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Fillers aim to stop the clock

March 10, 2008 |

Debbie Williams of Amelia isn’t turning the big 4-0 or having a mid-life crisis. She doesn’t yearn for a shockingly taut chin line or baby-smooth forehead. But a few weeks before her 39th birthday, she was looking for a little pick-me-up.

Like many 30- and 40-somethings, Williams turned to a non-surgical injectable filler to smooth those irksome lines and restore youthful volume to her cheekbones.

“There’s something about turning 39. I just wanted a little something, to freshen up a little,” Williams said. “But I didn’t want to not be able to raise my eyebrows at my kids.”

Botox treatments are the No. 1 cosmetic procedure for 35- to 50-year-olds, the bulk of people who seek facial and other bodily enhancements. But “next-generation” injectable gels are now the second-most-popular option – driving a non-surgical beauty industry that’s grown eight times nationwide in the past 10 years.

Locally, at least seven “medical spas” have sprung up, offering Botox and other injections.

That’s in addition to the dozens of doctor’s offices from Fairfield to Florence that offer the fillers. They promise a more youthful appearance for $300 to $900 an injection, every three to 12 months.

But as the popularity of cosmetic injections rises, new questions are being asked about who can – and cannot – safely administer them.

Licensed physicians are not required to have formal training or certification to administer an injectable gel. And in Ohio and Kentucky, licensed nurses can inject fillers “under the supervision of a qualified doctor who has prescribed the injectable treatment,” according to state law.

“The big issue that’s up for discussion is what does ‘physician supervision’ mean? It’s sort of unregulated right now,” said Dr. Vito Quatela, past president of the American Academy of Facial Plastic and Reconstructive Surgery and a member of the Physicians Coalition for Injectable Safety. The group was formed last year to bring attention to the appropriate use and setting for receiving cosmetic injections.

“I am deeply concerned when you have a day spa that’s evolved into a medical spa, and the doctor who’s supervisory isn’t even on-site; he’s a name on the wall,” Quatela said.

The Kentucky Nursing Board last month adopted guidelines specifying that the physician – or registered nurse with advanced training – must be in the room if a licensed nurse practitioner administers the injection, and must be “readily available” if a registered nurse performs the procedure. The Ohio Board of Nursing is considering similar guidelines.

Local practitioners say the guidelines – even though they’re not legal requirements – are welcome.

“There’s confusion in the medical community about who can do it, so imagine what it’s like for the public,” said Kathy Jones, a registered nurse and licensed plastic surgery nurse.

Although a botched Botox treatment or dermal filler injection rarely does permanent damage, even a tiny variation in the depth or technique of the injection affects the aesthetics of the end result.

Sandy Berling of Union believes the bruising and puffiness beneath her eyes that she experienced following a Restylane injection last year was due to the rushed technique of the plastic surgeon.

“His nurse got me ready, he came in with the needle, stuck it in (the skin beneath) my eye, and patted it real hard and left,” Berling says. “The way they made me feel was that I wasn’t very important to them, that maybe I wasn’t spending enough money or something,” says Berling, who since then has had several successful Botox and filler injections.


Fifty percent of all cosmetic procedures and 46 percent of dermal filler procedures are performed on 35- to 50-year-olds, according to a survey by the American Society for Aesthetic Plastic Surgery.

Today’s fillers are often synthetic or laboratory-created gels based on substances that occur naturally in the body but break down as we age. Some of the most popular brands are Restylane, Radiesse and Juvederm. Most clients receive 1 to 2 milliliters of the filler, which is injected into the skin via a syringe, usually after a numbing agent is injected into the area. The procedure takes less than 15 minutes.

Increasingly, patients are turning for their treatments to “medical spas,” which offer cosmetic dermal injections, laser vein and hair removal and light therapy skin treatments in addition to spa services such as massages and facials.

Eleven months ago, Williams had her smile lines and lines above her lips filled with Restylane by Dr. Navkaran Singh at the Avalon Salon and Aesthetic Day Spa in Oakley. She was so pleased with the subtle change that, for her second filler procedure in January, she added a few injections to the skin over her cheekbones to enhance her bone structure.

“People were saying, ‘Did you get new makeup?’ It was just very natural,” Williams said of her first treatment.

Like Williams, most 30- and 40-something filler clients are looking for a little pick-me-up, not the full lift of cosmetic surgery.

“A lot of women in their 30s are coming in to get these procedures,” said Kathy Jones, the owner of Kathy Jones Skin Care in Fort Wright. “They’re looking to stop the clock rather than reverse it.”

Singh, the medical director at Avalon, said his filler clients generally want to take off five years, but “don’t want to look like they’re 30 or 20 again.”

Unlike Botox injections, which block the transmission of nerve impulses to the muscles, dermal fillers fight the signs of aging on the face – such as sunken eyes, less-pronounced cheekbones and sagging eyelids and jowls – by filling in for the buoyancy that breaks down as skin ages.

“How we view aging has evolved a little. We used to look at it as sagging, so you had the lifting (to address it),” Quatela said.

Adding volume via a filler can, visually, fill in for a face lift or other surgical procedure.

“If somebody comes to you with baggy eyes and doesn’t want to have surgery, you can fill in the tear trough and it looks like you lifted their eyes,” said Jones.

“It’s an optical illusion. And that’s a lot of what plastic surgery is.”


According to a survey by the American Academy of Facial Plastic and Reconstructive Surgery, 96 percent of facial plastic and reconstructive surgeons believe dermal fillers will continue to dominate cosmetic procedures in coming years, mainly because of the convenience of the non-surgical treatments.

“We’re seeing that minimally invasive-type treatments that offer patients less downtime are increasing in popularity,” said Dr. Peter A. Hilger, president of the American Academy of Facial Plastic and Reconstructive Surgery.

“The goal is to have a nice, natural-looking outcome – you don’t want to look like you’ve had surgery.The trend toward non-invasive cosmetic procedures has allowed more Americans to get the look they want without having to turn their busy lifestyles upside down.”

Because most filler treatments last 12 months or less, they’re more expensive to maintain long-term than a surgical procedure, but clients are willing to pay the price for the convenience.

“Over time (a filler) can cost more than a specific surgery,” said Dr. Allison MacGregor Holzapfel, a plastic and reconstructive surgeon with Mangat-Kuy Plastic Surgery Center in Edgewood. “It’s not always about money, but about the downtime.”

With the exception of swelling the day of the procedure and the chance of slight bruising, there is no downtime associated with filler treatments. The average time away from work for a face lift is about two weeks, and cheek implants usually require one to two weeks of recovery, according to figures from the American Society for Aesthetic Plastic Surgery.


For Williams, a stay-at-home mother of three, downtime wasn’t an option.

After a brief consultation and a half hour to allow a numbing agent to work, Singh injected 1.3 cubic centimeters (1 cc equals 1 milliliter) of Radiesse into each smile line and the skin over each cheekbone, stepping back several times to eyeball his work before massaging the gel into place using the pads of his thumbs.

Fifteen minutes after the first injection, Williams is out the door, with recommendations not to sleep on her face or do heavy exercise for 72 hours.

The Radiesse, which is thicker than Restylane and injected deeper into the skin, fills in more over the first month. Her plumped-up cheekbones will last a year or more, Singh said, and her smile lines will be undetectable for nine to 12 months, depending on how much she smiles and laughs.

Although the effects of injectable fillers are marketed as a “liquid face lift,” practitioners said the procedures aren’t interchangeable.

“This whole new genre of fillers, where we can use them deeper and actually use them as filling, has complemented what we can do,” Quatela said. “(But) it will never replace a face lift.”


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