On 10th January 2023, aesthetic journalist Alice Hart Davis, who is turning 60 this year, was featured in a Daily Mail UK article on the treatments she’s had over the past 20 years entitled “I’ve got 20 years of filler stuck in my face - it’s meant to dissolve over two years” While the title is sensationalistic the overall message from the article is one that sensible injectors (and I like to think of myself as one!) have been saying for years - you do NOT need to have filler “top-ups” every 6-12 months as the industry training companies will often tell you because fillers can last far longer than we first believed, upto 11 years, as it turns out, depending on the individual, the brand and type of filler used and more.  So does this mean all dermal filler is bad and we should all abandon it? Alice says no, as do I, with my thoughts on her article as well as what I regularly discuss with patients in clinic and my advice around dermal fillers.  Choose your provider carefully, ensure they’re an expert and stick to them. one person/clinic for your face it does not have to be me (I say this in clinic to every new patient also)  is experienced and does their job well including complications management  the skill is in repetition over thousands of hours and many years, not in a 2-day or 2-week boot camp or doing this on the side  choose your practitioner based on their skill, not price of product - the same product in 2 different hands can yield very different results if they are cheap, there’s a reason for it; what corners are being cut or are they practising on you?  medical aesthetics is entirely discretionary and my advice usually is, if you can’t afford it (yet), keep saving; it’s better not to start than to start and stop as there can be an initial phase where it may look/feel like you are going backwards. Think of it like a home renovation - it can look & feel crappy while you are in the middle of it.  realistic expectations and managing your anxiety around slow results, and common non urgent side effects is vital; medical aesthetics is usually for patient people  trust in your provider and what they suggest. It’s ok to have a plan in mind, but go in with an open mind and be prepared to listen to the advice of the person you’re consulting.  Filler for enhancement, maintenance or volume restoration are different. younger people, mostly young women, commonly seek lip enhancement if they have genetically thin or asymmetrical lips. For these cases, 1-2 mls in 2 more more sessions is usually enough, and maintenance with additional treatments only as and when needed every 12-18 months or longer.  for maintenance from as early as our 30s, filler can be used to subtly replace early volume loss before it’s very noticeable and the standard guide tends to be 1ml (the size of a blueberry) per decade; so for someone in their 30s, you’d expect around 3-4 mls just to maintain volume. Keep in mind a ketchup packet is 5mls.  volume restoration is different entirely which is what Alice likely had when she began in her late 30s/early 40s, the typical age I start seeing women wanting to address persistent signs of ageing that they can no longer ignore, among them volume loss. When volume loss begins to take its toll on our face rarely as early as our 20s, they can present as hollows under the eyes, flatness around the cheeks and temples as well as prominent smile lines and early laxity around the lower face. Restoring lost volume can take far more than the 1ml/decade rule, easily double that in most cases, until maintenance is reached.   Once you’ve reached maintenance, less is more. while there is no doubt that the initial outlay for a holistic full face rejuvenation is expensive the longer you leave it to begin, I always compare it to other discretionary spending we all undertake - holidays away; home renovations; orthodontics; designer fashion and more.  thereafter, maintenance is far more manageable and given what we know of the longevity of fillers now, placed well, it can be the gift that keeps on giving for many more years until there is further volume loss due to the ongoing ageing process.  at this stage I actively discourage my patients to focus on other modalities to maintain their results.  For maintenance of skin quality without risking pillowface, collagen inducing therapies are my preferred treatment  when you pick a clinician with significant experience and a wide skillset, you’re more likely to have a bespoke holistic plan devised for you that avoids overcorrection and odd results.  at Skin Essentials, our focus is always on using dermal fillers in the initial stages to replace volume as quickly as your budget will allow, while working on skin, lines and wrinkles in the background, and then maintain with skin therapies and other collagen inducing modalities such as biostimulatory filler, which dissolve in a reliable manner to induce your own collagen in the process.  If sagging  is your biggest and most pressing concern especially if you are also postmenopausal, you should not delay surgery if you can afford it.  at Skin Essentials we pride ourselves on holistic, evidence based medical aesthetics  we would never feel comfortable taking your money or selling you a product or service that we didn’t believe was right for you.  fillers do not lift, they only replace volume which can subtly provide lifting effect in some faces if at any point what worries you isn’t amenable to non surgical or minimally invasive procedures, I’ll be the first to suggest a referral to a plastic surgeon as there is no reliable way as yet to LIFT skin without surgery.  The take home message from all of this?  dermal fillers in experienced hands are exceedingly safe and risks are rare but not

