Despite the easygoing label fillers incorrectly received, Hartman has lost count of the number of patients he’s seen with complications, asymmetries, and random bumps from visiting inexperienced or insufficiently degreed practitioners.
“It’s not just about sticking a needle in somebody’s face,” he stresses. “Years of experience and correcting other people’s mistakes and having a broad spectrum of patients so you can see how different products work in different areas, on different skin types and textures is invaluable. There’s a lot of hard learning that takes place when you’ve been in the trenches with fillers and, unfortunately, been exposed to some negative outcomes.”
In addition to board-certification, the bare minimum for a practitioner’s qualification, Hartman urges patients to question how many filler procedures they do on the regular — “and by that I mean a weekly, monthly, daily basis” — and dig deeper into their past experience by asking how many complications they’ve not only seen and resolved themselves but also sloppy work from others that they’ve corrected, to determine whether their knowledge base is sufficient.
A good doctor will proudly share photos of their work and choosing a doctor whose aesthetic matches your own is the key to a blissful outcome. “I think looking at the facial aesthetic goals is very important, just in terms of what they’re looking to achieve,” says board-certified dermatologist Rhonda Klein, referencing the varying sensibility of her patients. “My aesthetic may not be the same as my patient, and in that sense, it is helpful to look at pictures” to align on goals and a procedure plan.
“I always say that you have to like the style who injects,” explains New Port Beach-based board-certified dermatologist Heidi Goodarzi, referencing two schools of thought many injectors tend to have. One common perspective, and that held by Goodarzi, is the injector as the artist who will not be swayed by requests she perceives as “extreme or body dysmorphic” and will certainly not perform filler in a way that “is not my taste,” while others defer to their patient and “inject to their satisfaction,” regardless of how ill-fated they desired outcome may be.
“My preference is to enhance beauty, fight the aging process a little bit,” she explains. “If you don’t like the way the injector looks, or their staff looks, or their work online, or what they’re showing you in the office, run!”
Most doctors tend to stick to a light hand with first-time filler patients to ease into the process and view their first appointment as relationship-building and educational, for both doctor and patient.
“I always start by asking them, what has brought them to the point that we’re having this conversation, what it is they’ve started to notice, what they would like to change,” explains Hartman. “That gives me better insight to where they are mentally — there’s a big psychological component that goes into the decision to pursue cosmetic procedures.”
Understanding the sensitivity surrounding a patient’s insecurity allows for a more strategic, nuanced approach. And more importantly, allows the practitioner to skirt a potentially awkward conversation by reeling in a patient’s unrealistic goals in a thoughtful, empathetic manner.
In those instances, Hartman opts to “gently educate them about how their bone structure won’t support what they want, or how this will put their other features out of proportion, or how it’s just not a good idea to do so much at one time because you’ll stretch the skin and set yourself up for problems later, but overall, it’s definitely an opportunity to educate.”
To a first-time patient, it may seem like overkill to ask for the exact filler type, but to Rabach, it’s crucial because “the expectation of what the product can do is really, really dependent on what type of filler is used and in which area.”
She breaks the two classes of filler into two categories: dissolvable and non-dissolvable. Dissolvable fillers are hyaluronic acid formulations, “which are just like a big sugar molecule,” most commonly used in beginner patients, while non-dissolvable fillers are biostimulatory and composed from a range of other materials, each with a different set of side effects, impact periods, and endurance.
Unlike the skin from the collarbone down, facial skin texture is diverse and tender, with each area requiring a specific technique to administer.
Take, for example, the hyper-sensitive undereye area, says Rabach. “Those dark circles that we all have under our eyes most of the time, it’s not only that the skin is thin, but there are a lot of vessels under the eyes that show through the thin skin,” she explains. “That’s an area that could get very bruised if you don’t use a cannula.”
Rabach describes a cannula as “a sort of blunt, flexible straw,” which should be used in sensitive areas that require less filler, but increased precision, while the traditional filler needle can be used for cheeks, chin, or other larger areas.
“I consider a filler procedure one of the most high-risk procedures anyone can get done,” says Goodarzi. “When you inject fillers — for the best of us and the worst of us injectors — there’s always a chance that you could inject this occlusive gel into a blood vessel,” which could result in skin necrosis to the area that the punctured blood vessel supports, or blindness, if that blood vessel feeds the eye area.
“In all honesty, I don’t know of another medical procedure that you blindly inject into an area with a risk of injecting into a blood vessel,” cautions Goodarzi, emphasizing the importance of selecting an experienced practitioner “who has gone through medical education in the classical form of it, medical school residency” to mitigate risk that “exists for all of us.”
Goodarzi warns all patients to read consent forms carefully — and if one isn’t given, that’s a big red flag in and of itself — and to ask your doctor, “OK, in the event that this happens, what are we going to do? What infrastructure do you and your center have in place if we have a side effect? Do you have a clear plan of action of how we’re going to deal with that?”
Thankfully, occlusions are statistically rare and can be resolved with the appropriate toolkit, but feeling a sense of confidence and safety, to Goodarzi, is “the most important thing, I think” when considering dermal fillers.
