The beginners guide to cosmetic injectables

Do you know your neurotoxins from your HA fillers? We simplify the jargon and give you the what’s what of injectables.

Plump cheeks, smooth foreheads and perfect pouts have led many of us down the cosmetic medicine path. Injectables – anti-wrinkle muscle relaxants and dermal fillers – are usually the go-to treatment for beautifying our looks and defying age, with minimum discomfort and no downtime.

The surge of minimally invasive procedures has been significant and with an ever-expanding and increasingly sophisticated array of options available today, you need to know your options.

We now have an enormous range of fillers, many of which can last a long time and be used to re-volumise and sculpt ageing faces. We also have neurotoxins to reduce lines and wrinkles, as well as lasers to effectively treat a wide range of skin conditions.

‘In the past 10 years, we have seen significant improvements in the technology and design of soft tissue fillers,’ says Sydney plastic surgeon Dr Steven Liew.

‘There are now different grades of fillers designed specifically for use in different parts of the face and different anatomical levels of facial structure.’

All about fillers

Fillers are used to plump out lines and smooth skin, restore volume to areas where tissue commonly degenerates with age, fill in pockmarks and acne scars, contour or reshape facial features and add volume to the lips. They are also a popular adjunct to treatment with anti-wrinkle injections to create a universal result.

Fillers are gel-like in consistency, and the type of filler (composition and viscosity), the area of injection and the depth of injection all influence the final result, and how long they last. Fillers can be made with biodegradable substances, such as collagen or hyaluronic acid (HA), or non-biodegradable substances like silicone.

Fillers can be used in multiple areas. ‘There is a lot of science behind soft tissue fillers that make them customisable to each patient’s individual requirements and to different areas of injection,’ says Dr Liew.

As with most cosmetic procedures, a holistic approach using fillers will obtain the best result. ‘As we age, the whole face ages – there are priority areas but, essentially, the entire face is subject to ageing.’ Dr Liew explains.

‘Gone are the days where patients come in and ask to have their nasolabial folds filled and that’s enough. We now know that treating the nasolabial folds will not change the patient’s overall appearance. We want to address and harmonise the face as a whole so the patient will look the best for their age at any age. Through communication, understanding and education, together the patient and practitioner can create some truly spectacular results.’

The benefits of HA

The longevity of results with HA dermal fillers can last anywhere between 6-18 months and beyond, depending on the amount of filler injected, the depth of injection and the level of movement at the injection site. The duration of the result is also affected by the extent of cross-linking between the hyaluronic acid chains, as well as the concentration and size of the HA particles themselves.

Increased cross-linking and higher HA concentrations boost the viscosity and elasticity of the dermal filler. This extends the longevity of the result. Larger HA particles, alongside higher concentrations, tend to absorb more water and result in more tissue swelling following injection, also increasing the duration of effect.

‘I prefer to use HA-based fillers because hyaluronic acid is versatile, long-lasting and effective,’ Dr Liew explains. ‘It also comes in a variety of grades to cater for the different requirements of every patient.’

‘The other benefit of using HA fillers is that, in the rare occasion where there is a minor adverse reaction such as swelling or lumpiness following injection, the HA can be easily dissolved with a chemical called hyaluronidase. This works almost immediately and acts as a lifeboat, or a safeguard, in case the outcome is not as good as we like,’ Dr Liew adds.

Hyaluronic acid is a substance that occurs naturally in the body. It is associated with attracting and maintaining hydration in the skin. For this reason, the benefits of dermal fillers are double-fold – adding volume and attracting hydration at the same time.

Filling fine lines & wrinkles

When injected superficially, dermal fillers can help smooth out fine lines and fill superficial wrinkles. Commonly, the HA chains are smaller and softer in superficial filler products, reducing the risk of lumpiness post procedure.

‘These fillers are used for areas that are more delicate, such as the corners of the mouth, the lip line and the crow’s feet,’ Dr Liew explains. ‘These fillers need to be very soft so the product can be placed superficially in the skin to smooth the area without the risk of seeing or feeling the product after injection.’

A small amount of filler is usually required; as the objective is to fill a line or wrinkle, not necessarily add volume to the area.

The small particle size, and low quantity of HA injected, means results typically last around six to 12 months. The level of movement in the area – for example frowning, talking and squinting – also affects the duration of the result.

‘The lip area tends to have slightly less longevity due to the degree of movement in the region,’ Dr Liew explains.

Adding volume

Medium volume HA fillers use medium-sized HA particles, which combine with the body’s own HA to enhance the volume of targeted tissue.

These fillers are injected more deeply than superficial products, and are used to treat deeper skin folds and enhance volume in certain areas.

‘In areas such as below the cheek, we prefer to inject soft fillers a little deeper, so they’re encased in the fat region,’ Dr Liew explains. ‘This provides some soft-tissue padding in the area.’

Medium volume HA fillers typically have a greater number of cross-links between the HA particles, compared with superficial fillers. This increases cohesiveness of the product and longevity.

