Injectable treatments have been used in the face since the late 1800s following the invention of the syringe. Among the first attempts was an injection of liquid paraffin into the lips, which was disastrous. In the 1950s, liquid silicone became a popular filler for the breasts and was subsequently used in the face. A combination of complications and legal concerns ultimately forced this practice underground. Modern use of injectables in the realm of facial restoration and rejuvenation dates back to the 1980s with the FDA approval of collagen fillers. Injectables have become an important and ever-growing segment of the facial rejuvenation industry over the last two decades.

The overall growth in minimally invasive procedures between 2000 and 2016 was 180% according to the National Clearinghouse of Plastic Surgery. Cosmetic injectable neurotoxin procedures experienced a 797% growth during that period. Seven million injectable procedures were performed in 2016. This is a result of many factors. Patients hope that new less invasive technologies will eventually replace traditional surgical treatments thereby obviating the need for longer recovery and greater expense, downtime, and discomfort. New technologies have to some degree fulfilled these desires. Another element adding to the enthusiasm of physicians for injectables is our deepening understanding of the dynamic volumetric nature of the aging face. As we gain more experience with fillers, we understand more fully how they can address many of the changes that contribute to a less than desirable facial balance. The safety and straightforward nature of fillers make them an ideal choice for many indications in the face.

Due to the variety of applications, and the relatively low-risk nature of the filler procedure, many individuals are good candidates for filler placement. The most important element of the history is to ascertain the patient’s goals. A thorough understanding of what the patient hopes to achieve should be established followed by an honest assessment by the physician of what he or she can realistically accomplish. Computer imaging is a very beneficial way of illustrating what can and cannot be achieved given the patient’s desired procedure, the patient’s budget, and the physician’s capabilities. Once mutual goals and understanding are reached, certain elements in the patient’s health history should be obtained. The patient’s history with previous filler injections can be very enlightening in terms of both alerting the surgeon to any undesirable reactions and the patient’s history of dealing with past disappointments. Preventative management is the best way to avoid risks. Risks for bleeding and bruising should be elicited such as a history of using anticoagulants or taking aspirin or NSAIDS. The patient with a history of perioral herpes simplex should be identified so that preventative measures can be initiated.

General health issues such as diabetes mellitus, collagen vascular diseases, or use of steroids or Accutane should also be noted. Any history of allergic reactions should be documented. If products with animal origins
(such as the bovine collagen used with PMMA) are being used, any history of allergies to animal products should be established. Skin tests should be done when appropriate. Cigarette smoking and active sun exposure should be noted. It is also important to establish the patient’s tolerance for bruising during the time that the patient plans to undergo treatment. If sensitive work or social events are imminent, it would be best to postpone the injections to a time when some bruising or swelling is more tolerable. Any recent facial procedures such as peels or other aesthetic treatments should be documented. Patients who are on antiretroviral therapy suffering from facial lipoatrophy will benefit from restorative fillers and were in fact the first FDA indication for fillers such as Sculptra. Patients who have congenital or acquired facial lipoatrophy also benefit greatly from fillers.

Preprocedural planning begins during the consultation. Once treatment areas are identified and goals and outcomes are mutually understood, the physician should explain all of the risks to the patient and obtain a signed consent. If the patients have taken any common agents that contribute to bruising, they should be counseled that they may bruise more than average or perhaps be rescheduled. Photos should be taken of the entire face from five views as well as appropriate close-ups. Fees are thoroughly discussed in advance as are “touch-up” policies.