S04E72 The Secret Lives of Dermal Fillers - How Long Do They Really Last?

How long do fillers like Restylane and Juvederm really last? Distinguished hosts, Dr. Sam Jejurikar @samjejurikar from Dallas, Dr. Sam Rhee @bergencosmetic and guest host Dr. Lawrence Tong @yorkvilleplasticsurgery from Toronto, (subbing in place for Dr. Salvatore Pacella @sandiegoplasticsurgeon) explore the surprising longevity of facial fillers. These plastic surgeons discuss how this volume may last well beyond their expected duration. We delve into the factors that may contribute to this extended lifespan, including how our bodies interact with fillers over time and the role of injection sites in determining their durability.

Our discussion also demystifies the complexities of dissolving procedures for those considering a return to their natural look or opting for surgical alternatives.

This episode also shines a light on the contrasting philosophies between board-certified plastic surgeons and other treatment providers. As we compare and contrast, we discuss the influence of financial incentives on treatment plans and the importance of prioritizing patient care over profits. The candid conversations extend to the risks associated with filler complications and the unified patient management approach that transcends practice settings. Join us for these enlightening insights on this revealing journey through the world of facial rejuvenation.

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S04E73 The Secret Lives of Dermal Fillers - How Long Do They Really Last?

[00:00:00] Dr. Sam Jejurikar: Welcome, everyone, to another episode of Three Plastic Surgeons at a Microphone. As always, I am Sam Jejurikar from Dallas, Texas, and I'm joined by my colleague Sam Rhee from Paramus, New Jersey. We have a pinch hitter today for Dr. Salvatore Pacella. We are lucky enough to be joined by Dr. Lawrence Tong, esteemed plastic surgeon from Toronto, Ontario.

Welcome gentlemen. Um, today we're going to talk about a couple of, uh, of some disparate topics. Um, we're going to talk a little bit about, um, about dermal fillers, which are really, really popular. And then we're just going to talk about, uh, procedures in general that we, uh, are finding to be popular in our own practice and what, how this kind of matches up with American Society of Plastic Surgery guidelines.

Rhee for our usual disclaimer.

[00:00:53] Dr. Sam Rhee: This show is not a substitute for professional medical advice, diagnosis, or treatment. It's for informational purposes only. Treatments and results may vary based upon circumstances, situation, and medical judgment. After appropriate discussion, always seek the advice of your surgeon or other qualified health profe, uh, provider with any questions you may have regarding medical care and never disregard professional medical advice or delay seeking advice because of something in this show.

[00:01:17] Dr. Lawrence Tong: All right, I am going to start by talking about dermal filler longevity. So most people know what dermal fillers are. These are materials that are injected, um, usually into the face. They're typically made of hyaluronic acid and they are used to restore or enhance facial features. Uh, the thing I wanted to discuss with you guys today is that, um, traditionally we've been taught or we've been told that these fillers Last a certain amount of time, typically anywhere from about six to nine months, depending on what type of filler it is, and then by that time the filler has gone away and And then the patient will come back and sort of re up and you know add some more filler I'm just wondering if you two have experienced some of the things that I've seen in that I think that these fillers actually last quite a bit longer Um, in the face than, uh, what's been, uh, what's been advertised.

Uh, so for example, um, I have patients who've, uh, started filler with me and they would come back every, you know, six months, nine months to, to get a refill, but then I would see that over time, um, they would come back and I would say, okay, you don't really need anything this time, or you just need way less than what we've typically done for you.

So if any of you have, uh, comments about that or experiences with that, I'd love to hear it.

[00:02:47] Dr. Sam Rhee: Uh,

[00:02:47] Dr. Sam Jejurikar: definitely, okay, when I was, I've definitely seen what you're, what you're describing and basically in the same patients too, it's not necessarily the patients that are first or second time filler patients, but patients who have sort of had a lifetime of filler. I have definitely noticed that as you know, um, If you think a filler lasts for 12 or, you know, 12 months, when a year goes by, it looks as though we just did the filler and these are patients that we've done, you know, for, for years, I've also noticed when, you know, when you're operating on some of these patients, like when you're doing a facelift on a patient who has had chronic filler in their cheeks or in their, um, Nasolabial folds.

