Fillers in Dubai: Tips to Achieve Successful Outcomes
Fillers in Dubai
INTRODUCTION
Dermal fillers have revolutionized the field of cosmetic dermatology. With the aging of baby boomers, dermal fillers have become a sought-after rejuvenation procedure as they offer a youthful, three-dimensional look with minimal downtime. Dermal fillers are gaining popularity because of the increased attention by the media and the availability of a wide array of filler materials available at prices more affordable than before. The use of fillers for soft tissue augmentation with the synergistic use of botulinum toxin and a variety of complementary procedures has become the mantra for rejuvenation.
Presently, the fillers available in India vary in source, longevity, site of deposition, and cost. The focus of this article is to analyse the fillers available in the market and to provide practical tips that would enable the dermatologist derive optimal results for the patient.
CLASSIFICATION OF FILLERS
Fillers can be classified either on the basis of longevity in tissues, or based on their source.
Based on longevity
Fillers are classified as temporary, semipermanent, or permanent. Temporary fillers stay in the tissue for less than a year, semipermanent fillers for up to 1–2 years, whereas permanent fillers are substances that remain in the tissue more than two years. However, there is some confusion in the classification of semipermanent and permanent status of some fillers, with some sources classifying any filler that lasts more than one year as permanent.
Based on the origin
Fillers may be classified depending on their source as:
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Human
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Animal
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Synthetic
Knowing the source of the filler is important as it helps the dermatologist to take decisions about the need for preskin testing and to know the patient’s preference. Many patients may not wish to use animal products for religious or personal reasons.
Temporary fillers
Temporary fillers are also referred to as nonpermanent fillers. Their stay in the tissue is for less than 12 months and hence, they have the advantage of spontaneously disappearing if the patient is not satisfied with the results. Similarly, an adverse event with such fillers is also a temporary one, as seen in the majority of the cases. However, rare permanent side effects have been reported even with temporary fillers.
Some of the common temporary fillers available in India are described here:
Bovine collagen-based products
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Zyderm 1
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Zyderm 2
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Zyplast
Human tissue-derived collagen
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Cosmoderm
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Cosmoplast
Synthetic fillers: Hyaluronic acid-based fillers
A wide range of hyaluronic acid products is available with varying hyaluronic acid concentrations and cross-linking structure and hence, also in their indications
Fillers in Dubai Table 1
Temporary fillers, their indications, and sites of placement
Semipermanent fillers
Semipermanent fillers undergo slow degradation with time over a period of 1–2 years. Side effects with semipermanent fillers are more common and longer lasting than temporary fillers.
Fillers in Dubai Table 2
Semipermanent fillers, their indications, and sites of placement
Permanent fillers
Permanent fillers are fillers that remain for longer than two years in the tissyue. Side effects with permanent fillers tend to be more permanent, and complication is the main issue with any permanent filler.
Fillers in Dubai Table 3
Permanent fillers, their indications, and sites of placement
Other materials, which are less commonly used, include Artefill and Silicone.
INDICATIONS OF DERMAL FILLERS
Fillers are mainly used in the rejuvenation of facial areas. However, dermal fillers may also be used in nonfacial areas and for cutaneous defects.
Facial areas
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Wrinkles and folds
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Lip Augmentation
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Depressed scars – postsurgical, traumatic, postacne, chickenpox, and other diseases
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Enhancement of facial contour
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Periocular melanoses and sunken eyes
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Dermatological diseases – angular cheilitis, dermal atrophy, AIDS lipodystrophy
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Earring ptosis, atrophic earlobes
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Nasal depressions
Nonfacial areas
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Neck
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Décolleté } Rejuvenation
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Hands
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Corns and calluses – to reduce contact points, pain, and risk of ulcer formation
CONTRAINDICATIONS
Complications of fillers are generally rare; they include:
Absolute
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Hypersensitivity to products
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Unrealistic expectations
Relative
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Keloidal tendency
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Patients with autoimmune disease
PATIENT EDUCATION AND ASSESSMENT
Patients should be counseled about the nature of the filler, what to expect, longevity, any possible side effects, and the cost. An assessment of both the physical and psychological states of the patient is necessary for a successful outcome. Written informed consent ensures compliance with regulatory and legal requirements as well as the management of the patient’s expectations. Pre- and post- photographs are important to critically analyse the results of the treatment and also, to prepare for medico-legal situations.
