had premixed Lidocaine, or Radiesse which could be readily mixed with Lidocaine, the Hyaluronic Acid fillers (Juvederm, Restylane, Perlane) were not mixed with any numbing fluid for increased patient comfort.

Over the last 10 years, after thousands of injections with all sorts of FDA approved fillers, prior to Hydrelle, and having not ran into a single problem whatsoever, I have unfortunately noticed 2 recent issues with Hydrelle.  One patient developed a diffuse allergic reaction to Hydrelle about 35 days after the injection with diffuse symmetric facial swelling.  The allergic reaction was treated with medication and the swelling resolved, but then a granulomatous reaction followed just a few days later.  This is being treated with Hyaluronidase and steroid injections to dissolve the Hydrelle particles and the scar tissue.  She has improved significantly and she should have no long term effects from this.  The second patient had Hydrelle to her lips and she developed a localized infection on one side.  This was treated with antibiotics and drained and she is back to normal again.

My recommendation to other Plastic Surgeons and Dermatologists is that just because something is FDA approved, it does not guarantee its safety.  I have prided myself in always waiting for more data before offering a product or service to my patients.  In the case with Hydrelle, my patients were so excited about a Hyaluronic Acid filler with Lidocaine that I started offering this product when it entered the U.S. market as an FDA approved filler.

I would say, for now, Juvederm and Restylane remain the two most versatile fillers with the highest relative safety index.  Could the two incidences with Hydrelle have been pure coincidence?  Perhaps.  But I find it odd that after 10 years and thousands of injections, these two incidences occurred back to back in the same week with Hydrelle.

Although Collagen based fillers such as Zyplast and Cosmoderm had initially dominated the market, they fell out of favor due to their short lasting results and the potential for allergic reactions.

Over the last five to ten years, we have seen the Hyaluronic Acid dermal fillers become the predominant work horse for most Plastic Surgeons and Dermatologists.  These are used for reduction of nasolabial folds (smile lines), Marionette lines as well as other wrinkles on the face.  They are used for cheek enhancement as well as lip plumbing.  Tear troughs under the eyes can often be reduced using these fillers.  As with any filler, a properly trained and licensed injector with good judgment and technique is the key in success and avoiding complications.

Restylane gained FDA approval first in the United States followed by Juvederm. These two Hyaluronic Acid (HA) fillers have been the most versatile synthetic dermal fillers in the United States.  Other HA fillers such as Hylaform, Captique and Prevelle never became as popular.  Allergan plans on introducing a Juvederm with Lidocaine (numbing medicine) pre-mixed, in the near future.

However Hydrelle by Coapt is already here!  This is an FDA approved HA filler with a higher concentration of HA molecule and Lidocaine added.  The higher concentration of HA molecules mean that 1cc of Hydrelle will give you more HA and volume and wrinkle correction than 1cc of Restylane or Juvederm.  The added numbing medicine means that patients who require several shots in the same area for fine contouring will have less pain and more comfort during the procedure.

There is no one great filler.  Each patient needs a unique assessment and approach.  For those who are happy with Restylane or Juvederm then I would recommend sticking to what you like and what works best for you.  But for those who want to try something new, then Hydrelle may be worth a shot!

You can find out more here:

http://www.hydrelle.us/patients/patients_landing.html

We will be one of the very first practices in the country to offer this new safe “Botox” alternative.

Take a look at the press release below for further details.

FDA Approves DYSPORT for Therapeutic and Aesthetic Uses

Here are the facts:

1) The larger overall governing body in the United States is the American Board of Medical Specialties (ABMS).

2) There are 24 medical specialty boards under the ABMS.

3) The ABPS (American Board of Plastic Surgery) is one of the main boards overseeing the training and qualifications of Plastic Surgeons

4) The ASPS (American Society of Plastic Surgery) and the ASEPS (American Society of Aesthetic Plastic Surgery) are the two main societies of Plastic Surgeons.

5) Boards are not the same as Societies or Academies. Boards are the governing bodies responsible for examination and training qualifications. Academies and Societies are merely membership groups or clubs concentrating more on educational meetings as well as Marketing and media.

6) The members of ABPS, ASPS, ASEPS are Plastic Surgeons also known as general plastic surgeons. These are usually made up of surgeons who have finished 5 years of general surgery training concentrating on abdominal surgery followed by 2 years of plastic surgery covering the entire body. It is not rare to spend only 4-6 months out of the 7 years on the face. They can then become certified by the ABPS and can then join the ASPS &/or the ASEPS.

7) ONLY THE ABPS, ASPS, ASEPS which are closely related groups and made up of general plastic surgeons insist on making sure that your plastic surgeon is certified by the ABPS or a member of the ASPS.

8.) The fact is that the field of Plastic Surgery dates back to head and neck surgeons (Otolaryngologists) who created and coined the field.

9) The fact is that the prestigious American Board of Otolaryngology (ABO) and all of its members are certified by the American Board of Medical Specialties (ABMS) in the EXACT same manner as the American Board of Plastic Surgery. The difference is that ABO does not advertise or market itself due to its bylaws.

