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Static ageing In recent years dermal fillers have become more advanced with much longer lasting results writes Karen Ellithorne. The newer fillers on the market all have their own unique attributes that work in specific ways to rejuvenate and plump specific areas of the face, with the most common ingredient being Hyaluronic acid (HA). Hyaluronic acid is a polysaccharide that is present in most human tissues namely the skin, bone, cartilage, synovial fluid, eyes, muscles etc.  In the skin it is generally found on the extracellular matrix and is responsible for the maintenance of the structure and plumpness of the skin. It is also responsible for the transport of water and nutrients in the skin and helps to attract nutrients. Hyaluronic acid is a skin protector and also a strong antioxidant. As we age the levels of Hyaluronic acid slowly decline, leading to loss of moisture and breakdown of collagen and elastin fibres. “The current fillers on the market consist of a carrier gel combined with HA that mimics the body’s action of collecting moisture in between the cells. This action plumps the skin, which then appears younger and healthier, and the appearance of wrinkles is reduced,” says Dr Gerhard van Niekerk, an experienced aesthetic doctor and trainer at Eternal Youth, with practices in Somerset West and Knysna. Jacky Shaw, practice manager at Lambton Medical and Aesthetic Centre, says that dermal fillers have changed in their composition and application over the decades. “Fillers were first introduced in the late 1980s using a fat transplant method purely to correct facial defects. Once results were seen, scientists began formulating a suitable substance to reverse the signs of ageing. The first FDA approved filler was made of bovine collagen. Unfortunately, it was not cost effective nor easy to inject. “Finally in 2003 the first FDA-approved Hyaloronic acid dermal filler was launched into the aesthetic market. The benefits of this ‘new’ HA technology was its ease of use, longevity compared to bovine collagen and importantly, the low incidence of adverse side effects such as allergic reactions etc. Most of today’s fillers also contain Lidocaine for minimal pain or discomfort,” says Shaw. What areas can be treated with dermal fillers? “Patients generally suffer from three main ageing concerns in the facial area,” continues Shaw. “Firstly, they get the formation of lines or wrinkles. Secondly, the good fat that serves as the scaffolding below the skin starts to deplete and descend, resulting in a loss of volume. Lastly, due to environmental factors and the intrinsic ageing process, we also lose elasticity in the skin forming a crêpe-like texture called elastosis. “When a patient presents with lines or wrinkles on the face it is important to distinguish between static and dynamic lines because the modality of treatment differs for the two types of lines. Dynamic lines are formed by muscle movement below the skin that forms a wrinkle from that constant contraction of the muscle ie. smiling, frowning etc. These dynamic lines are generally treated by muscle relaxing injections as they respond well to this treatment. If, for instance, a wrinkle or furrow does not smooth out after about three to four sessions of injection, then the doctor may resort to fillers to smooth the wrinkle further. “Static lines, however, are formed by gravity and volume loss and are ideally treated by dermal fillers. The type or viscosity of the filler will then be matched to fill the depth or extent of the line,” says Shaw. What are the typical areas treated with fillers and where have you seen the best results? “If one follows a holistic approach to the face, starting at the forehead and moving done to the décolleté, every area will be able to be treated if you work with a comprehensive range of fillers,” says Van Niekerk. “The typical areas include forehead and frown lines, crow’s feet, sleep lines on the cheeks, nasolabial, marionette and mental creases. Neck and décolleté wrinkles can be treated on a superficial plane whereas volume loss on the forehead, temples, cheeks, infra orbital, nasolabial, marionette, chin and jawline can be treated on medium and deep planes.” Dr Anton Potgieter, a Sandton based plastic and reconstructive surgeon, says that good results can be expected with all filler treatments if the area is correctly treated and if the patient is a good candidate for the treatment. “Cheeks are probably the area of the face that requires the greatest insight to treat and surprises the patient if done well,” he adds. In Shaw’s experience the most dramatic results are experienced in the mouth/lip area. “Dramatic does not mean the dreaded ‘trout pout’. Clients can walk in with dehydrated, shrunken lips surrounded by barcodes (smoker’s lines) and walk out in 30 minutes with beautiful smooth, soft and rejuvenated lips. Hollywood has given lip fillers such a bad reputation by overfilling or applying incorrect injection techniques in the lip area. I would advise that clients only go to an advanced injector for lips,” says Shaw. What can I expect before, after and during the procedure? Shaw would advise all patients to have a thorough consultation before the procedure in order to feel more comfortable and to know what to expect. Says Shaw: “It is of the utmost importance that the client to understand the realistic outcomes that can be achieved with the procedure to avoid disappointment due to unrealistic expectations. Disappointed clients are lost clients. During this consultation the patient should be asked what area is of most concern to themselves. This should be addressed first and thereafter you can discuss other areas that could do with improvement. I generally form a priority list in the form of a treatment plan. All possible risks such as tenderness and possible bruising should be explained,as well as factors that influence the longevity of the product such as smoking, sun damage, excessive exercise etc. Slow and steady is a good ethos to follow as it builds client confidence and allows for budgeting. “As the filler reaches its full effect, very often the list of priorities alters due to changes in the face following each procedure. It is also a good idea to wait out the filler maturation time of two weeks to see the final result as fillers attract moisture to the area and expand a further +/-20% more.”  After the consultation Shaw will book a 45-minute session for the procedure to ensure a relaxed environment. Before and after photos are taken for the client’s benefit as results are more visible when photos are compared. Shaw finds it very satisfying to plot her client’s aesthetic journey via photos. “The filler is injected slowly and in some areas the sensation is more of a feeling of pressure rather than pain. We perform dental blocks when doing extensive procedures around the mouth as this area is very sensitive. Massaging is done after the injection just to ensure that the filler is evenly distributed. Our follow up appointment is booked for two weeks post procedure. “After the procedure the client is asked not to manipulate the area or have any facial treatments for two weeks until our follow up. On the day of the procedure the client should not do any extreme exercise or heat treatments such as sauna. Clients are advised to treat their fillers well to achieve longer lasting results, such as daily sun care and a good skin care regime. Any pain, inflamation or bruising normally settles within a day or two and most of our clients go straight back to work following their procedure,” concludes Shaw. With many dodgy imports on the market what should a doctor look out for when  purchasing fillers for their practice? Van Niekerk says that all products that are sold commercially for aesthetic use in South Africa  should be registered with the MCCSA (Medicine Control Council of South Africa). However he strongly advises sticking with brands that have FDA approval and CE certification to ensure that the product has a high level of manufacturing using pure and safe compounds. This way the product will also have proven clinical studies and saftey profiles.
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