PROCEDURE OF FILLER INJECTION
The aesthetic benefit for the patient with temporary fillers can be attributed to 90% technique and 10% substance, whereas it is usually 99% technique with permanent fillers.[3]
Preparation and anaesthesia
The area of injection and also the surrounding skin should be cleaned properly with antiseptics. Anaesthesia is important for technical benefit and the patient’s comfort. Anaesthesia can be ensured by:
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Application of ice
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Topical EMLA cream application
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Regional nerve blocks – infraorbital, mental, maxillary, submucosal – as applicable, depending on the area
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Distraction Techniques such as massage, application of vibration
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Talking in a soothing and comforting manner – Talkesthesia
Injection technique
The choice of the injection technique depends on the indication, its location, the filler substance, size of the needle, and the experience of the injector. The techniques include:
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Linear threading technique
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Serial puncture
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Fanning
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Cross-hatching
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Depot
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Fern
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Cone
The first four techniques are used commonly, whereas the last three are only used in special situations. It is important to place the filler in the right place and the bevel orientation is not a significant issue at any site.
Postinjection management
Patients should be asked to avoid extreme cold or heat for 48 hours. Massaging of the treated area and strenuous physical activity should be avoided for six hours. Patients are asked to sleep with their heads elevated for one night; skin care routine may be followed after 24 hours.
Measures to achieve successful outcomes
A comprehensive treatment plan should be devised to suit the needs of each patient. Choosing the right filler for the right indication is vital. Where essential, combinations of fillers with botulinum toxin should be used to optimize the results. In such cases, it is advisable to inject the botulinum toxin first, wait for a week to see the improvement, and then, inject the filler to achieve best results.
FACIAL ANATOMIC AREAS: SPECIAL CONSIDERATIONS
Glabella area
Always choose patients with a positive glabella test. Inject small boluses relatively superficially, using only moderate pressure while injecting. Always watch for erythema and stop injecting when you see blanching as this will reduce the incidence of ischaemic necrosis which is common in this area. Techniques used in this area are usually a combination of linear threading and serial puncture techniques.
Nasolabial fold
This is the ideal indication to start with for a novice injector. Stretch and compress the skin to visualize the fold. Inject into a site medial to the fold to avoid further cheek ptosis. Overcorrection is common here and this leads to change in animation, lumpiness, and bumpiness. Remember that nasolabial folds always display a degree of natural asymmetry which should be discussed with the patient prior to injection. Usually a linear threading or a fern technique is chosen to treat this area.
Lips
The lips are the focal centre of the lower face. It is always important to consider antiviral prophylaxis in a patient with a history of herpes simplex episodes.
The height of the lips and the proportion of the upper to lower lip should be considered. The lower lip should protrude slightly beyond the upper lip. The upper lip should be 2/3 of the volume of the lower lip. Usually lip augmentation is done with a larger particle-sized filler in contrast to lip line augmentation which is done with a smaller gel particle-sized filler. Overcorrection of the upper lip can lead to a “duck bill” appearance. As lips swell immediately following the injection of the filler, steroid prophylaxis needs to be considered.[7]
A linear threading technique is done for volume augmentation and a microdroplet technique is used very rarely when one has to inject near the submucosal area.
Periocular area
The best candidates are younger patients with thicker skin and minimal to moderate volume loss. A depot injection at the level of the periosteum essentially traps the gel implant creating a long-lasting effect. Edema and ecchymosis are quite common in this area. Too superficial placement or thin skin in this area can lead to visibly pale nodules or Tyndall effect. Injection of filler into the periocular area is a difficult procedure and only a person with good training and experience should attempt it. One should also be aware of serious side effects such as blindness (see under complications).
COMPLICATIONS OF FILLERS
Temporary fillers have fewer complications and transient adverse effects when compared to semipermanent and permanent fillers. Adverse effects could be injection-related or filler material-related and may appear either immediately or later.
