Dr Dev Patel discusses treating young patients and why he believes the term ‘filler’ is no longer relevant, especially when looking to achieve natural looking results for this patient demographic
If I were to sit here and tell you that the term ‘dermal filler’ has become obsolete in aesthetics, you would probably think I was joking. But, hear me out. I am not saying this to be controversial or because I don’t use these products regularly in my practice, quite the opposite. Like most aesthetic doctors, ‘fillers’ are one of the mainstay treatments I offer in my clinic. However, I believe the word ‘filler’ is no longer an accurate description of the products or techniques we use in aesthetic practice, as it only reflects a small portion of their capabilities. This is something I tell my patients at their very first consultation. Of course, we do still ‘fill’ some lines, such as the fine static lines around the mouth or tear trough. For these types of treatments, I use a blanching technique with BELOTERO Balance.11 I inject the product superficially into the dermis to ensure I do not unduly change the contour of the face in that area, as that is not the aim of this treatment. But that, for me, is where ‘filling’ ends.
Sadly, in an unregulated industry, many people are still being “filled”. Some patients are treated as if their face is one empty compartment that can be filled up, obliterating all angles and curves. We can’t possibly expect our patients’ features to remain human-like and natural if we employ this approach. Thus, I explain to patients that they should think of these products as ‘dermal pillars’ and that our aim is to establish support and structure to achieve a more complementary contour to the face.
In a word, no. Many years ago, when I started in aesthetics, I declined patients under 30 for anything other than lip fillers. Fast forward to more recent years, and that approach now seems medieval to me. While I welcome the new legislation banning the use of injectables on under 18s, I explain to my patients that ageing is a multi-layered process and that we mature from our mid-20s onwards. The skin itself changes, with increased laxity, primarily due to loss of collagen. Its support structures also diminish with the shrinkage and downward movement of fat compartments and the depletion of the facial skeleton. Thus, the primary benefit of dermal fillers (returning to that term for now) for someone in their 50s is likely to be restoring this lost support where the product is used in place of the fat and bone that was once there. With certain dermal fillers, especially my favourite RADIESSE Plus6 (calcium hydroxyapatite), one can also offer patients the bonus of a prolonged skin-boosting effect, which peaks around six to nine months after treatment.
So what about the 20-something patient, as shown in the images? (Figure 1). This young man is at the peak of aesthetic beauty (I use that term in the global sense), so why would I treat him when he has not experienced the loss of bone and fat support that come with ageing?
In his case, there is a genetic deficit of the support in question, namely fat. He was never meant to have it. It is who he is. Unfortunately, as is the case with many patients who present to me, the impact of this fat deficit can be significant in their lives. They may face comments such as, “Are you ill?” or “Are you not eating?” or “You should see your doctor and get checked out.” I have heard these examples and more from several patients. Of course, there will be many more people out there who won’t be making such comments to their faces, but their behaviour will nonetheless be influenced by the person they see in front of them. Why? Because, like the sound of it or not, humans respond more positively to humans that appear healthier. In fact, this applies to almost everything we see in nature.
If I presented a freshly picked rose to you, you would most likely say, “Oh, thank you for this beautiful flower.” If I gave the same rose to you a few weeks later when it is wilting with black-rimmed petals, you’d probably say, “Why are you giving me this thing?”. Health is beauty, and we are drawn to healthy things. There is plenty of evidence to back this up from studies conducted by psychologists and cosmetic surgeons/physicians.1-3 Going back to our young male patient, we can see that this is not about restoration but about enhancing a natural deficit to improve his quality of life.
RADIESSE7 was approved by the FDA in 2005 and has remained one of the few fillers that have approval. RADIESSE Plus6 – a pre-mixed version with 0.3% lidocaine – was launched in 2015. RADIESSE7 is backed by extensive research4-9 and is indicated for medium to severe folds and wrinkles in the face and to treat facial wasting in HIV+ patients. It’s made of calcium hydroxyapatite, consisting of microspheres of calcium suspended in a gel. These microspheres immediately improve folds and contour and stimulate the production of new collagen and elastin, which peaks at six to nine months post-treatment. In expert hands, the complication rate is extremely low.
In the case shown here, a single treatment lasting 30 minutes was performed. A total of 3ml of RADIESSE Plus6 was used with both needle and 22gauge cannula to achieve a 3D contour that reflected a healthier face. 0.5ml of BELOTERO Balance11 hyaluronic acid filler was also placed in each tear trough. Looking at this patient’s photos when he attended for a review two years later (Figure 1), you can see there is still a marked improvement from the images prior to his treatment in 2019. This is a common observation in patients treated with this product. I am also happier using RADIESSE Plus6 in more mature patients with skin laxity. As it does not work by attracting water, I believe it gives more natural-looking results and much needed collagen in the months to come. I strongly recommend 1-1 training on the product and using it only once you are a competent and experienced injector.
There has been such a rapid advance in not only the knowledge we have of the ageing face but also facial anatomy. Yes, that's right, the anatomy I was taught at medical school was not wholly accurate! Modern techniques of scanning with dyes have revealed sub-compartments, e.g. supportive fat pads, that we previously believed to be one continuous layer of fat.10 This has enabled us to broaden our insight into how we assess the face and where to inject it. The educated injector can thus take a much more holistic approach with dermal fillers, considering areas previously unconsidered by even the most expert of injectors, and indeed areas which most patients will still not ask to have treated. Examples being the temples, chin, forehead and pre-auricular area. The number one psychological hurdle for someone considering treatment is the fear of looking unnatural after treatment.
I am not surprised, considering that we rarely see natural results highlighted in the press. This does not make news. Trout pouts and over-puffed celebrity cheeks make news. If they are bombarded by these images, then, of course, our patients will have this fear. In the UK, many injectors are poorly equipped to appropriately treat, and thus many people can have their human-like features morphed into distinctly un-human and 'alien-like' forms. However, we can demonstrate that with the intelligent use of high-quality products and ensuring global harmony is maintained in the face, one can simply bring a degree of freshness back to the individual. As I have said before, if someone can tell my patient has had work done, I have failed.