What are soft tissue fillers?

As we age, we form fine lines on the face and around the mouth. Lips lose their fullness. The cheek starts to droop, causing a deepening of the nasolabial fold. The tear trough area near the eye. All these are subtle signs of aging, and many are due to loss of fat and soft tissue volume in the face. I find for most of my patients in their 30s and 40s volume loss, not skin laxity, contributes significantly to the aging of the face.

Collagen was the first filler to come out, and since then there has been a multitude of fillers on the market.  Now the most commonly used soft tissue fillers are hyaluronic acids: Restylane®, JUVÉDERM®, Restylane® Lyft (formerly called Perlane®) Voluma®, Refyne, Defyne, Redensity, RHA2, RHA3, RHA4.

There is also another class of filler which is a collagen stimulator, called Sculptra®.

  • Fillers are a nonsurgical procedure I perform in my office.
  • There is little to no downtime.
  • They provide a subtle improvement in aging.
    • For the lips, Restylane®, RHA, and JUVÉDERM® make the lips a little fuller and get rid of the fine wrinkling around the mouth where lipstick bleeds.
    • They can be injected into the lower eye at the junction of the cheek, the “tear trough” area, to give a nonsurgical lower eyelid lift.
    • They can be injected into the cheekbone area to give the entire face a lift.
    • They can be used in the nose to do a nonsurgical rhinoplasty and reshaping (lift the tip, straighten, hide the bump)
    • When using Sculptra®, it is injected throughout the face, including in the temple, eye, cheek, and jawline to give a subtle, natural “liquid facelift.” *NOTE: Dr. Greenberg does not recommend Sculptra if you will want to do fat transfer in the future.
"Dr. Greenberg works with fillers as well, and, again, the results are beautiful. Those lines around your eyes and mouth will smooth out and melt away. It’s you, it’s all you, just with the clock cranked back a bit." - O.S., Belmont
*Individual results may vary
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Fat TransferSurgical Filler

Dr. Greenberg LOVES fat transfer.  When you age, you lose facial fat.  A lot of the aging you see (lines around the mouth, the nasolabial folds) are due to natural fat loss.  Filling the face not only helps it lift and get rid of fine wrinkles, when you use fat, the stem cells in the fat help improve the quality of the skin.

Fat transfer is really a surgical filler, so it is done in the operating room.  Frequently Dr. Greenberg will inject HA fillers in the office for years before people are ready to do something longer lasting.  This is a good way for you to see what fillers do to help make you look younger and have you be comfortable with Dr. Greenberg’s technique before doing the fat transfer.  She favors a very subtle, natural look.  Fat grafting involves some liposuction (usually from the abdomen or love handles), processing of the fat with a centrifuge, and then small injections done all over the face. Microfat and nanofat are used.  There is swelling and some bruising, hence her advice to think of fat as a surgery, not an in office-back-to-your-crazy-bay-area-life-in-a-minute procedure.

Please see the section on my website about fat transfer to the face for volume.

Filler Preparation

Fillers are an injection, which means there can be bruising. Some people never bruise, some frequently bruise. If you have never done a soft tissue filler injection before, don’t do it right before a big event in case you bruise. Bruising varies a lot by patient and by location of where you are injecting.

  • If you are on any medication which increases bruising (aspirin, Advil, Motrin, Vitamin E, fish oil), you should ideally stop two weeks prior to the injection.
  • Avoid working out right before and after the procedure to help minimize swelling and bruising.
  • See my blog on how to avoid bruising.
  • Arnica and bromelain can help decrease bruising.
  • If you bruise, depending on the size of the bruise, it can take a few days to a week to improve.

The appointment usually takes about 30 minutes. You can drive to and from the appointment. No pain killers are needed as there is a numbing medication in the filler injection itself.  We will have you ice prior and after the injection to help with pain and decrease swelling and bruising.

which filler should i use?

There are so many fillers on the market.  What do you use? Where? How much?

WHICH FILLER? Alas, I cannot advise you until I see you and how you react with the products.  There are general rules.

  • There are fillers which are “thicker” and “more structural” which give better, longer lasting volume to the cheeks.
  • There are fillers which are more “flexible” and perform better in high motion areas like the lip and nasolabial fold.
  • There are fillers which are “thinner” and do better in thin skinned areas like the tear trough.

There are different brands.  I find people tend to do better with one brand or the other, but the brand varies between patients.  So if you do a syringe of Restylane or RHA, and it goes away quickly, next time try Juvederm.  They are both great companies with good products.  Think of it like Coke and Pepsi.