Early complications
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Hypersensitivity reactions
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Haematomas and ecchymoses
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Infections – reactivation of herpes simplex
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Nonhypersensitivity-related swelling
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Acneiform eruptions
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Erythema – transient or permanent
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Skin necrosis
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Embolism (blindness)
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Tyndall effect
Late complications
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Implant migration
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Telangiectasia
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Granulomas
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Lipoatrophy
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Hypertrophic scarring
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Sterile abscess
The treatment of complications should be aggressive and initiated as soon as possible after occurrence. Effective treatment of complications and assuring patients in the interim are the keys to successful practice.
NOVEL THERAPEUTIC AGENTS AS DERMAL FILLERS
Stem cells
Adipose tissue is easily obtained through liposuction and it provides a good source of stem cells which serve as a useful agent for soft tissue regeneration or repair. It has been found that fatty tissue has the highest percentage of adult stem cells of any tissue in the body with about 5000 adipose-derived stem cells per gram of fat vs 100–1000 stem cells per milliliter of bone marrow.
Autologous vein transplantation
Autologous vein transplantation can be performed with the unwanted veins of the patient. The procedure involves extracting varicose or other unwanted leg or hand veins of the patient, soaking the vein in hypertonic saline to destroy endothelial cells, and then, implanting portions of the remaining material (containing collagen, elastin, and muscle) into the dermal defect. The endothelium is destroyed to prevent newer angiogenesis in the implanted area. So far the results have been long-lasting with no complications. Although results are encouraging, this procedure is laborious at present, and is restricted to patients with unwanted veins.
CONCLUSION
With a variety of fillers flooding the market and with the aging of baby boomers aspiring to retain their youthfulness, careful selection of the patient, the dermal filler, and the technique can maximise patient satisfaction and lead to a successful outcome
Breast Augmentation Dubai With Sientra Silicone Gel Breast Implants
Breast Augmentation Dubai | 1 March 2018
Breast Augmentation Dubai – A surgical procedure to increase breast size and to treat such conditions as sagging or drooping of the breast (ptosis) or breasts of different size, shape, or placement (asymmetry). The first time a breast implant is placed to increase breast size or treat such conditions as ptosis or asymmetry, it is referred to as “primary augmentation.” Any time there is another surgery to replace the implant, it is referred to as “revision-augmentation.” Any surgically implanted artificial device intended to replace missing breast tissue or to enhance a breast. A lump in the breast.
Abdomen Anaplastic Large Cell Lymphoma (ALCL) Areola Asymmetry Atrophy Autoimmune Disease Biocompatible Biopsy Body Dysmorphic Disorder (BDD) Body Esteem Scale The part of the body between the upper chest (breasts) and the pelvis (hips); often called the stomach. ALCL is not breast cancer; it is a rare type of non-Hodgkin’s lymphoma (cancer of the immune system). The pigmented or darker colored area of skin surrounding the nipple. Uneven appearance between a woman’s left and right breasts in terms of their size, shape, or breast level. Thinning or diminishing of tissue or muscle. An autoimmune disease is a disease in which the body’s immune system attacks its own cells or tissues by mistake, causing damage and dysfunction. Autoimmune diseases can affect connective tissue in the body (the tissue that binds together body tissues and organs). Autoimmune diseases can affect many parts of the body, like nerves, muscles, glands and the digestive system. The ability to exist along with living tissues or systems without causing harm. The removal and examination of tissue, cells, or fluid from a living body. A psychological condition characterized by excessive worry about an imagined or minor physical flaw to the point that it can interfere
with normal daily activities. A series of questions asking about a person’s feelings about his or her body.
Breast Augmentation Dubai
reconstruct a breast after tissue was taken out because of cancer or injury. Breast reconstruction also includes the surgical correction of a breast that has failed to develop properly due to a severe abnormality or congenital defect. The first time a breast implant is placed to replace breast tissue is referred to as “primary reconstruction.” Any time there is another surgery to replace the implant, it is referred to as “revision-reconstruction.” The process of a soft tissue hardening when the mineral calcium builds up in a certain place. Tightening of the scar tissue (also called a capsule) that normally forms around the breast implant during the healing process after surgery. In some women, the scar tissue (capsule) squeezes the implant. When this occurs, it is called capsular contracture. This results in firmness or hardening of the breast. Capsular contracture is classified by a scale named Baker Grade.
