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PST 013: Injectables — Read the Transcript

May 21, 2018

Listen to the full audio here

Welcome to Plastic Surgery Talk with Doctor Stephen Mulholland, brought to you by SpaMedica in Toronto, Canada. This week’s podcast is on injectibles.

Injectables have really led the industry in gaining patient buy in, consumer buy in into aesthetic enhancement. What are injectibles, simply defined, injectibles are needle based rejuvenation techniques. Or needle based aesthetic techniques that can help shape and contour, relax and rejuvenate the facial anatomy and sometimes even off facial anatomy.

More specially what are injectibles, what needle based products are they? Well most commonly it’s broken into two broad categories. The neuro toxins are the Botox Injectable like products and these work by relaxing muscles that we don’t want to use. Excessive muscles of animation. Number one the 11’s, or the frown lines, number two the crows feet on the side of the eye, the worry lines, the lip lines, the down going mouth pout lines, the orange peel chin necklace lines, and then some other more uncommon body areas such as excess sweating of the armpit. Sometimes relaxation of the chest muscle and shaping of contours such as the calf, the shoulder and the square jaw. So Botox Injectable relaxes muscles, relaxing muscles can change shape and change animation.

The other broad class of injectibles after Botox Injectable, and by the way, Botox Injectable is a generic name for a specific kind of neuromodulator from Allergan called Botox Injectable, but there’s also other manufacturers. Pharmaceutical company named Galderma that makes Dysport. A pharmaceutical company called Merz that makes Xeomin and Xeomin, Dysport and Botox Injectable all fairly equivalent and can do similar things. Just that Botox Injectable is far more studied, far more known, and therefore far more common to be used.

On the other side of the equation, the other group of injectibles are called fillers. Injectable products that either lift, support soft tissues such as wrinkles and contour. Or they’re bio stimulatory in nature, they don’t lift and support but their micro spherical products that stimulate new collagen. And so the biggest class of soft tissue fillers that lift and support without any bio stimulation are very inert and safe and these are the sugar gels. And the sugar gels are broken down into different brands of sugar gel. The hyaluronic acid sugar gels families consist of Juvederm, Restylane, Teoxane (or Teosyal), Astellas, and Belotero. These are the most common ones available in the United States and internationally.

Then there’s the bio stimulatory, these are smaller little particles of polymers or structures that stimulate our own skin, our own soft tissue to make our own collagen. The most common is Sculptra, which is little repeating polymers of polyglutamic acid, Radius, which are little repeating units of calcium oxide apatite and Bellafill, which is polymethacrylate. These little structures, when we inject it, don’t lift and fill as much as stimulate our own collagen to lift and fill and they’re longer term. These are the two broad classifications. Botox Injectable and soft tissue fillers.

So what are the benefits of these injectibles? Well if you think about it, individuals who have angry expression lines and wrinkly faces and a little loss of volume. The three D’s of growing old; deflation: which is loss of volume, decent: which is soft tissue falling, and then deterioration. Animation can be improved significantly with the use of injectibles. So the value of injectibles as a non-surgical, quick fix for lines and wrinkles, soft tissue fillers for loss of volume and plumping folds and frozen shape, usually can be done within 15 minutes, camouflage right away. You look, if it’s done properly, natural, not overdone and there’s no surgery. There’s no risk of surgery.

The down side is Botox Injectable wears off in three or four months, you’ve gotta come back and soft tissue fillers once every year you need to come back. So it needs repeat visits, safe and easy to do, can look really quick natural, and if you combine them with energy based devices like a photo facial or fractional skin tightening you can get a really, really nice result without any surgery. So the advantages, ease of access, relatively affordable and can look great. Can make you look five to ten years younger.

Are they safe, are there any risks? They are very safe when injected by a well trained professional, a doctor, like a plastic surgeon, dermatologist, facial plastic surgeon, or a well trained nurse or a PA, or a nurse practitioner that works under a doctor. They are very very safe. Occurrence of complications that are serious are one in millions. There are some expected side effects, not really complications such as bruising and swelling that go away. Occasionally Botox Injectable will spread or dribble or an area into a sensitive area of muscles and that’s very rare, but it can cause some temporary drooping of an eyelid or facial smile assymetry. Generally adjustable, self limited and goes away and very uncommon.