Much of medical aesthetics done well, is subtle, so very subtle. People often believe they would not consider aesthetics because of the many, many examples of bad aesthetics we see walking all around us. They don’t want “duck lips” or “trout pouts” or “avatar cheeks”, “chipmunk cheeks” and more.   Many people never notice the temples hollowing even as other indirect signs of this begin to bother them - sagging around the eyes and cheeks, are a great and common example. The temples lose volume with age as fat pads are lost, overlying collagen in skin is lost, and bone gradually erodes. Since there’s already a natural concavity to the temples—actual hollows in the skull itself—you may see this area changing faster than other parts of the face or not be aware that this is what is contributing to your aged look: worsening of the crow’s-feet, dropping of the outer brow, giving a more mannish appearance, and even changing the shape of the face, giving it a peanut-shell shape. So what do you need to know to determine if you might be a suitable candidate for temple filler, or if it is what you need instead of more cheek filler? 1. Temple filler is subtle Almost all the work we do at Skin Essentials is subtle but with temple filler, we often get some pushback “I’ll cover the area with my hair/ scarf” except it doesn’t quite work like that. In order to address the areas that you do see, which bother you, we do need to begin with the temple if they are contributing or responsible for some of those changes. Done well, the temples still remain slightly hollow, but with better blending in of bones between your forehead and eye socket, which become more and more pronounced over time with temple hollowing. 2. Some people are more prone to hollowing in this area People who are naturally slim will look gaunt earlier, which can give an unhealthy look, but equally, in women, an overly angular appearance to their face which can be displeasing for them. Equally, people who are athletes and into high intensity cardiovascular exercise, are more prone to temple hollowing at earlier ages. 3. The Temples will hollow out in everyone, and those of with big cheeks may look worse than those with symmetrically slim faces Dr Joshi has yet to have any filler to her cheeks and around her eyes but she had temple filler 2 years ago and is likely due for more now, because when she smiles, her cheeks look “too big” next to her temples and out of balance. 4. Temples are a high risk area, so please choose your doctor carefully. Experience and qualifications matter here. Big blood vessels are close to the surface here, and you don’t want an inexperienced clinician treating you here. Look at the price as your insurance in the event something goes wrong and choose wisely. 5. Temple fillers are sensitive They can feel funny going in, and due to the tight space here, with swelling after treatment, they can cause a tight/swollen sensation, a headache as well as discomfort chewing for a day or two until it all settles. Any lumps or bumps, a given with any fillers, may also look or feel more apparent for a few weeks until they settle. 6. Temples are rarely treated alone By the time we see patients there’s significant ageing going on in the face, beginning at the temples and extending down to other areas - around the eyes, cheeks, the ears and the lower face. The skin is no longer held up by the loss of fat pads in these areas, and pools around the lower face, giving “eyebags”, hollows, sagging cheeks and eventually, jowls. This is exacerbated if sundamage also contributes to faster collagen loss, with more laxity.    The problem is to begin to address the concern from where it began and it can add up to a fair bit initially (8-10 mls or more depending on the degree of volume loss) over 3-6 months till we’ve addressed all the volume deficit. After that, you may need 1-2 mls a year as and when the need arises. Left too late, as with the patient on the left, who had a face and neck lift (not my patient), there’s not much we can do non surgically to help, so timeframe matters.      Ready to get started? If I can offer some advice, it would be to find someone who has a plan with a clear timeframe and budget to help you decide if you want to start at all - if you start, will you make it work and invest in yourself? As always, none of this is medically necessary, so if you are unwilling or unable, then my opinion is, you should not start. If you do decide to start, take a leap of faith with your trusted doctor, invest and trust. As always, I encourage you to seek the longterm therapeutic relationship over vending machine style aesthetics, wherever you go. 

