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

Evolence: A New Breed of Fillers


Recently, new wrinkle filler called Evolence has been getting a lot of attention, especially after Demi Moore and other Hollywood types have admitted using it.

This is an exciting time in cosmetic surgery as many new and effective products have become available.  As the minimally invasive revolution continues, patients find it difficult to take precious time away from work or play and want significant lasting results with minor recovery.  Enter Evolence!

Evolence is new to the United States after recent FDA approval, but is the number one filler in Israel and has been used outside of the US for ten years.

What sets Evolence apart from other wrinkle fillers is its unique collagen composition.  While most of the other popular fillers are made of synthetic substances, Evolence is the first all natural filler.  It is made from porcine tendon which has the closest structure to human collagen and has been used for decades in heart valves, skin grafts and other medical and surgical products.  Although collagen fillers are not new, they fell out of favor due to two things.  One was that patients were allergic to the older bovine collagen fillers.  Evolence has a unique proprietary process of removing the allergic components of collagen and no allergy testing is required!  This is a huge and new step for injectable collagen fillers.  The other drawback of previous collagen fillers was that although they did a good job, they simply did not last.  Evolence has a patented Glymatrix technology which is a sophisticated cross linking process that extends the length of the filler for up to or over a year.  I can speak personally to this filler.  I was chosen to be one of the teaching staff for Evolence and attended an injection training session in January of 2008 in the Cayman Islands.  The meeting was off shore as new fillers that are not FDA approved cannot be injected on US soil.  The instructors were offered free filler, so I had my smile lines injected.  As I type this blog entry it is exactly one year later and my filler is still present.

The main difference between Evolence (the new collagen) and other fillers is that Evolence actually becomes part of your tissue.  It is collagen and is designed to replace the collagen we lose due to aging.  When injected, instead of being recognized as a foreign body (like most fillers) it is recognized as collagen and the body integrates it into the natural surrounding tissue and even grows blood vessels into it.  It also causes the body to produce some new collagen which can add to the result.  Pretty cool.

Perhaps the biggest advantages of Evolence is the fact that since collagen has many special properties, there is less swelling, pain and bruising with Evolence.  It is great for the patient who wants treated but has a big party in several days.

Right now Evolence is only FDA approved for the nasolabial folds (smile lines) but an new product called Evolence Breeze will be available for lip injections and is used very successfully in other countries.

Since new fillers seem to come and go every month (Artefil went out of business last in December 2008 ) it is critical for surgeons and patients to critically evaluate all new products before recommending them to patients.  Having had Evolence treatment on my own smile lines as well as using it on my patients, I can say that this product is a welcome addition to the armamentarium of cosmetic surgery providers that utilize injectable wrinkle fillers on their patients.  To find out more about Evolence visit www.evolence.com and for more information about cosmetic facial surgery by Dr. Niamtu in Richmond, Virginia visit www.lovethatface.com


Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia


January 21, 2009 Posted by | Lip and Wrinkle Fillers, minimally invasive facelift | , , , | Leave a comment

Facts on Facial Fillers


 Introduction to Injectable Fillers


The use of Injectable facial fillers is one of the fastest growing areas in the field of cosmetic surgery.  Many advances in have been made in the last 5 years that have led to safer, more predictable and longer lasting fillers.


Historically, surgeons have injected substances into the face and lips for over a century.  For the past 25 years, the choice of FDA approved fillers was very limited and basically was the use of bovine collagen (obtained from cows) products such as Zyplast and Zyderm.  While these fillers were effective, they required allergy testing and a one month wait for injection after a negative allergy test.  In addition, the did not produce lasting augmentation and the results were often gone at 3 months or less.


In December of 2003, the FDA approved Restylane for treating facial folds and wrinkles.  Restylane represented a new type of filler and is made from hyaluronic acid which is a naturally occurring carbohydrate that is found in the skin and other tissues of all mammals.  This substance is a clear gel with similar consistency as hair gel.  Since it is not made from animal products, there is no need for allergy testing which is a huge advantage as the patient can come to an office and have same day filler injection.  In addition, the hyaluronic acid fillers have a chemical process known as “cross linking” which prolongs their effect in the body, giving augmentation that can last 8-12 months.  Medicis, the company that makes Restylane also has a more robust filler known as Perlane which was FDA approved in 5-07.  This is a thicker filler that is used for smile lines (nasolabial folds) and other areas and provides a firmer support and lasts longer than Restylane.


