Peer to Peer
Filled to the brim
The benefits of premixing fillers with lidocaine with epinephrine, basic procedures that attract custom by building confidence, and why you should never ‘underfill' patients
Our panel this session comprises: Dr Jean Carruthers, a clinical professor at the department of ophthalmology and visual sciences at the University of British Columbia in Vancouver; Professor Syed Haq, an associate of PSA UK and the London Wellness Centre; and Rajiv Grover, an NHS consultant plastic surgeon who runs a private practice in Harley Street and London's King Edward VII Hospital.
Q: I injected a patient with a filler and lidocaine but find this time-consuming. Can more manufacturers pre-mix these?
Dr Jean Carruthers: The manufacturers are starting to do this. You could argue that all companies producing fillers should from the outset. But it is more difficult for the filler companies because they come under the device category. Once they start adding epinephrine they would have to satisfy the drug licensing authorities as well.
Patients are much happier with filler premixed with lidocaine with epinephrine because they can see the symmetry, and practitioners can really tell that they have done a good job.
With dental blocks and lidocaine, you're using maybe 1cc, perhaps a little bit more. This is 10 times as much as injecting lidocaine with a syringe of filler. A problem with separate, injectable lidocaine with epinephrine is you don't just affect the sensory nerves, you also affect the motor nerves, and the result is an asymmetric face.
Q: Is there an effective procedure for attracting prospective patients?
Rajiv Grover: Restylane Vital is said to be a big practice builder, because people will come for skin rejuvenation and will go on to try other things. Many people are frightened to have something done that gives a structural change to the face.
Dr Jean Carruthers: About eight or nine years ago, when everybody was doing microdermabrasion, people would say, “Oh, my skin feels so wonderful!” But you couldn't photograph it because it didn't look different; yet patients said it felt good.
Rajiv Grover: Hyaluronic acids also promote collagen formation, as the Wang study at the University of Michigan showed in 2007.
Professor Syed Haq: It was minimal. You have to look at the overall effect of collagen production, so I would ask what sort of percentage levels? Were they looking at overall changes in terms of correlating the collagen synthesis with volumetric changes over time? With remodelling, it's not just simply about creating collagen, because you have to revascularise the area, so you need neovascularisation. The cells have a higher energy output so they need to be supplied by oxygen and nutrients and so forth, so I still think the jury's out on that.
Q: Is offering mesotherapy good for attracting patients?
Rajiv Grover: Mesotherapy has a reputation for being a little holistic and less scientific. For it to develop a good name rather than just being a kind of vitamin injection, I agree that it needs some scientific backing.
Professor Syed Haq: There is a system—and the manufacturer is using interesting data from Germany—where a product called Lipomelt is being utilised in a delivery system that uses both electrostatic and mechanical propulsion. So-called micro-pores penetrate up to 6cm, making changes in subcutaneous tissue as well as the dermal layer. That's something that could be of interest.
Q: Why are more lips injected than cheeks when facial volume is so important?
Rajiv Grover: Good question, because the lip is not an easy place to treat—it's thin, it swells, it's very vascular, it has a great artery going from one side to the other, which is an end artery, so you can get tissue necrosis if you were to occlude it.
By comparison, injecting the cheeks—if you are superficial to the muscles, which you know you will be if you are in the fat pad—may result in only a little bruising. Yet many practitioners are scared of the cheeks. You know why? Because it's not a nasal labial fold. But if you think about it, you would see that the lip is kind of ‘tiger country' by comparison.
Dr Jean Carruthers: Some of the older patients really don't want their lips to look like Goldie Hawn's in The First Wives Club. They want to have their faces revolumised, and they need a little support in their lip because they have those rather obvious vertical lip lines. That's the trickiest lip to do, because you have to be so careful not to overdo it.
Rajiv Grover: Start injecting cheeks because I promise you, you'll find it's a lot safer than you think, you will enjoy doing it because it's artistic and creative and your patients will love it.