I post a lot about safety with medical aesthetics, adequate experience and qualifications as well as aftercare protocols with the clinic you choose.  Why does this matter? I was in a surgical training program between 2002-2011 and did it full time for most of those years. Practice and training absolutely matters and cannot be disregarded.  At the same time, there are some common myths I hear all the time, and because I post about vascular occlusions to help raise awareness, it often puts people off, including some of my own patients. As always, it remains absolutely optional, but it is hard, if not impossible, to rejuvenate volume loss in a face without volume via either fillers or fat. So if a patient is adamant they would not consider fillers for volume replacement,  realigning expectations may be needed.  In saying that, when I hear people say they’d only consider fillers to certain parts of the face due to risk in other parts, I feel it is my job to correct medical misinformation, same as when medical aesthetics is passed off as “just beauty” with no risk.  So what do statistics and the evidence tell us?  For an indication, I looked at a recent article published in the dermatological journal JAMA Dermatology 2021; 157(2):174-180 The authors conducted a study looking at outcomes among a chosen cohort:  370 dermatologists followed for a year between August 2018 and August 2019. average experience between them was 22 years in practice Between them, 1.7 million syringes of filler were injected.  Their findings in summary:  1. The risk of vascular occlusion (VO) using a needle or cannula was 1: 5000 syringes used.  Overall risk using a needle was 1: 5410/syringe  Overall risk using a cannula 1:40882/syringe The authors emphasised that the choice of use of needle or cannula is nonetheless clinician dependent, and based on their experience, the area being injected as well as the anatomy of the patient.  2. VO can occur at any part of the face. Some areas are considered higher risk but no part of the face is no-risk eg lips, as many commonly believe  In this study, lips and the nasolabial folds (nose to mouth smile lines) were the most likely areas to be occluded. Highest risk areas include filler around the mouth, the nose, the frown lines.  3. Participants with > 5 years of experience had a 70.7% lower risk of VO than those with less experience.  By ten years of experience, this risk had evened out.  Risk of VO twice as high in someone with < 5 years experience.  As we know with surgical training, repetitive practice leads to fewer complications over time.  4. 85% of VO had no longterm consequences  Most VOs, if caught and treated in time, did not lead to any longterm problems such as scarring or deformity.  5. Highest rates of VO at lips and nasolabial folds  A common misconception is the notion that lips are low/ no risk and that risks of fillers, including of blindness, which is rarer still, is only with filler to the rest of the face. In practice, the literature indicates that lips are among the most common areas to have VOs.  6. Highest level of severity at the forehead  The riskiest areas to inject remain the areas around the lips, the nose and the forehead, and so it makes sense that if this happens, the highest likelihood of complications from a procedure is injecting these areas, especially the frown.  Take Home Message?  Experience trumps almost everything else, and the overall risk is still very low of a VO, and of blindness even lower but more catastrophic. Experience does not simply mean someone who has been doing this for 5 or more years, but also, in my opinion, someone who is safe, and has protocols in place, with followup and aftercare for more risky procedures so that nothing major is missed, and someone who can open the clinic up at 2am for you on a Sunday if needed.  So please, choose wisely. Price should not be your main determinant, and it’s better to have no treatment than to risk it with an inexperienced clinician. As I always say, medical aesthetics should be reassuringly expensive because it’s your face and side effects, while rare, can be catastrophic.  Source : JAMA Dermatology 2021; 157(2):174-180 doi:10.1001/jamadermatol.2020.5102