Breast Implant
Breast Mass
Breast Reconstruction A surgical procedure to replace breast tissue or
Calcification/ Calcium Deposits Capsular Contracture
etc. and/or the immune system. Connective tissue diseases (“CTDs”) that involve the immune system include autoimmune diseases such as rheumatoid arthritis, lupus, and scleroderma. A use that is improper and should not be followed. Failure to follow contraindications identified in the labeling could cause serious harm. The major clinical study that supports the approval of a medical product (such as breast implants). For Sientra’s breast implants, the CORE study includes augmentation, reconstruction, and revision (revision-augmentation and revision-reconstruction) patients. Information on the safety and effectiveness of the implants are collected every year for 10 years after study participants get their implants.
Breast Augmentation Dubai – Displacement Extrusion Fibrocystic Breast Disease Fibromyalgia Fibrous Tissues
The production and secretion of milk by the breast glands. Complications that occur in the breast or chest area. Lymph nodes are glands that play an important part in the body’s defense against infection. They produce lymph, which travels throughout the body in the lymph system, and filters impurities from the body. Common areas where the lymph nodes can be felt with the fingers include: groin, armpit, neck, under the jaw and chin, behind the ears, and on the back of the head. Enlarged lymph node(s). When the implant is placed incorrectly during the initial surgery or when the implant has moved/shifted from its original position. Shifting can be caused by many factors, such as gravity, trauma, poor initial placement, and capsular contracture. Pertaining to the breast. A type of x-ray examination of the breasts used for detection of cancer. Plastic surgery of the breast. Surgical procedure to raise and reshape sagging breasts.
Death of cells or tissues. Palpability is when the implant can be felt through the skin. Visibility is when the implant can be seen through the skin. Major muscle of the chest. The areola is the pigmented or darker colored area of skin surrounding the nipple. Periareolar refers to the area just around the areola. Around the belly button. Surgery intended to enhance or improve the appearance of the body. A metallic element used to help make both silicone elastomer (the rubbery material of the breast implant shell) and silicone gel. After surgery. Information that warns the reader of a potentially hazardous situation which, if not avoided, may result in minor or moderate injury. Any artificial device used to replace or represent a body part. Sagging or drooping of the breast. Bleeding at the surgical site that causes discoloration and varies in degree and length of time. This is expected following breast implant surgery or other breast procedures. Removal of the implant, with or without replacement using another implant. Any additional surgery performed to the breast or chest area after the first breast implantation. The chance or likelihood that an undesirable effect will occur.
A hole or tear in the shell of the implant that allows silicone gel filler material to leak from the shell. Saltwater (A solution made of water and a small amount of salt). A surgical procedure to improve the appearance of a scar. Formation of tissue at an incision site; all wounds heal by the formation of a scar. Similar to a bruise, a seroma occurs when the watery portion of the blood collects around a surgical incision or around a breast implant. The Short Form 36 Health Scale; a questionnaire intended to measure physical, mental, and social health. The clinical Study that supports the approval
of a medical product (such as breast implants). For Sientra’s breast implants, the Study includes augmentation, reconstruction, and revision
(revision-augmentation and revision-reconstruction) patients. Information on the safety and effectiveness of the implants are collected every year for 10 years after Study participants get their implants. A breast implant rupture without symptoms or a visible change. Silent rupture cannot be felt by the woman or detected by a doctor through physical examination. Silent rupture can only be discovered through appropriate imaging techniques such
as MRI. Silicone is a man-made material that can be
found in several forms such as oil, gel, or rubber
(elastomer). The exact make-up of silicone will be different depending on its use.