And they've had it for, you know, for a decade or, you know, for a chronic period of time before the surgery that even when you're operating on these patients, you can actually see some of the filler in their soft tissue when you're doing the surgery. So I think, yeah, for sure. I think there is definitely a substantial amount of filler that over time the body just stops reacting to and it stops metabolizing.

[00:03:50] Dr. Sam Rhee: mean, I tried to do a quick lit search, and I have found a couple case reports where people have done MRIs on some of these patients, and it has definitely lasted for at least 27 months, plus, plus, plus, uh, in one case report, and then, uh, there was Uh, a case report about non surgical rhinoplasty where they were using hyaluronic acid like, like a Restylane or a Juvederm to, uh, help the, uh, nasal contour, the dorsum, and it lasted up to eight years in some of these patients.

So, um, I agree with both of you guys and that I've seen that in my own patients. Um, I do think it's location. specific or dependent in some ways. I think if there's a lot of motion, um, it tends to disappear faster. It's like, it seems like every lip injection I do, it goes, it looks awesome at like month three and disappears no matter what by month six to nine.

Um, but if I, uh, put that filler, say in the cheek area or in an area where there's not a whole lot of motion or pressure, it seems to last. A lot, lot longer. Um, and I don't know exactly why that is. Um, do you, I don't know if it's just that these areas are, you know, metabolically inactive, or there's just not a whole lot of, um, blood flow or contact.

I'm not sure. It's, you know. Is it because of the volume as well? Like, if you inject a small amount, does it resort faster? Do you find if you inject a larger volume, it tends to stay longer? I mean, that's sort of my guess to a certain degree.

[00:05:30] Dr. Lawrence Tong: Yeah, I think part of this stems from, uh, probably that we, we don't have a complete understanding of how fillers dissolve or, or break down. And, you know, we have, um, general ideas, but exactly what you said, Sam, uh, location to location probably has a factor to do with. And also, like you said, volume. So I think that what happens is that maybe once you get to some critical mass of volume, your body might not be able to break it down as effectively, um, anymore.

Uh, you know, for locations, just like you had said with the, um, uh, with the non surgical rhinoplasty, I do have a fairly large Asian population. And that is a pretty popular procedure to inject the bridge to get a higher dorsum. And I'll, I'll have patients that, um, you know, they'll come to me because they eventually want to get, uh, just a proper rhinoplasty, um, for surgery.

So we, we do that. You know, want to melt these, um, fillers before. And actually, they're fairly difficult to melt sometimes. I don't know if you have, um, experience with difficulty in trying to get rid of these fillers sometimes, um, when a patient feels that there's too much and they, they want to dissolve it.

[00:06:54] Dr. Sam Jejurikar: But just, yeah, that's actually where I was going to go to next because I think there's another, uh, variable that we haven't even touched on, which is not all hyaluronic acid fillers are the same. Um, there's different degrees of cross linking and there's different molecular weights with some of these.

And I've personally found that the fillers that we tend to use more in the cheek area and in the jawline area tend to stick around a very long time. And particularly, you know, this, I'm not sure if you guys have been, have tried to dissolve Volux or used a lot of, you know, Volux, but that's a really hard filler to dissolve.

Um, um, I mean, I have used 500 units of it on, on a patient to, to dissolve it all the way around their jawline area and been, you know, partially successful in that. When you're trying to dissolve filler in the nose, Larry, which, what kind of hyaluronic acid filler is it that you're trying to dissolve?

