Dermal fillers are primarily used to fill in depressions caused by facial aging or hereditary predisposition (e.g., flat cheeks). However, doctors are now starting to use them in non-surgical rhinoplasty although their use can be quite limiting.
Renowned Los Angeles plastic surgeon Dr. Tarick Smiley says fillers only suit patients with minor nasal deformity: a small hump or irregularity along their nasal profile. Those who require minimal bridge augmentation may also consider this non-surgical approach.
Patients with severe or more complex nasal deformity—e.g., drooping tip, significant nostril flare, large bridge, etc.—will need the standard rhinoplasty, a surgery in which the bony and cartilaginous framework of the nose is reshaped. It is important to consider the patient’s skin shrinkage to ensure that it can redrape well to the new contour, instead of appearing amorphous especially at the tip.
When performing non-surgical rhinoplasty, Dr. Smiley only uses FDA-approved fillers to conceal minor imperfections of the nose. Hyaluronic acid-based materials like Juvederm and Restylane are the ideal choice since they can be easily reversed should the patient is not happy with the results; an enzyme called hyaluronidase can be injected into the tissue to dissolve the particles.
Hyaluronic acid-based fillers generally last four to six months and so they require upkeep should the patients want to preserve their results.
For patients who want longer-lasting fillers, one possible alternative is to use Radiesse whose results can last between nine and 15 months. Its main ingredient is calcium compound, which is not easily broken down by the body.
Meanwhile, permanent fillers such as silicone injection should be avoided due to increased risk of lasting deformity, infection, and skin injury, Dr. Smiley says in a previous Snapchat post.
One of the selling points of fillers is the zero downtime, while rhinoplasty typically requires 7-10 days of social recovery due to the postop bruising and swelling.
Despite the impressive safety track record of FDA-approved fillers, they nonetheless demand meticulous injection to avoid skin changes (redness), lumpy appearance, and skin necrosis (death of tissue). Hence, a prudent patient ensures that only a licensed/qualified injector does her procedure.
Dermal fillers approved by FDA have been evaluated for safety and effectiveness through extensive clinical studies and data collection. Primarily, they are used to smooth out wrinkles and to improve facial volume or contour.
Recently, leading Beverly Hills plastic surgeon Dr. Tarick Smiley has treated a patient with silicone gel injected into her cheeks about 10 years ago, a procedure that was done outside the US.
The non-FDA approved foreign material injected into this patient’s cheeks is causing pain and unnatural contour, which becomes more pronounced as she smiles and makes an expression.
It should be noted that the FDA has not approved silicone gel or liquid silicone injection anywhere in the body due to risk of deformity, infection, and migration.
The patient sought the expertise of Dr. Smiley to remove the foreign material that was already causing her pain and unnatural cheek contour—i.e., when she smiled, the lump of silicone gel bulged out, with its edges becoming more prominent and palpable.
“The foreign material does not move with the muscle and other soft tissue. It moves in one piece and is very hard, which of course looks unnatural,” says Dr. Smiley on Snapchat.
Furthermore, Dr. Smiley says the patient was at risk of infection, which could lead to facial disfigurement if the foreign material would remain in her cheeks.
To remove the synthetic material, Dr. Smiley created small incisions inside the mouth so all the scars would remain hidden. Then, he re-arranged some of the buccal fats to prevent contour irregularities.
Dr. Smiley says it is impossible to remove all the silicone gels because these are infiltrated into the soft tissue and are not “self-contained” like implants; however, he was able to remove most of the foreign materials injected into the patient’s cheeks, which resulted in more natural facial contour and lower risk of infection.
Because it is extremely difficult to remove free liquid silicone injections, the celebrity plastic surgeon advises patients to only use dermal fillers approved by FDA; they include Restylane, Juvederm, Radiesse, Belotero, and Sculptra.
The vast majority of FDA-approved dermal fillers are made of absorbable materials, which means they are gradually absorbed by the body within 3-6 months.
PMMA microsphere is the only non-absorbable [permanent] dermal filler that has been approved by the FDA; however, this is often used in other medical devices such as bone cement.
Selfies and social media are driving the popularity of lip augmentation, as people nowadays see their online photos regularly and might feel the pressure to always look good, says leading Beverly Hills plastic surgeon Dr. Tarick Smiley.
