The Filler Files (Part One)

Dermal fillers at The Prager Clinic for facial rejuvenation and anti-ageing.
Dermal fillers are excellent for skin rejuvenation ... in the right hands.

A Brief Look at Turning Lines Into Lumps and Mad Cow Disease

Hyaluronic acid dermal fillers are possibly the best way to restore and maintain skin health, skin structure and tissue integrity – but it depends on who is using it and how they use it.

When I first arrived in London, there were only two areas that people injected filler into – the nasolabial folds and the upper lip. Apparently, that was all there was to restoring youthful looks.

Maybe it was time spent working as a model in South Africa that sharpened my eye, in terms of aesthetics, but right from the start I was intrigued by the idea of using cosmetic injections to make people more attractive.

It quickly became apparent that what was being used and what was being done, wasn’t necessarily hitting the spot, and this was largely due to the most basic of thinking.

young face = no line

old face = line

take away the line and the old face becomes young

As I said, this is toy town thinking, and here’s why.

As you age you develop nasolabial folds, but if you simply inject the fold and leave a sausage of product there it might technically satisfy the medical aim, but aesthetically speaking, it doesn’t quite work. You simply exchange a line for a lump.

Possibly because I was young enough to see the difference, and I believed in finding a better way, in 2014 I published a study examining the results of treatments available. I concluded that even with the best Botox doctors at that time, and according to the principles that governed the industry then, people actually ended up looking worse for being injected.

If you’re interested in reading more, the study can be found here.

It was clear there was a lot to improve on in the industry.

One issue was that medical approaches tend to be symptomatic; there’s a problem, like a high temperature, and a drug is administered to lower that temperature. The fact that a fever, or a higher temperature, actually helps the body speed up metabolism and increase the efficiency of the immune system is often neglected.

The use of fillers was approached in a similar way. No one was looking at the bigger picture.

Moo-ving On

Another problem with fillers in the early years was that the substance was tricky.

In the 90s – and I never injected this, by the way – we saw the arrival of bovine collagen. Yes, real cow collagen farmed from a domestic herd kept on the verge of sterile conditions in America.

Unsurprisingly, it was found that Mad Cow Disease was a risk factor that could limit its use.

I’m told that cow collagen was actually a beautiful substance to inject. The trouble was, once injected, the body quickly realised what was happening and did its job by upgrading an enzyme. This meant that as soon as the cow collagen went in, the body attacked it and took it out again.

There were also significant allergic reactions recorded, ranging from mild inflammation and redness to severe responses such as granulomas and tissue necrosis.

Naturally, it was at this point that the dreaded plastic surgeons decided to intervene in the injectable market … by inventing a new product.

One such case involves a guy called Gottfried Lemperle who led the team that invented a dermal filler named Artecoll for cosmetic use. The whole premise behind Artecoll was longevity.

You see, at that stage, people never seemed to ask how a product might look in their face, but rather how long it might last.

As a consequence of this fixation with duration, people started to have all manner of stuff injected into their faces from silicone to plastic to paraffin. Some of the results were nothing short of disastrous.

Furthermore, these fillers were indiscriminate about who they took down, with notable victims being Priscilla Presley and Meg Ryan.

Sadly, all sorts of crazy problems emerged thanks to adverse reactions and scar tissue that refused to stop growing.

And that was the sorry state of the industry in the 80s and 90s, until Restylane and hyaluronic acid (HA) came along.

New Is Not Necessarily Improved with Fillers

I admit that I used a product similar to Artecoll for around six months when I first came to London, and they cost me a lot of hair. Yet, at the time, these products were considered to be totally safe by virtue of everybody using them.

Funnily enough, many of those who used these fillers will always deny the fact now, which adds another layer of concern about the ethics of various practitioners.

Thankfully, we next saw the large-scale use of HA which, by itself, is by far the safest of all the products out there. And it can be dissolved.

From 2002 onwards I have injected nothing but HA. Of course, many more products have come on the market, but I don’t feel the need to experiment with people’s faces. From my own personal experience, whenever I used a new product, it usually went wrong.

You see, it’s not uncommon to inject a new product and see great results, and then have a patient return nine, 10, or 12 months down the line with a problem. The truth is, filler injections can be problematic.

Another baffling fact about the face game, is that when I first started out, there was nobody even remotely concerned about the anatomical structure lying underneath the skin. People injected willy nilly.

Many cosmetic practitioners don’t even know how to aspirate when applying aesthetic. On one hand they’re concerned about injecting product into a blood vessel – a no-no that can cause vascular and tissue damage – on the other hand, none of them can actually aspirate.

In layman’s terms, when you aspirate you pull back on the plunger of the syringe thereby checking you’re in a blood vessel, something that becomes visible if blood is found in the syringe. A pretty normal procedure when you’re in the business of injectables.

Of course, when you inject filler, you absolutely want to avoid hitting a blood vessel, so you really ought to understand and be proficient in aspirating.

As it happened, I was one of the first to aspirate routinely, something I demonstrated when doing conferences. As a result, I was consulted by the manufacturers of Allergan’s then-latest product range on how to design a syringe that you could aspirate with.

As a side note, it was to my pride and joy that when I met with the late, great Frederick Brandt, I found he routinely aspirated too. For those who don’t know, Dr Brandt was hugely respected for his expertise in cosmetic facial augmentation using fillers, so it was nice to be in the same ‘club’ as him.

From Here to Filler Eternity

Today, permanent fillers are still around and many people still use them, though I don’t know why in many circumstances.

Permanent fillers were actually developed back in the 90s for HIV sufferers whose retroviral drugs came with a major side effect known as lipodystrophy.

This meant that their facial fat pads would basically disappear, become eroded, totally destroyed. For this reason, permanent or semi-permanent products such as Artecoll and Aquamid were invented.

All permanent fillers work on the same principle; there is a carrier product, which could be HA or water, or some form of collagen, and within it you have plastic particles, basically small, non-dissolvable bits that you inject into the skin.

The skin then forms a capsular around each of these particles, a collagen capsule, basically creating a cyst-like structure to protect the body from foreign material, and that in itself gives the filler more grip.

So, the idea was good in theory and, most of all, it was done on people who were appreciative of any form of volume in the face, regardless of the possible overreactions.

However, to then inject this into a healthy organism simply because it lasts longer and gives more volume was nuts.

Granted, it was initially thought that HA only worked for somewhere between six months and nine months, mainly because there was not enough knowledge about them and that’s what everyone was told. Yet, in 2003, I injected Allergan’s thinnest product, at the time, under the eye area and I discovered that it was still there in 2007 or 2008. I then used a dissolving agent now available to reduce it and take it away.

For this reason, I always find it a little disingenuous when industry experts write about being shocked to find filler in their faces when they have been routinely topping up the product for free every three to six months. If you add and add and add, as I know many have been doing, then you naturally add to the lifespan.

What’s perhaps more concerning, however, is the fact that there are practitioners injecting who are seemingly unaware of the real lifespan of HA fillers, possibly because they’re new to the game and don’t have the benefit of 10 or even five years of practice behind them.

Saying all that, people still sign up for semi-permanent or permanent fillers, so go figure. They want it in, they don’t want it in? Welcome to the world of aesthetic medicine.

Tune in to next edition of The Filler Files where I’ll take a look at disasters such as ‘pillow face’ and try and explain ‘the why’ behind the insanity. After that, we delve into the murky world of industry standards, who sets them and why? In the meantime, don’t have nightmares – just visit a responsible practitioner.