Reducing under-eye circles

‘As some patients age, rather than having drooping skin, they become gaunt and hollow, particularly around the eye area. This is where I find fillers to be very useful,’ Dr Liew says. ‘Each injection can last up to three to four years, as the product is usually placed quite deeply to reduce the risk of visibility and palpability post-procedure.’

In 2015, a dedicated dermal filler for reducing under eye circles and hollows was introduced to the Australian aesthetic market called Teosyal Redensity [II] by Teoxane. It uses a unique HA formulation, designed to add hydration, elasticity and firmness to the skin around the eyes.

In the past, when surgery was the only option available, rejuvenation tended to be the domain of the rich or famous. Now you can take years off a person’s face at a fraction of the cost with neurotoxin injections to minimise lines and wrinkles combined with strategic filler placement, giving the eyes and overall face a fresher, younger appearance.

These non-surgical measures have revolutionised the aesthetic anti-ageing industry and made it available and ‘acceptable’ to a much broader audience.

Building & contouring

Deep volume fillers can restore facial contours or add volume where it is needed. These fillers have a distinct volume-enhancing effect, and are used to treat folds and facial depressions, as well as filling deep contours and hollows.

‘There are certain fillers specifically designed for volumisation and to increase facial contour and projection,’ Dr Liew explains. ‘These fillers are firmer and are essentially placed on the surface of the bone. They are used on the nose, cheek and chin.’

Commonly, these fillers act more like facial implants and, once injected, integrate fully with the facial tissue. Because of their high viscosity, deep dermal fillers do not migrate from the injection site and results can last from 12 to 18 months.

All about anti-wrinkle injections

Commonly known under the brand names Botox, Dysport and more recently Xeomin, botulinum toxin has become one of the biggest players in the field of cosmetic enhancement.

The treatment offers patients an effective non-surgical alternative for reducing lines such as frown lines and wrinkles to rejuvenate the appearance of the face and help reverse a prematurely aged appearance.

What is it?

Botulinum toxin is a protein produced by the bacterium Clostridium botulinum. In cosmetic procedures, botulinum toxin works by blocking nerve stimulation to wrinkle-causing muscles, which prevents the muscle from contracting and significantly reduces wrinkles and fine lines.

As a muscle relaxant, it is commonly used to treat crow’s feet around the eyes, the frown lines between the eyebrows (glabellar lines) and the worry lines across the forehead. In addition, it can be used to produce the effect of a brow lift by relaxing the muscles that drag down the brow and even in the masseter muscle to create a slimmer looking jawline.

Botulinum toxin is used by thousands of women and an increasing number of men to help rejuvenate the appearance of the face, most often to reduce a tried or over-worked expression when the face is static.

According to the most recent statistics by the American Society for Plastic Surgery (ASAPS) botulinum toxin injections ranked number one in the top five minimally invasive procedures performed in the US in 2015.

Although Australia doesn’t currently have definitive data about cosmetic surgery trends, we seem to follow American statistics to provide an insight into emerging and changing trends. These statistics highlight that this age-defying, wrinkle-busting powerhouse has become a very familiar, accessible and ‘normal’ anti-ageing treatment.

How does it work?

Cosmetically, injections of botulinum toxin work by relaxing wrinkle-causing muscles, softening existing facial lines and helping to prevent the formation of new ones.

A few tiny injections are administered just under the skin, reducing nerve stimulation to the targeted muscles. The procedure usually takes about 10 minutes, but this can vary depending on the number of areas being treated. Because men tend to have larger and stronger muscles, they often require more injections to achieve the optimal results.

Anaesthetic is generally not required for the treatment as the needles are very fine and only a small volume of the product is needed, making the treatment virtually painless. If the patient is particularly concerned, the practitioner can numb the area using ice or topical anaesthetic cream before administering the injection.

The effects are not immediately visible. Over the next few days, the muscles gradually relax, and it often takes around three to four days for final results to become visible, normally reaching their full results by one week.

It is important to note that botulinum toxin is gradually reabsorbed by the body over time, so repeat injections are necessary about every three to five months in order to maintain results. With continued use, the effects may start to last longer because the targeted muscles have ‘unlearned’ the response that originally contributed to the development of the lines.

In its 14 years of cosmetic use, there have been no reported long-term or permanent side effects from the use of botulinum toxin. Common side effects are generally restricted to minor temporary redness or bruising at the injection site, and some patients can experience slight headache or nausea post treatment.

There is a very slight risk that botulinum toxin can cause a temporary weakness in nearby muscles that can result in a slight drooping of an eyelid or eyebrow, lasting anywhere from around one to six weeks. Treatment with botulinum toxin is not recommended for women who are pregnant or breastfeeding.

Other uses for botulinum toxin

Botulinum toxin can be used in many ways to not only minimise wrinkles and lines but also lift and sculpt the face. It’s able to:
• Block the action of the nerves that control sweat glands, and in this way treat excessive localised sweating (hyperhidrosis), especially severe underarm sweating.
• Create a subtle lift around the eye area via injections in the outer corners of the brows.
• Soften and minimise the appearance of an overly square jaw (masseter hypertrophy) through intramuscular injections around the jaw area, resulting in a more oval-looking face shape.