What are fillers and how to choose them

Svetlana Tkachenko, Candidate of Medical Sciences, Associate Professor of the Department of Dermatology, Venereology and Medical Cosmetology, Kharkov National Medical University (Kharkiv).

Pain management

Pain management during an aesthetic procedure is an important clinical parameter that significantly influences patient satisfaction. Pain is subjective and approaches to pain management must be individualized. The physician needs to assess each patient's pain threshold and provide pain management options that are optimal for the individual case. Effective pain management begins before the procedure begins. A calm and confident patient will require less anesthetic than a worried and anxious patient. It is clear that effective communication and a calming room environment will promote patient relaxation and improve the effect of additional pain management measures. The pain may be caused by the needle or may result from the actual insertion of the filler.

It is possible to pre-mix the filler with a local anesthetic. The technique of pre-mixing calcium hydroxyapatite filler with lidocaine was approved by the FDA in 2009 and significantly reduces pain when mixed with lidocaine prior to treatment . Although this mix changes the physical characteristics of the filler, these changes were not clinically significant . Approved fixed combinations of hyaluronic acid fillers with lidocaine are popular. It is known that some doctors prefer to add lidocaine to the solvent when reconstituting poly-L-lactic acid, but this use is not indicated in the instructions.

For some patients, non-invasive pain management options such as analgesics or topical anesthetic are sufficient. Applying ice is the simplest and most common method and produces a temporary local anesthetic effect. However, such analgesia is short-lived and must be supplemented with an anesthetic.

Commercial topicals containing lidocaine and/or betacaine are effective tools for pain relief. These drugs achieve their effect by reversibly blocking nerve conduction at the site of application. The analgesic effect is short-lived, but when used by qualified medical personnel, side effects are minimal. It should be noted that the FDA has issued a strong warning to consumers regarding the use of topical agents without the guidance of qualified healthcare personnel.

Infiltration anesthesia is the intradermal or subcutaneous injection of an anesthetic into the treatment area. This technique allows the anesthetic to diffuse through the dermis, but may result in significant distortion of the treatment area. It is this distortion that limits the use of infiltration anesthesia in soft tissue augmentation techniques. The exception is the lip area, since submucosal infiltration anesthesia has been successful in the practice of some doctors.

For many patients, regional nerve blockade is effective in numbing the pain of filler injections, especially in sensitive areas such as the lips. Regional anesthesia is performed by injecting an anesthetic around the nerve root, which leads to an analgesic effect in the area of its innervation. The block can be effective with a single injection of anesthetic, but there is also the risk of tissue distortion in the treated area. The practitioner must also be alert to the individual anatomical characteristics and changes in the neural and vascular anatomy, as well as in the structure of the patient's facial tissues. Attention to detail when performing nerve blocks improves overall analgesic effect and minimizes the risk of nerve injury or intravascular injection.

Injection technique

Proper injection technique ensures good results and avoids side effects. In this regard, the correctness of the injection technique involves both the manual injection technique itself, demonstrated by a specialist, and a specific injection pattern. Each dermal filler has unique characteristics that show the best results with a specific strategy. Each doctor has their own experience and personal injection style. In addition, the needs of each patient dictate changes in technique to achieve treatment goals. Most specialists develop their own injection style based on certain described techniques: depot, papule, tunnel, layering, fan, cross (mesh). The instructions for the drug often contain instructions on the preferred technique for proper use of the drug.

Combating complications

Safety is the most important factor when deciding to undergo soft tissue augmentation, as all dermal fillers are associated with some type of complication, which may be early or delayed. Most complications are temporary, localized reactions, but understanding the potential risk is critical when implementing a therapeutic plan. Side effects may be related to the injection technique or the drug itself. Complications associated with the injection technique include hematoma, infection, local tissue necrosis, acneiform eruptions, and nodules. Adverse reactions associated with the drug include allergic reactions and foreign body granulomas.

It is very important to distinguish between nodule formation and granulomatous reactions . Nodules are the result of a physical phenomenon that occurs to varying degrees when any filler is injected. They are usually clinically detectable within 2 weeks after treatment and are locally confined to surrounding tissue, maintaining their size until absorbed, treated, or removed by excision. The appearance of nodules is usually associated with drug placement and administration technique. Granulomas, in contrast, are an aggressive inflammatory response to treatment that occurs months to years after treatment. They usually form over the entire treated area, simultaneously and progress rapidly. Intralesional steroid injections are an effective treatment for such granulomas. Thus, in one prospective study , such conservative therapy caused resolution of injection granulomas within two years.

As with other aesthetic procedures, proper physician training, appropriate patient selection, appropriate drug selection, and excellent injection technique are key steps to minimize the risk of side effects. Although proper care is necessary when using any filler, long-term stimulating type fillers require special attention in the evaluation, education and treatment of each patient. Such fillers, as a rule, require additional treatment to achieve the desired aesthetic result, and are worse in terms of tolerability and reversibility than volumizers.