Episode 4: Fillers

The basics on Fillers.  When did fillers become a thing and who is the appropriate patient?  Where are fillers used and how to avoid the freaky filler face?  
Techniques, placement and the right patients are selected to give the best results.
What are my favorite filler products?  And why?  There are reasons why certain fillers excel over others for certain areas.  We hope you get something out of this episode!

Thank you for your listenership!

Transcript

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Dr. Minni Saluja 0:02

Hi everyone. Thank you so much for joining us for the next episode of "Just Laser It and All Things Cosmetic. I'm here with Kane and with Link, and we're going to talk about fillers and I will tell you something

Kane Rogers 0:14

funny. Yeah, I just want to make sure, did you

Dr. Minni Saluja 0:16

press the record button? I did. I did. This time I

Kane Rogers 0:18

did not the last time. So everybody, you just missed the best podcast. That we just did without

Dr. Minni Saluja 0:23

recording it. Oh. So now we're gonna try it again. So, okay, so Kane had a good idea because fillers are a broad topic and we're gonna kind of piecemeal this into different episodes. But Kane, what are we gonna talk about today with

Kane Rogers 0:34

fillers? Well, it's not just a broad topic, it's a topic that a lot of people are already familiar with. A lot of people have probably already had it done. And so I got to thinking, you know, it's, there's a lot of nuance to it. I'm familiar with it because you do filler injections all day long. And so I have a familiarity, but what would I want to know if somebody recommended hey, Kane, Kane, you need filler? And so the first thing I I would want to know is, you know, what, what is filler? What type of filler? I know there's a, a lot of different types of filler, so just kind of broadly talk about that. Number two is why do I need it? What's going on with the aging process that would, that filler would address. And then number three is kind of where do you place it? There is a lot that's where the skill set comes in, I think, knowing where to place it and more importantly maybe how to place it, And then the fourth thing would be just what are some possible complications that I should be aware of? So those are the four things. What Why, where, how, and what are the possible complications?

Dr. Minni Saluja 1:32

Okay, so let's start with the what, and I'm gonna actually preface this with a little bit of history on kind of soft tissue fillers and whatnot. So back in the 1970s, researchers at Stanford actually came up with bovine collagen. And so bovine is from a cow. And so this type of collagen had a. allergy rate to it. And so what they'd have to do is they'd have to test it. They'd have to do two tests to make sure it was compatible. About 3 to 5% of of people are actually allergic to the bovine component. So while this was an idea, then they start, started to come up with, and that was actually FDA cleared in 1981. But then what came about was a human form of it. and the only issue with collagen, and we knew it as cosmoplast cosmoderm was that it lasted only for three months. So you would go through these injections that were a little bit painful, there was no lidocaine in it, as we have it now, and it would only last for three months. So you couldn't really fill your, basically at that stage, chasing lines and wrinkles. Now, fast forward to about 2004 where a non-animal based hyaluronic acid came about. And Kane, do you know what hyaluronic acid. No I don't. It's, yeah, it's a sugar molecule. Okay. So sugar molecule. So and a thanks for putting me on the spot. Sorry. Sorry. Came about and that was Restylane. So Restylane was really the first HA that came to market, and shortly thereafter, Juvederm followed it. And those were the fillers that we utilized for a long time. Radiesse came to the party, et cetera, et cetera, some other things. Sculptra was there in 2004 too, which we'll talk about. But then in 2018, a big change occurred in fillers and it made me love fillers even that much more. and that is Restylane the Restylane family came out with XpresHAn technology, which means that these fillers could then integrate with the tissue better and could kind of move with the tissue better. So when you smile, the filler smiled with you, which was, lovely. It was more natural in appearance. And then finally, in 2020, RHA. resilient hyaluronic acid has their own subset of fillers, which I love a lot as well. So I've gravitated more towards these two lines of fillers.

Kane Rogers 3:46

the latest innovation that's, that's come out the past couple years.

Dr. Minni Saluja 3:49

Correct. The most natural type of results in my opinion. And that's why I've gravitated to these

Kane Rogers 3:54

two, which is what people are after. Right. Is that that subtle? That subtle

Dr. Minni Saluja 3:58

improvement. Correct. They wanna look rejuvenated. They don't wanna look like freaky filler face as you call it, And so, and there is, you know, and why does freaky filler face occur? So freaky filler face occurs because people are utilizing a, maybe the filler's being placed in the wrong area, but two, once someone. Once the volume loss has been restored, you don't want to do any more than that. You wanna be able just to put it back. And then, for example, if they're still laxity present, but they're filled, putting more filler in is not gonna lift them more or do any of those type of things, that's when other type of procedures might be done lasers, maybe PDO threads, or possibly even surgery. You know, maybe a facelift is

Kane Rogers 4:40

what's, but there is that, that there is a segment of the population that has that mindset that I just need more and more and more. And that's where you start to look distorted and it just doesn't look right.