10) The fact is that the only two ABMS boards (out of 24 member boards) certifying its members to perform “Plastic Surgery” are the American Board of Plastic Surgery and the American Board of Otolaryngology.

11) The American Board of Plastic Surgery certifies its members to perform plastic surgery on the entire body under the authority of the ABMS.

12) The American Board of Otolaryngology certifies its members to perform plastic surgery on the head and neck only (Facial plastic surgery) under the authority of the ABMS.

13) Some head and neck surgeons train beyond after their initial residency and board certification and complete an accredited fellowship under the governance of the American Academy of Facial Plastic & Reconstructive Surgery (AAFPRS) and then can try to obtain their second board certification under the American Board of Facial Plastic & Reconstructive Surgery (ABFPRS).

14) The AAFPRS is the Facial Plastic Surgeon’s society similar to the ASPS for Plastic Surgeons.

15) The ABFPRS is a sub-specialty Board under the governance of the ABO.

16) Members of the ABFPRS have to have completed certification by the ABO or the ABPS before being able to sit for the 2-day ABFPRS examination or submit their case logs for certification.

17) Facial Plastic Surgeons have completed a 5 year head and neck surgery residency followed by a one year fellowship exclusively in Facial Plastic Surgery.

18.) Here is the difference:
http://www.aafprs.org/patient/about_us/fps_vs_gs.html

19) There are other boards as well such as the American Board of Cosmetic Surgery (ABCS) and American Academy of Cosmetic Surgery (AACS), American Board of Laser Surgery, etc but these are not under the ABMS and are not validated by a single state in the U.S.

20) Only the ABPS and ABO (and its sub-specialty board ABFPRS) are responsible for maintaining high standards and safety criteria for their members performing plastic surgery on the entire body and face respectively.

21) Only the ABPS and ASPS recommend that your surgeon be certified only by them. The fact is that if you are seeking body plastic surgery then they are correct and your surgeon should be certified by them. However, if you are seeking Facial Plastic Surgery then your surgeon can be certified by the ABPS/ASPS or the ABO/ABFPRS.

Here is the training difference again:
http://www.aafprs.org/patient/about_us/fps_vs_gs.html

22) There are amazing surgeons certified by both societies and boards. Unfortunately, there are also some lousy surgeons certified by these governing bodies. Just because your surgeon is “board certified” it does not guarantee a safe and successful outcome. But it is the most basic and minimal criteria to start with. The rest depends on training, skill, experience, judgement, talent, ethics, etc…

The filler was a fantastic filler but the company’s business plan was unable to sustain the downturn in the current economic situation.

I have used Artefill extensively in the proper patient population and in the proper facial zones such as the nasolabial folds.  My patients have all been extremely happy with the filler.  The procedure is done over 2 to 3 sessions in order to get the proper amount of filling and to not risk over-filling.

Most of my patiets are done with their series but some have only had one syringe and are due to come back in a few months for the subsequent treatments.  I still have a few syringes of Artefill left.  Not many.  Just a few for my current patients.

Patients have been asking me for an alternative in cases where Artefill may not be available.  I want to loudly warn patients from falling prey to doctors advertising illegal and unsafe fillers.  The safe alternatives are Radiesse, Perlane and Juvederm Ultra Plus.  None of these are permanent but they do last a long time and should be a good safe option until another company is able to purchase Artefill or another safe substance and re-introduce it to the U.S. market.

I will wait to see how the company chooses to handle its current clients.  For now they are even refusing to honor their $300 American Express Gift card promotion.  I have made sure our office takes care of our patients even if Artes wont so that promises are not broken and that all our patients are happy and satisfied.

We will keep you updated in the coming months…

Artefill is essentially a mixture of purified Bovine collagen as well as Polymethylmethacrylate (PMMA) microspheres in an 80:20 ratio.  There is also 0.3% Lidocaine (anesthetic solution) mixed with the collagen for added patient comfort.  The collagen portion resorbs over several weeks but the PMMA micro-spheres remain and become encapsulated by the body as a permanent “filler.”  Most patients will require two or three treatment sessions spread about four to eight weeks apart in order to achieve the final desired result without “over-filling.”

The treatment initially involves a simple skin test to ensure that the patient is not allergic to the Bovine collagen component of Artefill.  If after a month, no signs of allergic reaction are seen then the treatment can be performed safely.  The skin test involves placement of 0.1cc of Artefill test mixture under the skin of the forearm in the same manner as a PPD (T.B. test).

The FDA has approved Artefill for wrinkle reduction of the Nasolabial folds (deep lines extending from the sides of the nostrils to the corners of the mouth).  Although the FDA approval is for correction of the nasolabial folds, Artefill can also be used for the correction of other deep facial lines.  Artefill should not be used around the eyes, in the lips, or in superficial lines.  However, it can be used for permanent tissue augmentation such as for malar (cheek) augmentation in place of a malar or submalar implant or in place of fat injection or even a mid-face lift.  It can also be used to augment the chin or the pre-jowl area in place of implants.

The cost is higher than traditional fillers such as Restylane or Collagen but given its permanent nature, Artefill is cost effective overall with a cost per syringe that is only slightly higher than that of Radiesse (another filler that lasts about 12-18 months).