In 2015 alone, about 27,450 lip implant surgeries were performed in the US. On top of that, lip fillers accounted for a large percentage of the 9.2 million facial injection procedures, according to data released by the American Society of Plastic Surgeons.
This patient receives lip augmentation via Restylane, an FDA-approved filler commonly used to correct facial volume loss.
Dr. Smiley says that the vast majority of patients today desire for a more natural look, which can be achieved when there is a profound understanding of what constitutes an ideal “pout,” which of course is determined by gender factors and the pre-existing facial features.
And despite varying views on the ideal lips, Dr. Smiley says that recent studies have shown that most people found attractive “pouts” had their the lower lip about two times bigger than the upper lip. Also, female lips that took up about 10 percent of the lower third of the face scored higher in terms of attractiveness.
While most lip augmentation patients are women, there has been a significant increase in the number of men seeking some type of lip enhancement procedure. This new trend has a ramification—i.e., surgeons should understand the subtle but key differences between attractive female lips and male lips.
For instance, lip augmentation involving men should not create a well-defined “Cupid’s bow” shape; however, a slightly prominent bottom lip sulcus (dip) is perceived to be attractive. Also, a one-to-one lip corners ratio is desired to prevent feminine-looking lips.
Another “beauty” parameter, according to a recent study conducted by German researchers, is that female lips have a lower ratio between the lower vermillion height (lower lip) and the chin-nose distance than attractive male lips. This means that attractive female faces have a bigger “pout” in relation to the lower third of their face compared to men.
While several studies have pointed out that lips play a crucial role in the perceived facial attractiveness, Dr. Smiley says that other features also have their influence, adding that the “attractive faces are greater than the sum of their parts.”
Restylane for lip augmentation is a non-invasive way to improve the shape and fullness of the lips. In the hands of good injectors who have profound understanding of the beauty tenets and facial proportions, the technique can provide natural-looking results.
Dr. Tarick Smiley, one of the eminent Los Angeles plastic surgeons, has demonstrated how Restylane for lip augmentation can provide symmetric and natural-looking results, which were recently posted on his Snapchat.
The gold-colored vibrating device tricks the brain into thinking that the sensation comes from vibration, as opposed to the prick of a needle.
Restylane, Dr. Smiley said, is formulated with hyaluronic acid, a naturally occurring substance that gives the skin its “youthful plumpness and glow.” Aside from enhancing the lips, this type of FDA-approved filler or “volumizer” also works in age-induced facial lines and hollowness of the face.
While Restylane is a biocompatible filler and thus the risk of rejection is almost zero, it comes with a caveat: The body breaks it down gradually and so results only last 4-6 months, although when used as a lip augmentation the effects may be slightly shorter because the lips are always moving.
Less mobile areas such as the nasolabial folds or laugh lines tend to break down Restylane slower and so the results can last up to six months.
Because Dr. Smiley’s utmost priority was to create natural-looking results from Restylane, he first injected the lips border to improve their contour before giving them additional volume.
To further ensure natural results and avoid the “dreaded duck lips,” he made sure that the lower lip would appear bigger than the upper lip. One of the most common traps is making their size the same, or worse, the upper lip appears hugely disproportionate, a “look” which does not occur naturally.
Dr. Smiley said that respecting the pre-existing contours of the lips is the key to achieve natural results.
During lip augmentation, Dr. Smiley also used a vibrating device he placed adjacent to the injection site to “trick the brain so it would not feel the prick of the needle and instead focus on the vibration,” thus ultimately reducing patient discomfort.
His technique is backed by science. According to a recent study, the use of vibration device during lip augmentation provides analgesic effects, with 92 percent of patients saying they experienced significantly less pain with the addition of vibration.
Dermal fillers cheek enhancement is primarily used to achieve a more pleasant and youthful appearance. Hence, it requires precise injection and deep understanding of “universal” beauty and proportion to achieve results that look natural and pleasing, says leading Beverly Hills plastic surgeon Dr. Tarick Smiley in his recent Snapchat videos.
To demonstrate the effects of dermal fillers cheek enhancement, he showed a young female patient who wanted slight elevation and fullness on her upper cheek. She also requested for a conservative lip augmentation (involving only the lower lip) and a minimal skin lift and tightening along her jawline to reduce some of its fullness.