Dr. Minni Saluja 4:50

Correct. Or if you try to chase lines and wrinkles with fillers, that's not an indication either anymore. You, if someone's already filled, but they have a line, well, that's more of a skin issue that might be addressed with with different various types of label. So,

Kane Rogers 5:03

as a practitioner and somebody comes in to talk to you about filler, what are you, what are you discussing with them to, for, for the goal that you have in mind?

Dr. Minni Saluja 5:11

You wanna be able to replace. Their lost volume and we show them, we kind of draw on them to show them the areas that are lost. And what's interesting is how we age is so different. You know, when we, in our twenties, we do begin to lose fat, facial fat, and especially around the eyes, that's where younger patients lose their fat. And then we start to lose deeper fat. And we also start to get some laxity to our ligaments, our retaining ligaments. Hold things up as well. And we lose bone, so there's multiple things that we're losing as we age, but we wanna be able to restore the volume. Sometimes when there's bone loss, especially in the jaw line, we'll replace filler there as well to give a restoration, but not. More than

Kane Rogers 5:52

that. That. So you real, so there's a number of things happening. It's not just, Hey, I'm trying to fill an area, but you have fat loss, you have ligament laxity going on, and you've got bone loss, so collagen, elastin loss too. So, so there's a number of different things going on, and there's, there's a lot more nuance than just, Hey, just inject some fillers somewhere. There's, there's actual skill to it.

Dr. Minni Saluja 6:12

Correct. And you know, the, the areas where we inject, and this has to do with the type of product. So for example we do the lateral cheek area. If someone's lost a lot of volume there, they might get descent of their tissue over the nasal labial fold area. We place it in the nasolabial fold. We put it in the marionette lines. Certainly we place it in the lips, which has become a very popular thing. And I will say that. every face is unique and beautiful and you don't want to, it's almost like sometimes patients come in with a picture of a haircut, but a picture of a lip, and they'll say, I want these lips. Okay, we understand that you want a full lip, but if you're starting off small, it might take. Several sessions to get to a larger lip size, so it might take a year or two years to get there. The one thing that is, why is that? Why would it take so long? Because you don't wanna put too much too quickly in a smaller lip, otherwise you can get filler migration around the lips. So you wanna respect the anatomy, and over time, the lips will start to build a little collagen and elastin, and they'll stretch a little bit as well, where more filler can be placed at a different time. and so, so that's kind of the

Kane Rogers 7:16

reason for that. What are some of the common areas that, that you can address with fillers quite nicely.

Dr. Minni Saluja 7:22

So again, cheek area, that lateral cheek area nasolabial fold lips marionette lines, jawline, even the ear lobes,. I placed filler in the ear lobes, and what was interesting is when I was doing my fellowship out in California back in 2007, Patients were coming in and they wanted to have the balls of their feet injected so that they would have, they would be able to wear their high heel shoes.

Kane Rogers 7:45

Oh, I thought so. They could jump higher. Have a little more spring in their jump

Dr. Minni Saluja 7:49

No. So they could wear their, you know, interesting. Their. Stilettos and there would be more comfortable. We've even injected hands. The back of the hands is very popular to inject there. There's actually two fillers that are FDA cleared for that Restylane Lyft and Radiesse but you can use fillers, off label, other fillers in in various

Kane Rogers 8:06

areas. Well, you mentioned a different. A lot of different fillers and within even these families of fillers, the Juvederm family, the Restylane family, the RHA family, there's different fillers just within those families. So how do you like just determine this is the right filler for this particular area on this particular person? So it's

Dr. Minni Saluja 8:25

the properties of the filler. So if I want to lift more, I might pick a, stiffer type of filler. One that, that rebounds back to its shape. So I might choose that so it could lift a little bit more. For the lips, I might choose a softer type of filler, for the jaw line, I might choose Radiesse, which. More resembles bone, so different areas. And I tell you, we also fill the, the buttock area. That's another area that that patients like to have fill. It does take a lot of filler for that area. But that is another zone

Kane Rogers 8:54

as well. So you mentioned a lot of filler. So typically when somebody comes in, like, is there a, is there a typical amount of filler that you would recommend somebody have? Is it just,

Dr. Minni Saluja 9:06

It is based on their volume loss. But first, to understand that a filler, Kane is one milliliter. One milliliter, just to put it in perspective, if you were to go downstairs and get a teaspoon, I would need five syringes to fill that teaspoon up. One milliliter is 20% of a teaspoon, so it's