This is a very exciting product and hopefully over the coming months to years, it will prove to be a powerful tool in the armamentarium of the Facial Plastic Surgeon allowing us to help our patients avoid the cost and discomfort of routine and frequent injections two or three times per year.  It should also replace or augment fat injection in many locations on the face except around the eyes for now.

Now the other issue is “jowling” or “jowls.” This refers to fullness or sagging in the area of the jowls. The gold-standard treatment is a “traditional” lower facelift and the reason I place the word “traditional” in quotes is that if you have done your homework you will appreciate and possibly be overwhelmed by the fact that there are numerous approaches, incisions, dissection techniques and extents and methods for carrying out a “traditional” facelift.   No two surgeons do a facelift the same way – almost.

Some patients, especially younger patients with very minimal jowls and good skin tone, can benefit from a “mini” type lift and delay undergoing a more extensive facelift for many years. Again, there are many variations of “mini lifts” as well.

Liposuction of the jowls can be carried out very conservatively and it is somewhat effective. However, there are risks associated with it and, given the very slight benefits, it may not be the best option by itself.

As the appearance of the “aging face” is a result of tissue and volume loss, replenishment of this “volume” using fat grafting or fat transfer is a valid option. The same can be achieved with fillers or implants. As the area under the skin is “filled”, it “pulls” on the more dependent lower areas and in effect “lifts” the skin and jowls.

If you decide to go with a min-lift, you can expect a 5 to 7 day recovery for the edema, bruising and “rippling” to substantially subside despite what the advertisers of “weekend facelifts” and other marketing hype today would make you believe. Unfortunately, men cannot use makeup for cover-up and camouflage but they generally heal faster due to the nature of male skin with an abundant presence of hair follicles and sebaceous units.  Women can easily use makeup to cover the slight bruises that may persist beyond the first few days and go about their daily routines after a mini-lift. There usually is not much pain or swelling associated with mini-lifts although each patient may have a different experience. A very important consideration is incision placement, especially in men since again men cannot cover scars with makeup.   The proper placement and location of incisions are much more important than the length of the incision in assuring that the scars are hidden and camouflaged well.

As far as the neck, a neck lift with or without a cheek lift (which would make it essentially a facelift) is the gold standard for the treatment of a heavy neck with loose skin and extra fat tissue commonly known as the “turkey gobbler neck”.

However, neck liposuction in younger patients or combined with submentoplasty (where the platysma muscle is imbricated or sutured in the mid-line, creating a nice, tight “corset” with removal of a little bit of skin medially under the chin as opposed to laterally with a neck/facelift) is a valid alternative in someone with a moderate size neck. (In very large, heavy necks, a neck lift is still the preferred choice.)

Unfortunately, the highly-marketed modalities, such as Thermage and Contour lifts / thread lifts to name a few, do not properly or permanently address the aging neck and are often a disappointment.

The ideal candidate for submentoplasty is a patient who is relatively within their ideal weight to height ratio with moderate loose skin and fat who wants a nicer neckline.  This 45-minute “mini neck lift” provides exactly the proper amount of “surgery” for such patients.  The results are significant yet natural.  There is almost no pain and the only downtime is associated with the post-op bruising which can readily be covered with make-up.  The results are real and long lasting and do not rely on sutures or wires and the procedure is relatively quick and safe.   What allows this procedure to stand apart from almost anything else out there today is the use of a very small hidden “T” incision under the chin which allows removal of excess skin and fat as well as muscle tightening through this one-inch incision that is well hidden and inconspicuous.   Patients often return to work within 5 days and the cost is about half of what a neck lift would be.  However, proper patient selection is key to achieving the best results.  This procedure is amazing but it is not for everyone.

If there is decent of tissue with loss of volume then “filling” the areas will lift things and harmonize the face and replenish fullness.  Incidentally, implants or fillers will give a similar result in many instances.

Occasionally the best result is achieved with a combination of these modalities.  For example some patients look amazing and youthful a few weeks after a facelift but then notice some areas of “aging” again fairly soon after surgery as the swelling subsides. In such a patient, “filling” with a filler or fat at the time of surgery would have resulted in a better long-term aesthetic outcome. Each patient is different so each patient requires a somewhat unique approach – to some extent.

Options are numerous and depend on the patient’s age and anatomy.  Implants made in various shapes and sizes are great options.  Fat injection done in a series of 2 to 3 sessions will also result in naturally appearing fuller cheeks.  Fat can also be injected to the naso-labial folds at the same time if needed in older patients.  Filler injections although viable, were not cost effective until now.  Artefill, the first permanent “filler” approved by the FDA is a fantastic option for augmentation of the cheeks and effacement of the naso-labial folds.  Mid-face lift is also another option best used in older patients who have deep naso-labial folds and show inferiorly and medially descended cheeks.  This procedure may be combined with fat injection, filler injection or even cheek implants.

The ultimate goal is achieving a triangular face (with the base located between the cheeks and the apex at the chin).  This “inverted triangle” is associated with youth rather than the “rectangular face” associated with aging.