Contemporary Fillers: Cheers and Fears

According to Dr. Joe Niamtu III, knowing when to treat, when not to treat, and when to refer are all virtues of prudent injectors, regardless of specialty, seniority or type of practice.

When I first started injecting fillers in the mid 1990s there were two choices: Zyplast and Zyderm, both bovine collagen products. At least one allergy test (usually in the forearm) was required and then the patient would have to wait at least a month to see if there was a reaction. All that aside, the fillers did not do much, were not reversible and sometimes the effect only lasted for weeks. We have come a long way since then. In the first part of the 21st century, hyaluronic fillers were introduced and they were FDA approved, which was a true paradigm shift.

These fillers changed the minimally invasive cosmetic landscape and offered safe, reversible, natural and and long-lasting results. At first, the basic indication for these new fillers were plumping lips and filling nasolabial folds. No one, ever, came into my office in the late 1990s and requested “tear trough” or “mandibular angle” or “temple” fillers. These, along with many other innovative and useful treatments were developed by numerous providers from a plethora of specialties. While on the subject, the original gangsters of fillers included dermatology, ophthalmology (oculoplastic), ENT facial plastic surgery and plastic surgery. These specialties were natural choices as they all had expertise in facial surgery. I have always included my own specialty, oral and maxillofacial surgery in this qualified group. I think if you look back 15 years ago, the sum total of filler injectors were from a handful of specialties. In many instances some of these specialties attempted to monopolize filler treatment and availability to other peers. The excuse was patient safety, but I believe it was mostly economic and aimed to limit competition. In many instances, it was a combination of both. Personally, I have welcomed and taught any injectors over the past 20 years who were legally licensed to perform these treatments. I always thought that limiting education and availability to other specialties would be akin to only allowing certain specialties to use penicillin when it was first discovered. Having said this, I think it is essential to teach the safe way to do these treatments. Not just “where to put the needle” but much more importantly, essential head and neck anatomy and danger zones.

For those injectors who don’t want others perform these procedures, it is too late; that train has left the station! It is the responsibility of the expert injectors to pass on their knowledge to make sure legal injectors have the proper training for injection safety.

Ancillary Injectors

Virtually all of the doctors that had large injection practices 15 years ago were doing their own injections (including me). Looking at these same practices today, more injections are performed by physician extenders such as RNs, NPs and PAs. Although I still do a fair number of my own injections, I have taught my nurses how to safely and effectively inject.

Commoditization

This dispersion of available legal injectors has filtered down to virtually every specialty and also includes med spas and general dental practices. This is good news for filler companies, not so good news for profit or doctors fearing competition. I personally feel that as long as these treatments are being done safely, then it merely represents progress. Taxi drivers don’t like the entire Uber ride share phenom, but again, it is progress and delivers a service to a wider base. Whereas fillers may have been very profitable for doctors before they became available on every corner, today they are becoming commoditized. Every day I see offices or spas advertising lower and lower fees for a syringe of filler. This always has an effect on competition and profit and is a fact of life that happens in most every business; it represents progress. Most of my doctor friends that once did hair removal no longer do, as they can’t compete with med spas and patients can be very price conscious. The entire LASIK situation went from being thousands of dollars to hundreds of dollars and many ophthalmologists simply stopped doing it. Similarly, 10 years ago, it was uncommon to have orthodontic treatment by a non-orthodontist. Today many types of dentists perform orthodontic treatments due to advances in technology where removable plastic trays have preplaced “wire bending” skills. I promise you most orthodontists did not welcome this, but again it is progress.

Safety First

The key to progress must include the same safety margin as performed by traditional practitioners that originally pioneered and delivered these treatments. There is never a substitute for patient safety and predictable outcomes.

Taking all of the above into account, the progress of filler choices and injection site choices has ushered in a new era of complications. Blindness or massive tissue necrosis was truly rare in the early days, but have become more common and downright scary. The inclusion of treatment areas such the periorbital, perioral and glabellar regions has put the needle in close association to important vascular structures, which can lead to vascular occlusion resulting in blindness and tissue loss. Although I hear a lot of doctors blame this on unqualified injectors, it really can happen to anyone. Having said this, it makes sense that the more times a procedure is performed, the greater the risk of complications. A doctor that performs three facelifts a year may have few complications whereas a surgeon that performs 100 lifts a year will likely see more complications by virtue of statistics. Although I have seen severe complications from nontraditional injectors, I have seen many complications, some tragic, that were performed by well known, top-tier injectors. None of us are immune to this. Even the best surgeons and anatomists can experience an intravascular injection by virtue of abnormal anatomy or sometimes simply bad luck.

When I hear doctors rail about the competition, I shake my head as no one can prevent or change this, nor should they. Remember, it is progress. What they can do is to insist that all licensed injectors regardless of specialty or degree, receive the proper training required to do this safely. These safeguards may include petitioning state boards to require anatomy, didactic and proctored training for injectors that did not receive training in their core education. The filler companies can also take an active part in the dissemination of education to those who purchase their products. New injectors should avoid higher risk areas such as the tear trough or glabella. Understanding various options such as cannulas, aspiration, “vascular locating technology” retrograde or antegrade injection techniques, needle choices, syringe thumb pressure and tissue plane and vascular anatomy is requisite.

All injectors must be able to immediately recognize filler emergencies and begin the initiation of emergent treatment. It is the obligation of any injector to know the steps of treatment and have on hand the required medications or equipment necessary for immediate treatment. This is the “ACLS” of filler emergencies. Knowing when to treat, when not to treat, and when to refer are all virtues of prudent injectors, regardless of specialty, seniority or type of practice. Finally, it is the obligation of every single injector to have proper written and oral informed consent that includes catastrophic complications such as stroke, blindness and tissue necrosis.

Joe Niamtu, III, D.M.D., is an internationally recognized cosmetic facial surgeon practicing in Richmond Virginia.