Kane Rogers 9:28

not a lot. You wouldn't think that when you see that syringe, you wouldn't think that there's really that little. Filler

Dr. Minni Saluja 9:33

in there. There's that little, I always say that the company that's gonna really win will be the company that puts just a little bit more, so RHA actually puts 1.2 milliliters in their syringe, and Radiesse is 1.5 milliliters. But typically the, the Juvederm and the Restylanes are one milliliter. They're hyaluronic acid, that's the good thing, which means it is a humectant, which pulls in a little fluid, so you do get a little more filling effect that occurs just like a little sponge. Like a little sponge. So I always tell patients that while you see the filler, when I'm done, there's gonna be some swelling. But the, the true extent of where you're gonna see your filler is gonna be at two weeks. Just give it that time, and that's if you need more, wait two weeks to a month before adding more. But for example, if I've got a patient that has a lot of volume loss, I might say. Okay, you need three to four syringes, which sounds like a lot, but it's really not. Remember, it's less than a teaspoon.

Kane Rogers 10:27

So why would you separate it? Why would you, why would you have them come back for

Dr. Minni Saluja 10:31

more? Sure. Because as we begin to inject, what happens is we then, can cause a little swelling. So when you're on your third syringe, you're gonna cause a little bit of swelling. And I also wanna see how everything settles out to see where more might be needed. So I always think it's good to kind of stop at three to four syringes and then reevaluate in about a month.

Kane Rogers 10:53

Well, you mentioned that XpresHAn technology with Restylane, would that start because it integrates a little bit better? Would that, would you start to see that integration after a couple

Dr. Minni Saluja 11:01

of weeks? Oh, yes, you will. Yeah. Okay. In about two weeks you'll start to see that. And so, and then also the RHA has that resilient hyaluronic acid as well. But yes, filler is wonderful, wonderful to restore and no more. I was trying to find that. So that is the phrase that saves, restore and no more. And what we're gonna do is I. Now this is our Thanksgiving break. So when we return on Monday, the first three patients, which will probably last all of five minutes now,

Kane Rogers 11:32

they'll probably be on the voicemail by the time

Dr. Minni Saluja 11:34

we get back. Okay? But the first three patients that call in will get a Restylane syringe. We have three coupons, which will take $75 off. So the phrase again is Restore and no more because and no. That's what we wanna do with faces. We wanna be able to restore the volume, but we do not wanna add more to the

Kane Rogers 11:51

face. Very subtle enhancement, but not to where it's distorted. Correct.

Dr. Minni Saluja 11:56

And how do we do filler? You had asked that question. So when I do the face I like to use a micro cannula. A micro cannula has got a blunt tip to it. I use a 22 gauge micro cannula, which allows us to push little vessels away. It's safer for the face, so you don't cannulate an artery with it. And

Kane Rogers 12:16

cannulate means

Dr. Minni Saluja 12:16

stick it. Stick it. And if you put, if you stick your artery, Put filler in. That's the dreaded complication of arterial occlusion, which can lead to skin death. It can also lead to blindness depending on where you are. doing that. So definitely, definitely I'm a big cannula fan. I do use the needle for the lips. I do not do filler to the area between the brows. That is a supratrochlear artery lives right there. And that's where you can really increase your chance of blindness. So I do not do that. I put pdo, smooth PDO threads there much, much safer and can also give a nice result in that location. So use

Kane Rogers 12:57

microcannula primarily because it's safer,

Dr. Minni Saluja 13:00

it's safer, it bruises less. I don't want to say you will not bruise at all because clearly you can. Certain areas that I have to go into might knick a little vessel as I'm going in with my, you have to use a needle to get the cannula in. So certainly you can bruise and always kind of, kind of prepare for that. And then if you don't bruise, great. If you do bruise, then you have. Preparation for, why wouldn't you use it for the lip? The lips are, I have used canulas and lips, but lips you can get crisper with a little tiny needle

Kane Rogers 13:28

there. So is that, is that fairly standard in the industry? Is using micro canula pretty much anywhere than other than the lip?

Dr. Minni Saluja 13:34

Or is that just, it's becoming the standard and I think it should be the standard of care, but it's becoming that there's a little more technique that has to be learned with the cannula, but once you pick up the cannula, it's, it's really quite easy.

Kane Rogers 13:47

So when we, so we've talked about the different types of fillers. We talked about why we need fillers. We've talked about where you place it and how you place it, which is very important. And then you talked a little bit about the big complication. Are there anything, is there anything else that, as a patient I should be aware of that. Could occur.