Since the FDA approval of Restylane, Allergan Inc. (the makers of Botox) have had 2 injectable fillers approved by the FDA in 2006.  Juvederm Ultra is a hyaluronic acid filler similar to Restylane and Juvederm Ultra Plus is a larger particle, more robust filler, similar to Perlane.  The hyaluronic acid based fillers (Juvederm and Restylane) currently remain the most popular filler choices.


Hylaform, Hylform Plus are animal based hyaluronic acid fillers FDA approved in 2004,  formerly marketed by Inamed (now Allergan) that have declined in popularity with the newer non-animal derived hyaluronic acid fillers. Captique (also marketed by Allergan) is an additional non-animal hyaluronic acid filler that was FDA approved in 2004.


There is a continued effort to develop longer lasting fillers.  Although a permanent filler may sound like a perfect thing, if a patient has complications such as over fill or asymmetry, then permanent may not be a good thing!  In experienced hands, the longer lasting fillers work well and their lasting effect is appreciated by both surgeons and patients.


There are numerous fillers that claim to last longer than the hyaluronic acid fillers.  One of these FDA approved fillers is Radiesse.  This filler is made from a substance that has similar properties to the organic matrix in bone or sea coral.  These fillers have a consistency similar to tooth paste and due to their composition, can last up to 18 months.  Radiesse is most often used in the nasolabial folds and for cheek augmentation, but may be used in the lips by some injectors.  Since this is a thicker filler, it is generally used in deeper areas of the skin so there are not irregularities in the superficial skin.


Another new, longer lasting filler is Artefil.  This filler consists of microscopic plastic beads that look like pearls under a microscope.  The beads are mixed in a collagen carrier for injection.  Since the beads are plastic, they will remain in place permanently and thus provide a lasting augmentation.  One drawback to this filler is that since it contains collagen, it requires allergy testing one month before injection. 


With the previously described fillers, they work by filling the lip or wrinkle with volume and are gradually digested by the body.  Basically, when these fillers are injected, “what you see is what you get”.  There exists another class of injectable fillers that work in a different manner than simple augmentation.  Silicone and Sculptra work by an alternate method.  These fillers are injected into the deeper skin and they cause the body to make new collagen.  When these fillers are injected, they cause the collagen reaction that actually causes the area to grow over a 3-4 week period.  This means that when Silicone of Sculptra are injected, there may be little noticeable result at first, but over the next month, the body will produce collagen in the injected areas and the augmentation will actually grow.  With Silicone, very small micro droplets are injected into the lips or wrinkles and over the next month these tiny droplets of silicone will become surrounded with collagen and enhance the augmentation.  Since the Silicone will “grow” it is injected in very small volumes on a monthly basis until the desired result is achieved.  Silicone is considered a permanent filler as it stays in place and the body does not digest it.


Sculptra is substance known as L-Poly Lactic Acid which is similar to the material used to make a type of suture that is used to close lacerations.  This material, similar to Silicone, will cause the body to make new collagen in the area where the filler is injected.  Due to this, the reaction (like Silicone) is not immediate but increases over the next 3-4 weeks after injection.  Sculptra is popular for injection into the nasolabial folds and for cheek augmentation.  Some surgeons may also inject Sculptra in the lips and other regions of the face.  Sculptra, like Silicone does not require allergy testing.

Since the science of fillers is so prolific, we will see new fillers introduced on a regular basis.  In Europe, cosmetic surgeons have over 70 choices of various injectable filler products.  Several very recent FDA approved fillers include Evidence, Elevess, and Prevelle.


Elvess is a hyaluronic acid filler that contains local anesthetic (0.3% lidocaine) and was FDA approved in 12-07.  By combining a local anesthetic with the filler, the injection process is more comfortable for the patient, although most surgeons use local anesthetic injection routinely before filler administration.  Prevelle Silk is another hyaluronic acid filler with local anesthesia marketed by Mentor and is representative of the process of adding lidocaine to the actual filler product.