Following the publication of my post on cheap cosmetic injectables for Mamamia last weekend, I’ve been inundated by questions from people I’ve never met on social media, asking about the safety of injectables and specifically, of dermal fillers. One person said she’d been considering fillers to her lips and cheeks, but is now worried and scared and “How can you avoid getting a vascular occlusion? Is getting fillers in lips and cheeks ok?” As I do always, I encouraged her to seek a qualified and experienced cosmetic injector and to ask about their setup for recognising and handling a complication should it occur. It did get me thinking though, about how weekly now, we are seeing “botched” injectables on social media, not just dermal fillers, but also antiwrinkle treatments, and awareness is rising, but many people still seem unaware of what can go wrong, and equally, what that might look like because with rising awareness, is also rising anxiety which is good to some extent, and beyond a point, unhelpful.  Here is an image of the face, with a simplified drawing of the facial artery, which supplies the face, and its branches with focus on the area around the mouth, among the commonest areas that dermal filler is requested for and competed on.    When I did filler training (it was a weekend course over 2 days) years ago, we each injected 1/2 a side on a model eg 1/2 a lip or 1/2 a cheek under supervision. I was horrified at what could go wrong, and how, after this 2 day course for doctors, we were essentially given permission to go out and do dermal fillers, limited only by (in my case given my surgical background) common sense and a healthy fear of what could possibly go wrong. So how does a vascular occlusion occur? A vascular occlusion (VO) occurs when blood is no longer able to pass through a vessel. It may be a complete blockage or a partial one, causing a reduced blood flow to the parts of the body downstream from it.  A VO may be caused by many things, but in the case of aesthetics, it is most commonly caused by the accidental injection of dermal filler into a blood vessel. If left untreated, a VO of a blood vessel supplying the skin can ultimately lead to skin death due to loss of blood flow to it.                How common is vascular occlusion?  The reported rate of VO for all dermal fillers is thought to be around 1:100,000 cases, however it is widely understood among practitioners that this is likely widely underreported for the following reasons:  the rate of complications is rising rapidly and we do not have more recent numbers  increased popularity and the procedures being performed by less experienced injectors  many are underreported and if only partially blocked, may not show up with typical symptoms, or may be missed and therefore underreported, skewing data A summary by the FDA following a panel meeting on dermal fillers on March 23rd 2021 had this to say:  we all worry, and rightly so, about the highest risk areas for blindness from dermal fillers : the nose (41%) the cheeks (15%) smile lines (11%)and frown lines (10%)  what was new information to many of us was that the areas for highest risk of non-blindness related VO were as follows:  lips (38%) filler injections around the mouth ie smile lines (18%)  What does this all mean?  The report from the FDA, which is likely reflective of the state of most countries, shows that serious injury reports from the use of medical devices ie dermal filler have steadily risen, from 94 cases in 1996 to 1146 in the USA in 2020, a total of 10,325 cases between 1996-2020.  Keep in mind, these reports are in one country, and are assumed to be underreported because of the number of cases that go unnoticed or missed unless they cause serious and severe adverse outcomes.  So what is the take-home message?  safety first what are your injector's qualifications? how many years of general medical experience do they have before they ventured into medical aesthetics? do they know how to recognise an adverse outcome? are they contactable for the first 24 hours or so after a treatment which is when most VOs will present? can they seek help in a timely manner especially if unable to prescribe the antidote themselves, and reliant on a prescriber to do so?  You would, I hope, never consider getting surgery, even minor surgery, from someone who was not adequately qualified and experienced and did not operate from clean and medical premises. The premises themselves, is your assurance of the kind of care you should be expecting, so why would you compromise that with medical aesthetics and injectables, or anything that punctures the skin barrier such as many skin therapies?  Safety should always be first for you, and your treating clinician and if they cannot adequately reassure you, then you should not be going ahead.  As someone who has seen poor outcomes, they can often be harder to undo when I don't always know what was done, what was used, and how much of it was used. These are all medical procedures, and as a doctor, I have a duty of care to each and every one of my patients to educate them, consent them to the best of my ability and their understanding and to say no if I do not feel their expectations are realistic. After the procedure, I have a duty of care to manage any emergencies that arise in a timely manner and to see them through until resolved even if that means referring them on to someone else.  These are the basics every medic learns around patient safety and should be your assurance even if something goes wrong, since medical procedures can never be guaranteed. So please, choose wisely, choose someone qualified and experienced who can