[00:07:51] Dr. Lawrence Tong: Well, a lot of times these patients aren't originally my patients. They'll, they'll be going to, you know, med spas and things around the city or even out of the country. Um, it's usually Um, you know, some sort of form of hyaluronic acid, and I will inject these people sometimes three or four times, and it still doesn't look like it's completely gone.

Um, maybe, because I thought of it as, uh, maybe because there's, you know, potentially many layers that the filler could be sitting in, you're not injecting the hyaluronidase, so that's contacting, uh, all the filler. There's not that much tissue in that, that area. It's not like the cheek, which has, you know, potentially more thickness or the jawline area.

So, I'm not exactly sure why sometimes it's hard to dissolve some of this stuff.

[00:08:41] Dr. Sam Rhee: Yeah, I've done pre treatment dissolving with hyaluronidase or hyaluronics, whatever you want to call it, um, to dissolve the hyaluronic acid. And I never, like, especially if I'm like pre facelift or something where I'm trying to get rid of all the filler in the cheek, I can never get it on one go. I always feel like I gotta go in, I'll get maybe like 85 percent of it, and then I'll have to have the patient come even if I'm massaging the crap out of that area and trying to get that hyaluronidase into every compartment or every layer, and then I feel like there's still a little bit of residual.

Um, I

[00:09:19] Dr. Lawrence Tong: And then when you do the facelift, there's, it's, it's in

[00:09:21] Dr. Sam Rhee: still some in there sometimes. Exactly. And so I'm always like, I don't know whether I should just leave it and not even bother trying to dissolve it before I do any sort of facial procedure. Should I just like, what do you guys do? Do you try to be aggressive in terms of getting rid of the filler before you do a surgery treatment?

Or do you just leave it in place and, and, and go with it?

[00:09:43] Dr. Lawrence Tong: For me, as you've heard, for rhinoplasty, I'll try to dissolve it. Because I think that can affect, um, you know, the height of the dorsum, ultimately. Uh, for facial procedures, if it's, if it's in there, I don't, I don't try to dissolve it, um, I think that if it's there and it's not, not really going to go away, maybe that's something that can enhance, uh, your result to some degree, but the downside or the flip side is, well, what if it dissolves later on and, you know, you have some, um, a result that's maybe not as symmetric or deflated compared to, to what you would have had.

So I think with time, we'll, we'll sort of find out what the best practices are, but At this point, I don't do it for the face.

[00:10:25] Dr. Sam Jejurikar: Yeah, I'm, I'm very much like Larry on this one. I, um, for noses, I think it's important to dissolve it. Um, for, you know, for most, um, baselift procedures that I'm doing, I'm adding volume, you know, doing some backcrafting at the same time as well. And I think the volumes of filler relative to the volumes of fat that you might be putting in are not really comparable.

There's a lot more fat that you're putting in relative to what the filler volume is. And so I tend not to spend a lot of time.

[00:10:55] Dr. Sam Rhee: What is your favorite filler? What is, what are the, Brands or types that you really like to use in terms of your own treatments.

[00:11:03] Dr. Lawrence Tong: So for me, uh, I usually stick with, um, the Restylane and the Juvederm products. So, I don't know if it's exactly the same in Canada as the U. S. but Restylane Lift is sort of my usual go to for sort of all purpose. So I usually tell patients that I break down the filler into sort of three conceptual categories.

Sort of a, a sort of a bread and butter filler, which would be like the Perlina and the rest of them lift, which, which you can use in most places in the cheeks and the nasolabial folds, marionette lines. Then there's, uh, the softer fillers that I will call them. So those would be like your, um, Bobella, which is, uh, used for the upper lids, tear trough in the lips.

And then sort of how I Think of as the thicker fillers, so the Volux, which Sam had mentioned, or the Voluma, that are meant to give you sort of more volume on a sit.

