Cosmedica Clinic- Plastic Surgery guide for patients

The initial result is seen immediately. Then the resorption of the edema and the distribution of the product over time must be taken into account, so that the final result can be evaluated approximately 2 weeks after the injection. 

We think it's stupid to inject the whole amount and have the patient see the end result. We proceed that during the treatment we show intermittently and alternatively what is obtained and thus the patient can tell us if she sees a difference, if we still need to add volume or we can stop. In any case, if the injection is done correctly and a large amount of product is not stored, there is no need to think about removing the product. If there is a medical problem of ischemia of a tissue due to intravascular injection or due to the pressure created by the acid, we must be prepared to remove the product by injecting hyaluronidase. 

Another situation in which the melting of hyaluronic acid by using hyaluronidase can be considered is when the product has been injected too superficially and created the so-called Tyndall effect. This usually happens at the level of the circles. This would result in the impossibility of proper drainage of the lymph, due to the pressure of hyaluronic acid on the lymphatic vessels. This effect will create an appearance of fluffy and more swollen eyelids, which may be more pronounced during the morning or after a water retention and which may diminish during the day and in the evening. 

This translates into movements of the eyeballs that will release some of the lymph from the lymphatic vessels. This can last for years and if it produces an unsightly effect, it must be corrected by enzymatic digestion using hyaluronidase. Another condition by which hyaluronidase can be used is when nodules or granulomas appear after the injection. Nodules appear due to the technique of injection or dislocation of the acid and its conglomeration following special conditions that must be known by the patient and granulomas can occur both due to the quality of hyaluronic acid and the effect of thermogenic treatments that were made after hyaluronic acid injection. Under these conditions, the injection of hyaluronidase should be considered, which in most cases will definitely solve the problem.

But we consider it foolish to inject hyaluronidase to melt the acid because it has been put in excess, either because of the patient or because of the doctor. We do not encourage such practices when using large amounts of hyaluronic acid on the grounds that the patient wants very large lips or extraordinary cheekbones. These treatments do not categorize us as responsible and experienced doctors, so we do not accept such requirements from our patients, but we do not face such a thing, except quite rarely. Even when we have a patient who wants an artificial result, it is very possible to refuse treatment, explaining its implications. It is not the excessive volume that makes us more beautiful and attractive, but the result by which, for example, the lips seem bigger, but it does not seem to have been treated.

It all starts with the consultation, through the anamnesis and the objective local examination of the face, associated with the needs or desire of the patients. In the consultation we explain to patients what can be improved, how and how much hyaluronic acid can be thought of. Through this, we try to translate their desires into the amount of hyaluronic acid that will be needed.

This is not often easy, especially when the patient has a limited budget and wants a certain effect. Our recommendation in these situations is to start the treatment using 0.5 or 1 ml in a certain region and so patients can see what is obtained. There are sometimes circumstances when we use 6-8 ml of hyaluronic acid for a treatment because we want to do a panfacial rejuvenation, on multiple and extensive areas. These do not represent large quantities, if the hyaluronic acid is chosen correctly and is also injected properly, with an adequate distribution. On the other hand, at the opposite pole, there may be a treatment in which only 1 ml is too much for that patient. For example, we can refer here to lip augmentation, where different results can be obtained depending on the type of product. The effect is obtained immediately and we evaluate it together with the patient in the mirror. From experience we can inform the patient that for that treatment he would need a certain amount and then after the treatment he sees and expresses his opinion.

We do not recommend treatments that involve the use of large amounts of hyaluronic acid in a single area or the inappropriate use of a certain type of hyaluronic acid for a region because the risk of complications can increase exponentially. It is better for the patient to return at 3-4 weeks and supplement with another amount of hyaluronic acid, even with the same amount or with a slightly lower one and thus obtain the desired effect, than to use the entire amount in one. single session. These approaches are healthy both from an aesthetic point of view, as well as from the safety of the tissues and the patient.

We never know how long the retention of hyaluronic acid can last because it all depends on the wishes of the patients. There are also some medical conditions, such as some autoimmune diseases, dehydration, vitamin deficiencies, amino acids, Mg, Ca, or anemia, endocrine disorders or imbalances, etc. that can reduce the retention of hyaluronic acids over time, but most often, from experience, we consider that it depends on what the patient sees in the mirror and what he wants. 

