Dr. Niamtu’s Weblog

….on cosmetic facial surgery

Injectable Fillers in a Busy Cosmetic Facial Surgery Office

collage3 January is always an interesting time of the year as we review and reflect on our procedure numbers from the previous 12 months.  I was both amazed and intrigued to have injected 1,761 syringes of filler in the past 12 months.  I knew I was in the top 10% of injectors nationally, but did not ever really count the volume in the past as we mostly tracked surgical procedures.  What is also notable is that I personally do all filler and neurotoxin injections in my office.  Some practices have multiple physician injectors or non-surgical staff such as nurses and nurse practitioners that may inject.  In our office it is just me, so 1,761 syringes of filler means I was really busy.

In further reflecting about the popularity of injectable fillers, so much has changed in 15 years.  For those of us that were using fillers in the 1990’s, the choices were pretty slim.  Basically we had Zyderm and Zyplast which was collagen from cow tissue.  One big draw back was that some patients could have severe allergic problems and when mad cow disease surfaced, it upped the scare factor for animal collagen.  Allergy was rare, but allergy testing was a hassle because the patient had to come in a month before injection to have a test dose to determine allergic response.   Hard to imagine now in this day of “walk in/get injected” treatment.  The other and biggest problem of collagen filler was that it simply did not last.  It did OK for fine lines and wrinkles but sometimes only lasted a matter of weeks.  It was also pretty “creamy” in texture and did not do much for lifting or plumping.

Fast forward 10 years and NASHA fillers were introduced.  This stands for Non Animal Stabilized Hyaluronic Acid.  Hyaluronic acid is a naturally occurring carbohydrate that is found in many body tissues.  It has the consistency of hair gel and can be produced in thin and thick formulations.  The thinner (more watery) formulation (Restylane, Juvederm Ultra, Belotero) are used more for fine lines and wrinkles or outlining lips.  The thicker formulations (Perlane, Juvederm Ultra Plus, Voluma) are well suited for more robust applications like lifting or volume restorations, such as filling cheeks and smile lines.  If you desire more trivia, this viscosity or adhesivity is referred to as “G Prime”.

These hyaluronic acid fillers have been game changers because there are no allergy problems, and the results last for up to a year.  Another huge advantage of the hyaluronic acid fillers is the fact that they can be reversed overnight.  Although most patients want their filler to hang around, there are times where they may not like the result.  Injecting hyaluronidase (an enzyme that dissolves the filler) can reverse the result in a matter of hours.  That can be a great insurance policy.  Although we have semi-permanent and permanent fillers, they cannot be reversed and permanent filler can turn into a permanent complication.  I personally inject Radiesse and fat which are semi-permanent filler and silicone oil which is permanent filler.  Where and how we use these types of fillers is different from every day filler applications.  95% of patients are best suited for hyaluronic acid fillers.

Finally, the other reflection about fillers is how our usage has changed over the past 15 years.  I can promise you that no one ever walked into my office in the mid 1990’s and asked for cheek, teartrough, or brow filler.  In one respect, we did not think about it and in the other respect, it would not have worked well with the available products at that time.  Today, we use fillers in the upper face for forehead lines, eyebrow lift, and crow’s feet wrinkles.  We use them in the midface for teartrough, cheek, smile line and nose treatment, we use them in the lower face for lip, chin, jowl, mandibular angle and jawline augmentation.  The versatility of modern fillers has been both exponential and amazing and is truly an enjoyable part of my practice.  I routinely publish on filler use and technique and teach courses major filler companies to train other doctors.  I love performing surgery, but I also enjoy the artistry and sculpting that involves injectable fillers.  This is one of the reasons my job is so much fun.

January 27, 2013 Posted by | Lip and Wrinkle Fillers, Lip Augmentation, Minimally Invasive Cosmetic Facial Surgery, Removing Excess Lip & Wrinkle Filler | , , , , , | 3 Comments

Hyaluronidase to Dissolve Unwanted Lip and Wrinkle Filler



If you are old enough to have filler injections you are probably old enough to remember the scene from the movie “The First Wives Club” where Goldie Hawn gets lip injections and ends up with wickedly gigantic lips.

No one can argue that injectable fillers have added immensely to minimally invasive cosmetic facial surgery, but sometimes you can get too much of a good thing!

The complications associated with injectable lip and wrinkle fillers are usually pretty benign with under treatment and over treatment being among the most common problems.  Frequently, overtreatment is associated with novice injectors or poor technique, but even the most experienced surgeons will occasionally have an overzealous result.  There is no doubt that a patient may be disappointed with an under treated area, but they will be livid with an asymmetric or over treated area.  Let’s face it, no patient wants to walk around with excess filler in the lip, smile line or under eye area.

There are numerous fillers available and each of them has various positive and negative aspects.  The most commonly injected fillers are the hyaluronic acid fillers which include Juvederm Ultra and Ultra Plus, Restylane, and Perlane being the most popular.  Hyaluronic acid is a naturally occurring sugar that is present in many human tissues, especially the skin.  These fillers have been shown to persist in the body for up to a year, which is a good thing if you have the correct amount in the right place.  One additional (and I feel a huge advantage) with the hyaluronic acid fillers is the fact that they can be dissolved or reversed with a very predictable, safe and simple treatment that happens almost overnight.

Sound too good to be true?  It’ a fact.  Hyaluronidase is an enzyme that will dissolve hyaluronic acid rapidly and safely.  This medication is marketed as Amphidase and is mixed with local anesthesia and injected into the area of excess filler.  Almost like magic and almost overnight, the excess filler will dissolve, leaving a happy patient and surgeon.  Hyaluronidase has been used by doctors for injections for years, most commonly to assist the spread of local anesthetic solutions.  It has an excellent safety record although it is good to perform an immediate skin test and wait 5-10 minutes before treatment.  A small bleb of the inner surface of the forearm can be injected to see if it causes any inflammation in the area.

Hyaluronidase is used to dissolve excess or unwanted filler by mixing it with local anesthesia and injecting into the area of excess filler.

I have personally injected one of my patients and a bunch of patients treated by other surgeons with Hyaluronidase with good results.  The excess filler (assuming it is a hyaluronic acid type) dissolves in one or two days and is impressive.  Occasionally it is necessary to re treat an area with additional Hyaluronidase if the first injection did not take care of the problem.  I have used it to dissolve bumps on the lip, lips that were too big and fat or tear trough areas (the groove under the eye and above the cheek) that were over treated with good results.


The above patient was over injected with a filler and was unhappy with the excessive result.  She is shown 48 hours after Dr. Niamtu injected hyaluronidase into the area of excess under the eye.

To find out more about injectable lip and wrinkle fillers or other cosmetic facial surgery procedures visit www.lovethatface.com


Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia


August 28, 2008 Posted by | Lip and Wrinkle Fillers, Lip Augmentation, Lip Reduction, New Cosmetic Surgery Technology, Removing Excess Lip & Wrinkle Filler | , , , , , | 13 Comments