Dr. Smiley uses laser light to perform facial analysis. The idea is to identify the level of symmetry between the two sides to achieve results that look proportionate and natural.
In the video, Dr. Smiley said that “symmetry is important in facial dermal fillers” and so he uses laser light to ensure that the volume, shape, and height on both sides of the face are almost the same.
“While no one has a 100 percent symmetry, we can at least improve the proportion with meticulous analysis of the face prior to injection,” he said.
Because the patient’s right cheek had a little bit of more height than the left side, Dr. Smiley adjusted the amount of dermal fillers.
Dr. Smiley also used a laser light to help him determine the best placement of dermal filler injection. The light drew an oblique line between the tragus (small bump in front of the ear) and the corner of the lips; anything below it was not injected to ensure a nice contouring.
This oblique line helps Dr. Smiley determine where dermal filler injection should go to achieve some lifting effect. The area below the laser light does not receive any filler; the idea is to create a nice contouring or a slight depression.
“This line and the area beneath it are excluded. We only focus on the upper aspect of the cheek to create this nice contouring and definition, or a slight depression,” he said.
And by focusing on the upper cheek, Dr. Smiley said dermal fillers cheek enhancement will also have some lifting effect, further contributing to the pleasant and youthful appearance of the face.
To further achieve a more pleasant facial contour, the patient received a new modality (non-surgical) to lift and tighten the skin with the use of focused ultrasound energy.
“The Ulthera device can lift and tighten the skin along her mandibular area (jawline) to reduce some of its fullness, he explained.
While fat injections or dermal fillers can serve as an alternative to lower eyelid surgery, not all patients with under eye-bags can benefit from them.
The appearance of under eye-bag or “shadowing” is caused by different or even a combination of factors. Excess skin, herniated deep fat, loss or “shrinkage” of superficial fat (beneath the skin), or a combination of these variables may contribute to this aesthetic issue.
Before and after photos of a patient who have had fat transfer in her lower eyelid.
Basically, a “true” or standard lower eyelid surgery uses incision positioned very close to the lash line so the eyelashes can conceal the resulting scar. Referred to as an external incision technique, this allows the surgeon to remove excess skin and fat and possibly reshape the muscle.
However, not everyone with under eye-bags has excess skin. If the extra fat primarily causes this appearance instead, dermal filler injection (e.g., Restylane and Juvederm) can conceal the unsightly bulge.
The main purpose of dermal filler (as an alternative to lower eyelid surgery) is to make the lower lid bulge the same level as the upper cheek. This is a rather straightforward approach and does entail no or very little downtime; hence, it appeals in patients with busy schedule and cannot afford surgery and its ensuing “social recovery.”
But there is one caveat when dermal fillers are used to conceal the under eye-bag caused by excess fat: Touch-ups are generally needed at 6-12 months interval.
Meanwhile, fat injection or fat grafting is a method that provides longer-lasting effects than dermal fillers, with studies suggesting that its results last an average of 12-15 years. The procedure starts off with the collection of superficial fat (beneath the skin) usually in the tummy; only a few teaspoons are needed since the lower eyelid is just a small area.
The collected fat volume is then put in tubes and processed through centrifugation; the idea is to discard the oil, red blood cells, and other biomaterials except the fat cells. Afterwards, the purest form of fat is injected to conceal the bags.
It is important to note that fat injection and dermal fillers are basically volumizers (they add volume) and so they can also address the deep tear trough and the abrupt lid-cheek junction that come with aging.
It is not uncommon to combine volumizers with excision-based lower eyelid surgery to achieve the best results possible. This is particularly true for patients with excess skin, herniated deep fat, and abrupt lid-cheek transition, as suggested by leading Orange County plastic surgery expert Dr. Tarick Smiley.
Due to the laxity of skin and other supportive structures, the deep fat along the lower lid becomes prominent (i.e., it bulges out) with aging. In contrast, the superficial fat “shrinks” and thus gives the appearance of deep tear trough or abrupt transition between the lid and cheek.
To address the aforementioned problems, a small linear incision is made within the lower lid that allows the surgeon to remove the excess skin and reduce the deep fat pad. For additional fine-tuning, fat injection is used to create a smoother lid-cheek junction.