[00:12:02] Dr. Sam Jejurikar: I use, um, I mean, kind of all of the fillers that are out there to some degree in our practice, but, but the ones that most commonly are used in our, in our practice are the, are the Juvederm fillers. Family, you know, whether it's Volbella, deluxe, Voluma, velure, they're very confusing. Ultra plus like

They're, but they're, and, and, you know, they, they're different molecular weights, different levels of thickness. So for the lower, for the tear troughs, we use Volbella a lot for the, you know, for, uh. For the nasolabial folds, I use, I use, um, Velour for the cheeks, Voluma for the jawline, Velux. Um, and you know, there's, there's, there's role for things like Sculptra in our practice.

And, um, we use some of the RHA fillers a lot too. So, I mean, I can't say there's a favorite go to, it just sort of depends on the patient.

[00:12:56] Dr. Lawrence Tong: One thing that I wanted to mention is that because you see this phenomenon where the filler stays around for a long time, I think that that may be in part why we're starting to see patients faces. Have more distortion because they're used to getting their, you know, whatever, a couple syringes every, you know, half a year or a year.

And then over time, they just keep doing that and your healthcare practitioner or whoever that's doing the injection isn't sort of looking out for that or putting the brakes on things. That's when you can start looking sort of unnatural, let's say.

[00:13:39] Dr. Sam Rhee: Yeah, I would say my patients probably think I'm the biggest neg when it comes to fillers, uh, out there. And if any of them are listening, it's, they know like half the time they'll come in, uh, like. a year pass and I'll be like, yeah, it looks pretty good. I don't know if we really need to do the nasolabials that much right now.

And they want it. Like, they're like, it's my time. You said it was 12 months. It's time for me to get my filler. And I'm like, I don't think so. Let's just wait another six months and see what happens. And I am so glad when you said you wanted to bring up this topic, Larry, because I felt like it justifies, uh, my sort of aesthetic eye when I look at my patients and also to say, yeah, sometimes.

You really don't need it. And it's kind of weird as a plastic surgeon to be like, no, don't give me money to do something, but sometimes we actually do need to say that in order to sort of preserve, like you said, a proper aesthetic proportion for a person.

[00:14:37] Dr. Sam Jejurikar: Do you think that there's a difference, either one of you guys, in terms of the level of aggression that you as board certified plastic surgeons might use in putting in filler versus a nurse injector or a physician extender injector, people whose sole practice is injecting, whereas for us it's just a small portion of our practice.

Do you think that we are more likely to put the brakes on it?

[00:15:02] Dr. Lawrence Tong: Yes, so you, you know, you've heard, I'm sure you've heard that saying when if the only tool you have is a hammer, everything looks like a nail. So I think that, you know, if that's the only thing you have to offer, not everyone, but you, you know, you're more likely to just, um, go ahead and, you know, put some filler in.

Hopefully, you know, um, everybody will will have the sense and judgment to be able to, you know, say when. Um, you know, more fillers is not a good idea, but I think, um, as, as board certified plastic surgeons, because we have other options and, and maybe because, you know, we, we see that, uh, there's things in more sort of a global sense, um, we can, we're more comfortable with, um, telling patients, uh, when, uh, when to stop or, or when to hold off on things.

[00:15:57] Dr. Sam Rhee: I agree a thousand percent, Sam. I'm glad you brought that up because, um, it's not necessarily because we are surgeons, uh, Honestly, fillers and all of these other non surgicals are a relatively small part of my practice from an income perspective, right? Like, all of us will make way more money doing a procedure than we would doing, you know, filler treatments.

And so, for us, if you go to a meta spa and all they're doing are fillers, and that's their bread and butter, and that's what they're constantly doing all day, they're, I mean, let's face it, we all have financial incentive, but the financial incentive for them to do more And, you know, I have seen patients who have gotten three, like a trim, like three times the amount of volume that I felt like would be optimal for their, um, for their proportions or for their aesthetic features.