Dr. Minni Saluja 14:04

Sure. So can an infection occur? Sure an infection can occur. We always wanna keep the area clean as we're doing this. We use hibiclense and we use hypochloric acid when we cleanse over the skin. So that's probably a very small, as long as good technique is, is done there as well. Granulomas could occur. In fact there were. What is a granuloma? Granuloma is almost like a little nodule that can occur, and we were seeing that with some of the Vycross technology products where there was a 1.6% granuloma risk. I don't use the Vycross technology products anymore. I primarily use the the Restylane. They're good products, but there is a slightly higher granuloma risk. And one more thing to talk about too is. From a, you know, we talk, we're talking about fillers itself, but there's also a category of biostimulators, and so in that category falls two products. One is Radiesse which does fill, well, let's

Kane Rogers 14:59

back up. When you say bio stimulator, what

Dr. Minni Saluja 15:01

does that mean? It means you're stimulating your own collagen and elastin. Fill those zones in. So while Radiesse is in a carrier gel, there is a filler component to it. It also has this Biostimulatory property. So I like Radiesse for multiple reasons as well. I don't like it for areas around again, where I want a lot of movement that I just use my ha's because those integrate the best Radiesse I do it more for, again, over bone, so lateral cheek or the jawline. But Sculptra is another one. Only a biostimulatory. It doesn't have filler property to it. It just stimulates your own natural collagen and elastin. The only thing about Sculptra and I do love it, is you have to be patient. So if you think about filler filler, Is almost like your sod or your grass that you lay down instant lawn, instant lawn is filler. Okay? Whereas sculpture is your seed, so you're laying down this, these little PLLA granules that, that basically has to create. You're elastin in collagen. Now, I don't like Sculptra again around the circular muscles, around the mouth or around the eyes because again, the risk of granuloma formation if you're, which means that it's a basically a contained area of collagen essentially. So I don't use it for those areas, but I love it for the deep injections of the lateral face.

Kane Rogers 16:26

So you have Sculptra which is stimulating your own elastin and collagen. You have Radiesse which is stimulating your own elastin and collagen, but also has some filler properties. So you kinda get a little bit of both. And then you have your

Dr. Minni Saluja 16:37

fillers and then you have your HA fillers correct.

Kane Rogers 16:40

And, and you're trying to accomplish this nice, subtle kind of refreshed look. How long would I expect that look to last?

Dr. Minni Saluja 16:49

So with fillers, they can last anywhere between nine months to 15 months, depending on the filler that you select with Sculptra it can last once you get to goal up to 25 months. So it's a little bit longer lasting, but it takes multiple sessions to get there, depending on your degree of volume loss. Okay. But what's important to kind of recognize and is, and Dr. Laura Devgan had a good analogy with this and what she said was, if you think about an ice cube that melts at about 10 minutes, right? At five minutes, a portion of that ice cube is already melted. There's a little bit of a puddle that's still there, and at 10 minutes all of the ice cube has melted. Same thing with filler. When we say 15 months, it's not that you'll look good, good, good, good, good for 15 months and boom. Off a cliff. Off a cliff. It's not like that. It means that there's subtle degradation that occurs along the way. And certainly if we're starting out a little bit more subtle or a little bit more conservative with our filler, we might start to see that loss at six to nine months where we might say, Hmm, I had three syringes. I might need a touch up with one syringe to, to sustain me for a little bit longer. So is that what

Kane Rogers 17:53

you see about six to nine months? You may want to come in for just a little touch up. You may.

Dr. Minni Saluja 17:57

Potentially, you may, but a lot of times, once you've really filled a person in for, for some time, they really are about a year or so before they feel like they need more.

Kane Rogers 18:05

Okay. So once. Phrase that saves

Dr. Minni Saluja 18:08

is, is what is it? It is restore.

Kane Rogers 18:11

Restore and no more because we just want that nice, subtle, refreshed look. Not over filled. Correct. And I

Dr. Minni Saluja 18:18

have three. And you have three. Three, okay. That's it. So otherwise that's kind of the, the starting of fillers. And again, we'll delve more and more into fillers in later episodes. And I think the next one though, we're gonna deviate away from fillers. I think the next top topic is gonna be toxins. So the toxins that exist, that's

Kane Rogers 18:37

probably the most well recognized topic to cover. But again, there's a lot of nuance to it. There

Dr. Minni Saluja 18:42

is, and there's some exciting news coming out in 2023 with toxin as well. So that is it. All right. Thanks for listening, everybody. Happy Thanksgiving, everyone. Bye. Bye. Bye.