Soft tissue fillers, bruising, swelling, slight asymmetry, but the biggest fear would be the extremely rare complication of that filler getting in a vessel and occluding the blood supply of that vessel to the nose or to the facial skin and causing necrosis or blindness. Extremely uncommon. When injected safely with a non-sharp needle, microcannula, the risk of something like that happening is one in tens of thousands if not one in a million. So, it is unsafe to jay walk, drive on a highway and ride on a plane, we do that all the time. Soft tissue fillers and injectibles are a quick fix with a real significant solution that’s affordable and very safe.

Let’s say you’re a patient that is considering injectable rejuvenation to their face, frown lines, worry lines, crows feet or lip augmentation. For soft tissue volumization of your face, the question becomes, okay I’ll do it, it’s safe, it looks good, but how long does it really last? What’s the real cost to me of getting it done in a repetitive fashion? So Botox Injectable generally two to three times a year. Quite often your expenditures, depending on the clinic within North America, could be between $300 and $1000.

Soft tissue fillers, depends on how many syringes and what kind of syringe, but in general modest soft tissue volumization can be accomplished in two to four syringes for relatively young to middle age people and six to eight syringes with older people, and in general you’re looking at between $1000 and $2000 of soft tissue filler replacement once a year. So two to three times a year for Botox Injectable, one a year for soft tissue fillers. Most women spend more in a year on their hair care and their nail care than they would in injectables, but it adds a whole significant level of rejuvenation. So it’s cost effective, affordable, and easily accessible.

What if you don’t like it? Well, if you don’t like Botox Injectable it’s gonna wear off in three or four months, you just have to wait, there’s no antidote for Botox Injectable. No anti Botox Injectable, that’s why you want to have it done judicially when you’re first starting out by someone who’s an expert so that you get the results you’re looking for.

Soft tissue fillers if there’s some swelling or differential absorption or asymmetry or you just decide you don’t like the look, there is a filler antidote, which is why a lot of physicians in particular like the hyaluronic acid sugar gels like Restylane and Juvederm because if you don’t like it you can inject a little enzyme, reduce slightly, or remove it completely. So the concept of reversibility is a powerful one making the HA sugar gels, Juvederm, Restylane, the most commonly injected soft tissue filler.

Clearly when you’re balancing animated muscles, expressive muscles, frowning muscles, lifting muscles and you’re shaping faces, there’s an extreme degree of artistic expertise that is brought to your face. There are some injectors that are good on basic line management, minimizing squints and wrinkles and expressivity and that’s relatively easy and reproducible but truly shaping a face, creating youth and beauty with elevation and contours where there isn’t any, that takes more of a sculptors eye and there are very few injectors that achieve that level of injectable opportunity.

I think you have to source them out carefully, research online, look at YouTube videos, television appearances, before and afters of the kind of representative work that your sculptor, your injector’s, bringing to the face. And it really can be almost a surgical type like outcome with the right injector. So there’s a great degree of artistry and experience. Line management, managing a frown line, pretty straight forward. Shaping a face, making it look six, seven, eight years younger without looking like dreaded filler face and being overdone, that takes skill artistry and experience. So research carefully and I think you’ll find the right injector for your face.

Again, Doctor Stephen Mulholland here in Toronto Canada on Plastic Surgery Talk. Our podcast today was on injectibles as a broad category. I hope you found it informative and entertaining, if you did please share it on all your social channels and I look forward to seeing you again at our next podcast.

Dr. Stephen Mulholland
Posted by Dr. Stephen Mulholland
Dr. Stephen Mulholland has been practicing Plastic Surgery for over 20 years. He is one of Canada’s most renowned and best plastic surgeons in Toronto with his wealth of experience, artistry, and humbleness towards his patients.

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