LAS VEGAS In Dr. David M. Duffy's opinion, the perfect cosmetic filler doesn't exist and probably never will.
Current fillers on the market "are really a trade-off between results that don't last long enough and complications that last forever," he said. "In my view, the ideal filler would last 2-3 years, enough to give patients their money's worth, but not long enough to give them the problems that may occur."
Dr. Duffy, who practices dermatology in Torrance, Calif., discussed the contraindications and benefits of permanent fillers at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.
Patients demand permanent fillers for superficial defects from time to time without understanding that "there may be lots of serious, unreported complications with permanent fillers, particularly silicone, which has been used (pure or adulterated) in over 1 million patients," he said. "In fact, for every complication we see published, there are probably 10 that we've never heard about."
Key reasons to avoid permanent fillers in most patients, he said, are that temporary and semipermanent fillers are more profitable and less demanding to use, and more forgiving. "If you make mistakes with permanent fillers, they're for good; there's no margin for error," he noted.
Permanent fillers also require more time to inject, which makes them an unattractive option for hurried patients who want a true "lunchtime" procedure.
"You shouldn't use permanent filler before you get to know your patient," Dr. Duffy advised. "Temporary fillers give you an idea of how they're going to comply and respond."
Then there's the need for thorough training to properly place the filler. "Patient selection is quite demanding and there is a narrower range of appropriate defects than you have for the temporary fillers," he said.
"Be careful of the psychologically unstable patient who's had permanent filler placed by another practitioner and wants more," Dr. Duffy warned. "I won't treat patients who have had silicone placed previously. Problems can be delayed for 20 years, and you'll be blamed if they occur. I won't use permanent filler in polyallergic patients, and I won't make lips the size of Cleveland, no matter what they ask for."
Permanent fillers can be used appropriately in defects that are pliable enough so that when elevated the surrounding tissue is unaffected. They should not be used in areas where the skin is thin and hyperdistensible. Superficial defects "are very easy to overcorrect with permanent fillers, and if you do, it's there for good," Dr. Duffy said. "You can have delayed excessive fibrosis, particularly in high motion areas like the lips. And the implant may become visible as patients age."
Despite his misgivings about permanent fillers, Dr. Duffy currently uses liquid silicone in some cases. The product he uses most often is 1000 centistoke liquid silicone (Silikon 1000), which has 10 times the viscosity of water. "It's appealing because it's permanent, inexpensive, and wonderful to use," Dr. Duffy said.
For patients with atrophy related to HIV, he prefers 5000 centistoke liquid silicone (AdatoSil 5000), which has 50 times the viscosity of water.
The liquid silicone fillers don't have to be refrigerated, they will not support bacterial growth, and patients don't require allergy testing prior to use, said Dr. Duffy. "Most of the problems that I've see with silicone have occurred with infectious processes, particularly in patients with dental problems or sinus problems."
The most serious problems occur following misuse of silicone in "back room" operations. These include ulceration, cellulitis, granulomas, fistulation, blindness, and death.
"There are people who have made a lifestyle of criticizing silicone, because they see nothing but complications" and would never use them, he said. "Meanwhile, I've received some wonderful letters from patients who've received liquid silicone. I think there is a place for these products."
The conundrum about liquid silicone is the lack of objective data supporting its use and the lack of standardized product in years past, Dr. Duffy said. "Everything's anecdotal, with the exception of one unpublished study. This makes it difficult. Can you use these safely? Yes, you can. But you have to pick your patients well and know what you're doing. In the proper patient, silicone has no equal; good results are the norm and patients are enormously satisfied. Conversely, silicone's reputation makes it risky to use and the risk is particularly prominent for the physician, not the patient."
Dr. Duffy had no relevant conflicts of interest to disclose.
Despite Dr. David M. Duffy's misgivings about permanent fillers, he uses liquid silicone in some cases, such as in the patient above (shown before and after). PHOTOS COURTESY DR. DAVID M. DUFFY