Sientra, the company that sells these Silicone Gel Breast Implants, has designed this educational brochure to help you understand breast augmentation and to help you talk with your doctor(s) about breast augmentation. Sientra sponsored a large clinical study of these breast implants (also referred to in this brochure as the “Study”) that gathered data about these breast implants. The Study collected data from the primary augmentation and revision-augmentation cohorts of the CORE study, as well as pooled data from Sientra’s CORE and Continued Access studies for the primary reconstruction and revision-reconstruction cohorts. There are 1,788 patients participating in the Study. A total of 1,115 patients had primary augmentation and 362 patients had revision-augmentation. Of the 229 patients who had primary reconstruction, 156 patients were from the CORE study and 73 were from the Continued Access study. Of the 82 patients who had revision-reconstruction with Sientra Silicone Gel Breast Implants, 50 were from the CORE study and 32 were from the Continued Access study. Results from the Study are presented in Section 8 of this brochure. After you receive this information, give yourself time to read and think about the information. Because breast implants will require monitoring and care for the rest of your life, you should wait 1-2 weeks after reviewing and considering this information before deciding whether to have the surgery.
If you are having revision-augmentation surgery, your surgeon may advise you to have the surgery sooner. If you decide to have the surgery, you will be asked to sign a statement before the surgery. The statement says you have read and understood the information in this brochure and that you have been informed of the benefits and risks of breast implants. This statement is called the “Acknowledgement
of Informed Decision,” and there is a copy of it at the end
of this brochure. Make sure all of your questions have
been answered and you understand the information in
this brochure, before you sign the “Acknowledgement of Informed Decision.”
About Breast Augmentation With Breast Implants
The information in this section provides some general information about breast augmentation with breast implants
As shown in Figure 1, your breast consists of milk ducts, glands, blood vessels, and nerves that are surrounded by fatty tissue. Glandular tissue is firm and gives the breast its shape. The fatty tissue gives the breast its soft feel. The chest muscle (the pectoralis major muscle) is located underneath all this breast tissue but does not have much effect on the shape or feel of the breast.
What Is A Silicone Gel Breast Implant?
A silicone gel breast implant is a sac (implant shell) made of silicone elastomer (rubber), which is filled with clear silicone gel. Sientra uses implant grade silicone elastomer and implant grade high-strength silicone gel to manufacture its Implants. Sientra’s Implants are designed to resemble the human breast in shape, weight and feel. Sientra’s Implants are available in a variety of shapes and sizes, with either a smooth or textured surface. You and your surgeon can choose the Sientra round or shaped implant option that best suits your individual needs. Round implants provide volume in the upper breast area (called upper pole area). Shaped implants are intended to match the anatomy of your chest wall. Depending on your needs, shaped implants can also provide more or less volume in the upper pole area. Refer to Section 6.3 – CHOOSING THE RIGHT IMPLANT FOR YOU, for more information on the different silicone gel breast Implants available from Sientra.
Breast Augmentation Dubai? Breast implants are used to make the breasts larger or to restore or replace breast tissue. They are surgically implanted beneath your breast tissue, either on top of the chest muscle (subglandular placement) or underneath part or all of the chest muscle (submuscular placement).
stays within the scar tissue (capsule) around the implant. Sometimes, the gel does not stay there and may move to other areas around the body (gel migration). There have been rare reports of gel moving to nearby tissues such as the chest wall, armpit, or upper abdominal wall, and to more distant locations down the arm or into the groin. One group of researchers found silicone in the livers of women with ruptured silicone gel breast implants.1 Sometimes silicone travels into the lymph nodes. When silicone gel moves into the lymph nodes, they may become enlarged. When silicone gel moves into lymph nodes or other parts of the body, small hardened lumps of silicone (called silicone granulomas) may be felt. These lumps are NOT cancer, but it can be hard to tell them from cancerous lumps just by feeling them. If you feel any lumps in your breasts, around your breasts, in your armpits or anywhere in your body, your doctor should examine them. Your doctor may have to remove a small amount of tissue from the lump(s)
(called taking a biopsy) to find out if the lump is cancer. Before having a biopsy, be sure to tell your doctor that you have breast implants. Studies have been done to find out what, if any, effects migrated silicone gel has on the body.1-5 In most cases, no serious problems were reported. Several studies report that some women with migrated silicone gel experienced breast hardness, numbness and/or tingling in their extremities, and some seemed more sensitive to sunlight.1,4,6 In a few cases, migrated gel has caused nerve damage, hard silicone nodules (granulomas) in the body, and/or breakdown of the body tissues around the gel.5 Most doctors and researchers agree that there is NO evidence that ruptured implants or migrated gel causes
any disease that affects the whole body (systemic disease) like Connective Tissue Disease (CTD) or cancer. However, one group of researchers2,3 reported that women who had migrated silicone gel had a higher risk of getting a CTD. This is discussed more fully in Section 4.2.