Once you’ve made the choice to jump into the world of dermal fillers, preparation should begin about two weeks ahead of the injection appointment to minimize post-injection annoyances, like temporary swelling and bruising. Some doctors require an initial consultation appointment and a second appointment for the actual procedures, while others combine the two into one, if the patient feels certain and ready.
Prior to any filler injection, doctors will ask a series of medical history questions to determine whether individualized instructions to prepare for the appointment are necessary because “certain medical things, like a bleeding disorder or a family history of any kind of chronic infection where they needed hospitalization,” says Rabach, “will make a difference in how we prep the skin before the fillers go in.”
For patients without underlying conditions, preparation is more about managing potential bruising and swelling, rather than averting a serious medical concern.
“We advise patients to stop any supplements that may increase the risk of bruising, such as fish oil, and other medications, such as NSAIDs or Aspirin,” cautions Klein. “Also, alcoholic beverages, like red wine, can increase the risk of bruising, so we counsel patients on those factors, if they don’t want downtime.”
Avoid dental work for two weeks before and after getting fillers and smoking ahead of the appointment is definitely a no-no, says Goodarzi. And it doesn’t hurt to lay off super-salty food either, as that can boost the chance of swelling.
Every doctor has a different bedside manner with injectables, and COVID has introduced an entirely new set of protocols, precautions, and expectations. Fewer patient appointments, increased video consults and follow-ups versus in-person, temperature checks, and even administering injectables outside, are just a few of the new safety strides doctors are taking to ensure a positive and secure environment.
Klein’s modus operandi is to over-prepare her first-time patients for what to expect and provide ample time for the numbing agent to take effect, especially for patients who feel queasy with needles. For Rabach’s patients, “we talk through the entire process” so the patient is never left in the dark or caught by surprise.
She explains to her patients what she’s doing when she’s about to do it, including “what to expect, what the injections actually feel like and if there are going to be small pinches” to provide a sense of comfort, because getting a needle to the face is unsettling enough.
“Patients should know that fillers can leave mild to moderate bruising,” warns New York City board-certified dermatologist Howard Sobel, adding that patients need at least one week to recover before a big life event, particularly with lip filler. “It’s good to understand if the dermatologist has lasers in their office that can be used to break up any potential bruising post-procedure.”
Hartman agrees that both patients and doctors should jump on any swelling and bruising as soon as possible with a combo of ice packs, arnica, vitamin K, or bromelain. One of Hartman’s secret weapons against swelling is to pop an antihistamine immediately post-procedure to “stop the body’s natural reaction to overreact to this temporary implant.”
He also cautions patients to avoid makeup and exercise for 24 hours out of an abundance of caution, but generally, “there’s not really much aftercare” says Goodarzi, although she does ask patients to refrain from flying for 24 hours.
“I always say after filler, just give it a few hours,” says Klein, whose philosophy isn’t quite as conservative. “No yoga, no standing on your head, but if you want to go for a jog, do some light exercise, that’s fine. By the next day, they can absolutely go back to their normal routine.”
The gift of a high metabolism, for fillers, can also be a curse, laughs Hartman, because your body will break things down faster in all aspects, but notes that it truly depends on the type of filler used and the patient’s activity level.
The lifespan for a majority of fillers is 12 months, yet “that’s still going to be impacted by the area you’re using it in,” he explains. “If you’re putting it deep on the bone, like the cheeks, chin, or jawline, that’s going to fit better and longer than a more superficial product that you’re putting into the lips, which are constantly in motion, or the area around the mouth that we use constantly.”
Every doctor Allure interviewed for this story asks patients, especially first-time patients, to come back after two weeks for a post-procedure “high-five” appointment, as Rabach calls it, to support a patient’s emotional wellbeing, check on any lingering side effects, and confirm that the filler settled as expected.
“We see the patient and sometimes we’ll add to an area at that point. We try not to do too much at one appointment for a first-timer,” she explains. “We just check-in and ask, what do you think? Do you like it or do you want a little more?”
This question is key to decipher what is just run-of-the-mill bruising and what is an actual problem. “Pain is an indicator. Pallor is another, an area turning very white,” says Klein. “Vascular occlusion often has this red, star-like appearance to it. Any sudden change — changes in color and obviously vision changes are the most significant.”
An at-home guessing game isn’t the move, but calling to double-check with your doctor is. “We tell patients to call if there’s any question whatsoever and we will have them send a picture. There can be emergencies that need to be dealt with immediately. They can’t wait until the next day,” says Klein, a sentiment shared by all of the other doctors interviewed.
Don’t jump to conclusions immediately, fillers can take up to two weeks for the swelling to subside and the filler to settle into its final resting position. Also, take it from Hartman: “This almost never happens.”
“With the hyaluronic acid fillers, I remind them that there is an enzyme, hyaluronidase, which can dissolve it if they are unhappy, so we can always finesse it, smooth it, dissolve it, whatever it is they need and they’re really not married to the look.” Its reversibility has made HA fillers the golden child of dermal fillers, particularly in first-time patients.
Biostimulatory fillers are less forgiving, without a known product to reverse their effects, making it a product that Hartman says is “not for the novice injector, and it’s not for the inexperienced patient.”
All this to say, before you book an appointment for a cosmetic treatment with a board-certified dermatologist or plastic surgeon, it’s important to do your research and bring questions — your doc will be more than happy to answer them.