“HA fillers are popular to achieve a youthful look.”

Dr Anup Dhir, Plastic and Cosmetic Surgeon and Senior Consultant, Apollo Hospitals, New Delhi, shares insights on the use of botulinum toxin and fillers in aesthetic surgeries, related indications, treatments, and contraindications (if any) with Shriyal Sethumadhavan. 

D r Anup Dhir has been using botulinum toxins and dermal fillers in his aesthetic surgery practice for the last 15 years with good and satisfying results and very few complications. A Plastic and Cosmetic Surgeon and Senior Consultant, Apollo Hospitals, New Delhi, Dr Dhir says, “It is important to choose a surgeon who has good knowledge of facial anatomy and is experienced enough to deal with any side-effects, if they arise.”

Tell us about the use of botulinum toxin and fillers in aesthetic surgeries. 

Botulinum toxin injections, often referred to by the product names Botox, Neuronox or Myobloc®, are biological toxins (botulinum toxin) transformed into a therapeutic agent. Today, this toxin is used for the treatment of frown lines, forehead furrows, crow’s feet, lines around the eyes and wrinkles of the lower face. These injections have proven to be a popular nonsurgical cosmetic procedure. Aesthetic plastic surgeons have found that the type of lines and wrinkles that respond to botulinum toxin injections are those caused by the muscles – specifically muscles that contract during facial expressions such as frowning or squinting. Botulinum toxin blocks signals from the nerves to the muscles. The injected muscle is temporarily partially paralysed and can no longer fully contract, which causes the wrinkles to relax and soften.

Injectable temporary wrinkle fillers are also popular and can offer a more youthful look for a fraction of what a traditional facelift cost. Most will fill lines and wrinkles in less than half an hour with results that can last from six to twelve months or even more.

Injectable wrinkle fillers, unlike botulinum toxin injections that relax the muscle under a wrinkle, fill the line, crease, or area with one of several different substances. As a result, trouble spots nearly disappear, giving your facial skin a youthful look. In this technique, substances are administered in the skin to fill out or plump up lines on the face that have been created by the loss of elasticity in the skin as you age. By restoring the volume to these areas, the skin will look smoother and softer, resulting in a fresher and more youthful appearance. Earlier, collagen was used but since it was derived from cattle skin, newer substances such as Restylane or Juvederm containing hyaluronic acid have become available and are very popular.

In what kind of indications and treatments can surgeons use fillers? 

You may like to know that many visible signs of ageing can be traced back to volume loss. As facial tissues thin out, lines become etched around the nose and mouth and the cheeks look a little hollow. Dermal fillers can replace lost volume to help smooth wrinkles, plump the lips, and restore a more youthful appearance. Temporary fillers such as hyaluronic acid are popular to achieve a youthful look.

In what kind of indications and treatments can surgeons use botulinum toxin?

Botulinum toxin works by temporarily blocking nerve signals and muscle contractions. This improves the appearance of wrinkles around the eyes and between the eyebrows. It can also slow the formation of new lines by preventing contraction of facial muscles. It is useful for treating dynamic wrinkles of the face.

What about long-term safety record of using dermal fillers in plastic surgery?

Over time, long term use of dermal fillers can result in weakness of the muscles of the face, head, and neck. Although hyaluronic acid-based dermal fillers have a low overall incidence of long-term side-effects, occasional adverse outcomes, ranging from chronic lymphoplasmacytic inflammatory reactions to classic foreign body-type granulomatous reactions have been documented.

Are there any downsides or contraindications to using fillers and/or botulinum toxin in surgical procedures, that surgeons should be cautious about? 

Botulinum toxin is contraindicated in patients who are hypersensitive to any botulinum toxin preparation or to any of the components in the formulation. It is also contraindicated in the presence of infection at the proposed injection site. It also should not be given in nervous disorders like peripheral motor neuropathy, myasthenia gravis, a skeletal muscle disorder and progressive muscle weakness with carcinoma. It should also be avoided in certain ophthalmic conditions such as double vision, blurred vision and drooping of the upper eyelid.

The major contraindications to the use of a filler are any active infection near the site of injection, a known allergy or hypersensitivity to the filler material or to the lidocaine mixed in the syringe of the filler. Hyaluronic acid dermal filler injections are contraindicated and should not be used in the following situations:

• In combination with facial peelings, laser or ultrasound or other energy-based treatments.

• Patients with autoimmune diseases, breastfeeding mothers and in children, cutaneous disorders, inflammation, or an infection at or near the treatment site.

• Sportsmen and women should be informed that hyaluronic acid dermal fillers contain an active ingredient, which may give a positive result in a drug test.

Is there a message that you would like to share on a concluding note?

While all physicians are required to have a deep understanding of the human body, but not all physicians are taught to examine and understand the face and body from an aesthetic perspective. Plastic surgeons are uniquely qualified to perform cosmetic injections due to their aesthetic perspective and rigorous training to understand how surgical and non-surgical treatments will impact the appearance and function of treated areas. Although physicians in other specialties might bring a unique perspective, but they do not receive the same blend of aesthetic and medical training as plastic surgeons. Always choose a provider with training and expertise in aesthetic injectables, medicine and surgery, who provides a full spectrum of services. Never choose a provider based on price. It also helps to ask for beforeand-after pictures.