Evolence is a filler that is made from porcine collagen (derived from pig tissue) and claims to last up to a year when injected into the nasolabial folds.  Evolence has the consistency of a paste, does not require allergy testing and is yet another exciting example of the new generation of fillers.




Who is a Candidate for Injectable Fillers?



Facial fillers are administered over a wide age range.  Younger patients may seek filler injection for lip plumping and fillers are used in the lips and other areas on aging patients.  Men are also candidates for injectable fillers and are one of the fastest growing filler patient populations. Since filler injection is basically a simple and safe procedure most patients are candidates for injectable fillers if they want to plump their lips or wrinkles.  Fillers should only be injected by appropriately trained personnel that can manage any potential complications. 



Who is not a Candidate for Injectable Fillers?


Patients with significant allergies should check with their doctor before having any filler injected.  Also patients taking aspirin or any medication that could affect blood clotting should notify their surgeon prior to injection to avoid hematoma, bleeding or severe bruising.



What is the Intended Result of Filler Injection?



Fillers are intended to plump lips and soften wrinkles.  Different patients have different areas in need of improvement for their lips.  Younger patients may only need some slight plumping to augment their already youthful lips while older patients may need plumping, outlining (restoration of the youthful border of the lips) and injection of lipstick lines.


For wrinkles and folds, fillers are intended to “soften” the wrinkle or fold, not to eliminate them.  It is important that the patient has reasonable expectations prior to the treatment as not to be disappointed.  If you consider the wrinkle a depression in the skin, the filler will plump up the depression to make it less severe, but will not make it completely disappear.  Having realistic expectations is very important.



How Long Can I expect the Filler to Last?


Filler longevity is extremely variable and depends upon the type of filler used, the area it was placed and the metabolism of the individual patient.  Fillers generally do not last as long in areas of extreme movement such as the lips as compared to less mobile areas like the cheekbones.



How is the filler administered?


Every surgeon has a different way of injection filler.  Most surgeons will use a topical anesthetic cream and also administer local anesthetic injections (dental injections) prior to injecting fillers.  Ice is also applied before and after injection.  Injection generally only takes several minutes and some fillers cause immediate swelling so the patient may appear “over treated” at first.  This swelling generally resolves in several hours.  A follow up appointment several weeks after filler injection is a good idea so the surgeon can evaluate the result and touch up any areas in need.



What is the Recovery for Filler Injection?


For most patients, fillers can be injected in the lips or wrinkles and they can return to work the next day.  Occasionally some patients will swell dramatically, especially in the lips, so for a first time patient; they may want to schedule the initial injection on a Friday.  Occasionally patients will bruise from lip or wrinkle filling and this can usually be covered with makeup, but it is a good idea not to schedule filler injection right before an important social function in the event the patient experiences unusual bruising.



What are the Possible Complications of Injectable Filler Injection?


Like any procedure, filler injection can cause complications, but fortunately they are generally rare and minor.  The most common post injection complications are swelling and bruising, both of which generally are short lived and self limiting.  Over correction or under correction are also possible.  For under correction, more filler can be added.  In cases of over correction, sometimes the excess filler can be expressed out of the lip or wrinkle through a small needle puncture.  Hyaluronidase is a medication that will dissolve the hyaluronic acid fillers and can be used to reduce areas of over treatment.  Asymmetry is another possible complication where one side may be different from the other and again, requires filling of the deficient side.


In rare case allergic or foreign body reactions have been known to occur with fillers, but this is extremely rare.  All of the above potential complications should be thoroughly discussed with your doctor before injecting fillers.





Injectable facial fillers have broadened the scope of minimally invasive cosmetic facial surgery and provided increased rejuvenative options for both doctors and patients.  The represent an exciting and rapidly expanding part of anti-aging treatment and hold much promise for new fillers on the horizon.  What used to require surgery can now, oftentimes be accomplished in several minutes with minimally invasive injectable facial fillers.


For more information on injectable facial fillers and other cosmetic facial surgery click on




Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

May 9, 2008 Posted by | Lip and Wrinkle Fillers | , , , , , | 1 Comment