And, and not to say that we're so much better, it's just honestly, sometimes our financial incentive is just a little bit less to sort of really look out for, you know, What is right? Now, unfortunately, sometimes that also means some surgeons might push surgical procedures more than maybe non surgical, but that's where, as board certified plastic surgeons, we are supposed to be relatively impartial, appropriate, uh, care providers and, and no, listen.

We understand what your goal is and this is what we think it would take to help achieve that goal. And, and that's really a responsibility that we have as providers, that nurse, um, injectors, physician extenders, like it's really the same responsibility for all of us. It's just that the pressures are maybe slightly different for them as they are for us.

[00:17:46] Dr. Lawrence Tong: Yeah, one interesting thing that I see sometimes is I'll have a patient come in and they'll say they have bags under their eyes and they want to get a blepharoplasty and then I start talking to them and looking at them and, you know, I've seen more than a few cases where it's just filler, um, causing these bags and, uh, you know, we'll suggest dissolving it and that sort of takes care of the problem.

[00:18:08] Dr. Sam Jejurikar: yeah. I mean, the realities are many, many, many more syringes of filler in the U. S., and I imagine Canada as well, are put in by nurse injectors and physician extenders than, than by physicians. The vol, you know, the, I think it's, I, I heard it was 60 or 70 percent of all is, is done not by physicians, but by And so, that's the reality of it.

And the truth is, I don't mind that because I don't really want to practice full of doing fillers all day long. Um, even in my own practice, the majority of filler patients are either done at our med spa or by the physician's assistant in my practice. And so, who is very good and very conservative, by the way.

But, um, but, but I mean, it's just, you know, the realities are, we don't, there's very, we do know, we all know a few surgeons Who love doing fillers and seek it out, and it's a huge part of their practice. But the majority of us would much rather be operating, and we do this as a service to our patients.

We're not really going out trying to, trying to push a lot of this. Well,

[00:19:10] Dr. Sam Rhee: So

[00:19:11] Dr. Lawrence Tong: Yes, and I, and I think as, as surgeons. Um, you know, fillers are not entirely, this is a different subject matter, but fillers aren't entirely benign. It's not just putting too much in. You can have some bad complications, which you've probably discussed at a different podcast previously. And, you know, that also informs my decision as, you know, when you're putting this filler in, you know, if you don't have to put it in.

You are, every time you're putting morphine in, you are increasing risks of other things happening as well.

[00:19:45] Dr. Sam Rhee: always. I'm very mindful of that. It's a small thing, but it's not nothing. Let's just put it that way for sure. Um,

[00:19:55] Dr. Sam Jejurikar: you want to talk about another topic, Sam, or are we out of time?

[00:19:57] Dr. Sam Rhee: uh, I like that. That was pretty good. I think, uh, we should end with that. Um, as always, thank you, Dr. Jejurikar, Dr. Tong. Uh, if you're in Dallas, definitely go see Dr. Jejurikar. That's whom I would see. And if I was in Toronto, I would definitely go see Larry because, uh, Having trained with these guys, it's, uh, it's nice to sort of pick their brains and sort of see how their practices has developed.

And you know, what's always blows my mind is every time we talk about this stuff, I listen to you guys and I'm like, yeah, that's what I was about to say. Like the whole hammer nail thing, like. You know, the same thing with the physician extenders and the nurse injector. Like, you guys, like, read my mind. You guys, it's, uh, it's so funny how we are in different cities and we do different things, but so much of how we manage and think about these patients and how we manage patients is, is, is the same.

So I really love that. Um,

[00:20:54] Dr. Lawrence Tong: Do I complete you?

[00:20:55] Dr. Sam Rhee: do, Larry. You always complete me, Larry.

[00:21:00] Dr. Sam Jejurikar: Can you, can you, can you feel, can you feel me and Larry inside your head right now, reading your thoughts?

[00:21:06] Dr. Sam Rhee: I hear your voices, even as I think. Anyway, thanks so much guys, and I'll talk to you guys later.

[00:21:14] Dr. Lawrence Tong: All right, see you later, man. See ya.