WHERE to inject depends on where your issue is.  Just know that if you have a heavy nasolabial fold, the answer may be to inject in the cheek to lift the entire area.

HOW MANY SYRINGES you need varies.  It depends on the amount of volume loss, what areas, and how subtle you want to be among other factors. I am a naturalist, and subtle.  Most of my patients do one to two syringes.  You can slowly build an area up by doing and injection, and instead of waiting til it is gone in 6 months, come back instead at 4 months and build on what you have. I like subtle changes.  “You look good for your age.”  “I love that haircut!”  People can’t figure out why you look good, just that you do.

Why use a Cannula

Cannulas are blunt fine hollow tubes.  The benefits of cannulas are many:

  • Less bruising
  • Less pain
  • Less risk of inadvertently injecting into a blood vessel

So why not use it for everything?

Cannulas do not have much precision or strength as a needle, so for certain areas I think needle injections are better.  When you are injecting deeper into the tissue (like in the lateral cheekbone area), the needle has low risk of bruising and better accuracy.

But I love the cannula. I use cannulas all the time when doing fat grafting to the face, and love the technique. It does add a little cost, but particularly when injecting more superficially in the skin, I think it is great.

what are some filler names?

There are two big brands of HA fillers: Restylane and Juvederm. I like to think of them like Coke and Pepsi. Both are good brands. Both are well respected. Sometimes people just like one better than the other, sometimes they don’t care. I do find sometimes people do better with one brand than the other, meaning one brand lasts longer for them. Longer lasting = less $ and injections.

Each of the brands has different fillers within their brand. These fillers vary based on their “thickness,” so you pick them based on where you are going to inject in the face.

JUVEDERM brand: Juvederm (Medium thickness. Good for everything. My go to filler when doing multiple areas, though I don’t use directly under the eye in the tear trough), Voluma (thicker, usually lasts about twice as long as Juvederm.)

RESTYLANE brand: Refyne (thin, inject under eye, done with cannula), Defyne (thin, but thicker than Refyne. Use for superficial fine lines in the cheek or neck, also good for lips. Done with cannula), Restylane (medium. Can use anywhere), Restylane Lyft (Formerly Perlane. Best for the cheek.)

REVANCE brand: This is the newest HA brand on the market. They have 4 thicknesses: Redensity, RHA2, RHA3, and their thickest RHA4. It is particularly aimed at “dynamic” correction to look natural with movement.

do fillers hurt?

Yes. But how much varies by where it is being injected, if you are using a cannula, and your pain tolerance. The HA fillers all have numbing medication within the actual filler, but that usually doesn’t kick in at first. Areas like the cheek hurt less. Areas like the lips can hurt a lot.

Three common techniques to lower pain are topical numbing, icing, or vibration. I love icing the area. Not only does it help reduce the pain, the cold helps shrink the blood vessels to lower the risk of bruising. There was a study which looks exactly at which technique is best, and they found vibration was the best tool, so I use that as well in my clinic. Topical numbing sounds like it would be the best, but in the journal article it was found to be equal to ice and has to be applied 30 minutes prior for ultimate effect (so putting it on for 5 minutes isn’t enough). For established patients who want topical numbing, I give a prescription for the topical numbing so you can wear on your way to the office to allow the numbing to take effect. Can You Reduce Pain During Facial Injections? (laurengreenbergmd.com)

Sculptra® Collagen Stimulator

What is Sculptra®? You may have heard of the “liquid facelift.” Many of you use fillers like Restalyne® and JUVÉDERM® to fill in those lines around the mouth, the nasolabial fold, or the tear trough near the eye. When you need a lot of volume or want something that is longer lasting, Sculptra® may be the answer. It is not a new product. Sculptra® is approved by the FDA for restoration and/or correction of the signs of facial fat loss, or lipoatrophy. In a clinical study, the effects lasted for up to 2 years after the first treatment session in most patients. It is a natural, gradual change. Studies have shown it lasts up to 25 months.

The results from Sculptra® are not immediate; Sculptra® provides a gradual increase in skin thickness. It is like seeding a lawn, and the grass will then grow in gradually. It usually requires three treatments spaced 6—8 weeks apart. It stimulates your body to produce its own collagen. There can be bruising with each round of injections which may last a week. It tends to cover more of the face. It is a good option for those who need volume and want a facelift but don’t want to do surgery. I have been injecting it for a while now, and am pleased with the results.