In the beginning there was filler, and the gods of filler corrected the nasolabial folds and the upper lip, but the face was without form and void, and darkness was upon the hollows of the deep. The spirit of R&D then moved upon the face of hydrogen gel; and the filler gods said let there be more light, and there was light; and it was good. The gods then said let there be more lift, and there was lift; they said follow the golden ratio; and everyone followed the new trend, and the gods they kept on wanting because – and let’s be clear about this – suppliers want to sell more product.
The Show Must Go On and On and On…
As we know, when filler first arrived on the scene it was pretty much limited to nasolabial folds and the upper lip, but then people started to get more adventurous, injecting into all sorts of areas, which led to all sorts of complications.
Back in 2008/9 I made the point that for every ‘pillow face’ that walks down the street, I lose five new patients who basically think that if you have filler, this is how you end up looking. It wasn’t good.
But then Allergan – the big name in Botox – began to ramp up its academy structure. The company created something that was supposed to set the ‘gold standard’ with conferences and masterclasses featuring keynote speakers.
Over time it became a very slick roadshow, with the ‘chosen one’ being a Brazilian surgeon who became the authority on anything to do with injectables.
Away from the circus though, Allergan did something very useful. They created a system. This involved pinpointing areas on the face where filler could be injected to create a reasonably good cosmetic effect. This was ideal because it systemised the industry.
So, rather than everyone having an opinion on what was best, they did in fact isolate the spots that yielded cosmetic results with the greatest safety, and that was clever. It was also something people could easily follow, like painting by numbers.
Unfortunately, over time, the Allergan system became ever more complicated with new codes added every year, and new ideals promoted.
For a while they were totally obsessed with the golden ratio, the measurement of beauty that Da Vinci apparently applied to his paintings.
Sometime after that, things started to get very crazy – all of which was to be expected because what they really wanted to do was sell more product.
Time to Bow Out
The last masterclass I attended was in 2018. By now the favoured surgeon had become an abstract celebrity shrouded in mystery with the conference becoming an ever more cultish experience where injections were no longer done on the stage, but backstage filmed by several cameras.
I remember a presentation where everything looked great with the model – the neck lifted, the jowls were gone and all this with only 16 syringes of product. The message was clear: to gets results, you have to inject at least 15 syringes, and at least 10 of them at a time. This was supposed to separate the Beethovens from the Cliff Richards. It was insane.
To use this amount of product, the patients would have been sedated, pumped full of cortisone and antibiotics, and specifically chosen for the treatments being presented. Pull the same stunt at home and you will create havoc with someone’s face.
But, of course, people were so mesmerized and absorbed and obedient. They thought that if this is what they tell me to do, I shall do that. It was farcical and this, in my opinion, is what has given rise to the developments we see today.
A generation of doctors have been groomed in these masterclasses and it was time to pull out.
While I saw the benefit of the Allergan masterclass, I was not that obedient. Some things made sense, some things made a lot of sense, but I was also taking cadaver courses at the time and learning more about anatomy and method, and that’s the kind of knowledge you need in this line of work.
So, while Allergan obviously moved the bar up quite a bit, it pandered to a new generation of doctors with an Instagram understanding of aesthetics. As a result, the notion of beauty became distorted.
Over the years, more and more weird faces could be found in the audience. Some of the people I met in 2002 for the first time were unrecognisable by 2018. Filler use had spiralled out of control.
Saying that, if people are injected anatomically, in a safe and sound way, and they want to look like that, then I can’t comment on it. This is a matter of personal preference. I mean, who wants to have a ponytail at 55?
The Prager Lift
I was one of the first aesthetic medicine practitioners – if not the first – to advocate the natural look because when I first started in 2002, I saw a lot of guys with grey hair and glistening foreheads, and that was just weird.
Then came the Paris Lip disaster, and the sausage of product stuffed into nasolabial folds, and the conferences and masterclasses morphing into a mix of David Copperfield and space age coding and gene hacking.
To get away from the madness, I went to China to see how things were done there.
One interesting method was the Asian’s use of product either side of the temple area and further back in the hairline, almost up to the crown. It was basically a scalp lift.
In the west it was all about creating extra volume in the cheeks to lift everything below, which wasn’t a bad idea. However, when facelifts are carried out, the lift is created at the tight junction between cheekbone and face muscle structure in the front of the ear. So, why not do the same with filler, take it along the hairline and even further back, like our Asian colleagues.
With the arrival of the canula, this was perfectly viable. So, injecting behind the hairline, above the ear, and the temporal area is the cornerstone of the first part of the Prager Lift.
Using this method has several advantages. Firstly, most people looking for this treatment, have had filler injected as some point in their cheeks because they shrink as you get older, which makes the face look hollow and drawn. But what people forget is that bone density in that area also diminishes, which is why we get nasolabial folds. It’s a centralisation of volume. So, if we lose width in the overall face the whole thing tends to go in and down.
That’s why any mid-face area of augmentation isn’t a great idea. Hello, pillow face. However, by placing filler further back you can make that previously created volume along the cheek look a lot better.
Of course, everything has its limits, but the Prager Lift basically takes into account that most people have had filler injected at some point. It then takes into account that no one wants to see that filler. It also harnesses the face’s anatomical structure.
Let me explain; if we add filler into a tight area, we are going to make that area tighter. So, instead of injecting into a loose area and using tons of filler, we try and make an area that is potentially tight, tighter, thereby creating a similar effect to a wider face, but in a lot less visible way. Using this method, you avoid injecting into the nasolabial folds and you improve the jowls, which people previously injected into, creating oversized chins that then had to be balanced with even more filler further up the face.
In many ways, the London Lift is a take on the pony tail lift, that the Asians favour.
Using this method, we can inject at least two syringes, one either side, with virtually no downtime and no telegraph announcement that you have had filler.
Your Questions Answered
As we age, we experience skin pitting, acne scarring, and loss of elasticity, all of which is most visible in the areas where we experience sagging – so, around the mouth and cheekbone area. This is why the London Lift is primarily concerned with skin texture.
My interest doesn’t lie in injecting filler into someone’s face; the aim is to restore skin health and skin integrity.
In recent years, dermal fillers have come in for a lot of bad press because people went too far, and that’s a shame because dermal fillers don’t get the credit they deserve. Since 2018, I have not had one single allergic reaction towards the products I use. But I understand why people are concerned.
Last week, one of our patients wrote in to ask whether filler caused lymph drainage obstruction after the possibility was raised at a conference of plastic surgeons.
Injected superficially, hyaluronic acid does take longer to disperse. The deeper it goes, the easier it is for the skin to dissolve it. At a more superficial level – the thinner the skin, say in the undereye area – the less it disappears. Whether that then effects lymphatic drainage, I very much doubt it.
I hope that soothes concerns and, please, if anyone has a question they want answering, drop us a line, and I will happily share my thoughts with you.
In the meantime, relax. Do what you need to do to protect and maintain skin integrity, drain your lymph nodes with a quality massage, and enjoy the restorative power of the Prager Lift.