or without being replaced) at some point during the course of your life. You and your doctor may decide to remove an implant or implants because of a complication or to improve the cosmetic result. Based on the experiences of augmentation patients in the Study, the 3-year risk of implant removal (including removal with replacement for a size exchange) is 6% for primary augmentation patients and 11% for revision-augmentation patients. This means that 6 out of 100 primary augmentation patients and 11 out of 100 revision-augmentation patients who receive Silicone Gel Breast Implants may need to have one or both implant removed within 3 years after receiving their implants. Implant removal information from the Study is discussed more fully in Section 8.6.
Breast Augmentation Dubai – Benefits
Breast Augmentation Dubai | 1 February 2018
Women choose primary breast augmentation surgery to increase the size and proportion of their breast(s). In addition, women choose revision-augmentation surgery (replacement of an existing breast implant) to correct or improve the result of a primary augmentation surgery. According to literature reports, most women who have undergone breast implant surgery have reported high levels of satisfaction with their body image and the shape, feel and size of their implants.67 In Sientra’s Clinical Study, most primary and revision-augmentation patients were pleased with the results of their implant surgery. The results showed that most women who underwent primary or revision-augmentation with the Study Implants felt their breast implants made them feel more feminine and more attractive. In addition, the majority of these women indicated that their breast implants made them feel better about themselves. For more information on the benefits of breast augmentation with Sientra’s Implants based on the results of the Clinical Study, refer to Section 8.3 of this brochure.
Preparing For Breast Augmentation Dubai With Silicone Gel Breast Implants
Deciding to have breast augmentation with implants is an important personal decision that has both benefits and risks. You should decide whether it is the right choice for you after discussing all the options with your plastic surgeon and any other doctors who are treating you. This section will give you the information you need to make an informed choice and help you make a number of decisions that have to be made before your surgery.
Should I Have Breast Augmentation Dubai?
Breast augmentation with Silicone Gel Breast Implants
is one option that may be available to you if you wish to enhance the appearance of your breasts. A breast revision-augmentation surgery may be appropriate if you have had
a breast augmentation with implants but need to complete, improve upon, or correct a part of that first surgery (called the primary augmentation). Whether breast augmentation is right for you depends on many things; some of them are personal. You should take into account your medical condition, general health, lifestyle, how you feel emotionally, and your breast size and shape before surgery, as well as your hopes for breast size and shape after surgery. All of these things will affect the outcome of your surgery. Discuss your goals for breast augmentation with your doctors. You may also wish to consult your family and friends and breast implant support groups, to help you learn about the options and decide. Many women who choose implants as part of their augmentation say their augmented breast(s) help them feel more self-confident, feel better about their bodies, and/or give them a greater feeling of well-being. Other women are not satisfied with their implants because of complications, like capsular contracture, rupture, or pain.
Breast Augmentation Dubai With Implants – Understanding The Procedure The surgical procedure for breast augmentation consists of choices you and your surgical team (surgeon(s), nurses, anesthetist, etc.) will make as you plan your surgery. These choices include:
• The surgical setting (where the surgery will be performed, for example, in a hospital, surgery center, or doctor’s office),
• The type of anesthesia used,
• The location of the incisions made to insert the Implants,
(location of cut through which the breast implant is inserted in your body) usually used for breast augmentation surgery:
will not have enough skin and/or breast tissue to cover the implant you desire. In this case, you may be offered several choices. Breast implants that are too big for the amount of breast tissue or skin can cause problems: they can actually speed up the effects of gravity; your breasts may droop or sag earlier with implants that are too large. Implants that are too large can also cause implant extrusion, skin wrinkling, infection, and hematoma. You may be able to feel folds on the implant created by it being squeezed too tightly by the surrounding tissue and skin. If you do not have enough skin, and it is stretched too thin over the implant, you may be able to feel or see the edges of the implant under your skin surface after surgery. As shown in Figure 4, the Implants come with either a smooth shell or a textured shell; you should speak with your surgeon to find out whether he or she recommends smooth or textured implants for you.