There are some patients who want to increase their cheekbones 2-3 times a year with 1 ml of hyaluronic acid on each side in a single session and others for whom this amount would be much too much. This does not mean that we do not explain to them what they need, but sometimes the quantities differ. It all depends on what the patient sees in the mirror and on our indication. It also depends a lot on the artistic decision of us and the patient, but often they are not the same. Another issue we want to bring up is related to the usual mirror date. This means that immediately after treatment you will see a big difference, especially if you have worked on large areas. Then over time it will seem to you that the acid has resorbed and you are as before, actually forgetting how you were before, if you did not see the images before the injection. This does not happen in all patients, but in those who do occur, it may produce the need to return for completion. Our role as doctors and professionals in this field is to evaluate the result and appearance at that time and to indicate whether further completion is needed or not. So in the end, it depends a lot on the patient, but also on the doctor.

We do not encourage large quantities stored in a restricted area, or improper use of the product in that area, because there are risks of complications, which no one would want to assume.

Following a consultation that involves an effective history and a local clinical examination performed meticulously followed by explanations with the patient in front of the mirror, it is very possible to develop a strategic plan of sessions that involve injection of hyaluronic acid associated or not with neuromodulators. This plan can include a certain number of sessions over a period of several months between them, during a year, which can then be repeated, over a period of time, which the patient can establish alone or with us. It is very important that patients are informed about this plan, so that everything is clear and they know what to expect. On the other hand, we will inform patients that it is not mandatory to strictly follow that plan, because let's not forget, the acid will cause some tissue changes and it is very possible that those amounts of hilauronic acid that were expected at the initial consultation will not may be necessary because patients feel that they have achieved a result that they are satisfied with. What we do not encourage are individual, targeted treatments, when patients need to correct several areas and want this, but it is not explained to them. We receive many patients at the consultation after having performed such treatments in the past elsewhere and they tell us that if they had known how to establish a long-term plan, they would have obtained a better result and would have had a  lower budget.

Hyaluronic acid can be used for the entire face, from the insertion of hair on the forehead to the lower cervical level. What we want to emphasize is that the way it is used as a choice of the product itself, the appropriate depth of storage in the tissues under the skin and how patients are selected is the key to a good result and a satisfied patient. The degree of expectation of the patients must be in accordance with the anatomy of their own tissues and for this, a meticulous examination is needed in all the 3 levels of the face. This clinical examination must be associated with a complete history, with the establishment of the indication and the elaboration of a treatment plan, if the doctor considers that several sessions will be needed. We often face a patient requirement that is not in accordance with the treatment that should be done or a requirement that does not provide a complete result if it were not associated with another, for an adjacent area. Here, we can give a fairly common example: the patient wants to fill the nasolabial folds, but after clinical examination there is an atrophy of the malar area and the upper and lower zygomatic region (cheekbones). In this case, if we only fill the nasolabial folds and do not correct the entire region, the treatment would be insufficient. It does not mean that it cannot be done and that it will not offer an improvement, but it would be insufficient. That's why we try to explain to patients with a mirror in front of them, their particular situation and then to teach them what we should do for it and what effect the treatment could produce.

Therefore, we can correct forehead wrinkles, eyebrow lifting, filling the temples, lifting the central region of the face by filling the cheekbones and the malar region, filling the tear troughs, filling the nasolabial folds, enlarging the lips, filling the marionette lines, augmenting the chin, mandible line, hydrate the skin with the improvement of the texture also, or others.

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Depending on the texture of the skin, the amount that would be needed for a noticeable effect and last but not least the budget, we can choose the type of acid. Sometimes it doesn't matter and we can choose anything. Each range of acids has certain properties and even some types of acid in that range may be different from others in other ranges. Therefore, we often make the choice depending on the thickness of the skin and what the patient wants to get. Hyaluronic acid can be classified into 2 ways:- Depending on the hygroscopic capacity, we have it here two- macromolecular - which attracts water and is based on its hygroscopic ability to absorb water from tissues; the more hydrated the tissue, the more hyaluronic acid will be able to be maintained in the tissues by stimulating the collagen bonds in its structure. In these cases when we use such a hyaluronic acid, we ask patients to drink as much water as possible, because the body is hydrated by the capacity of ingested water, not by creams, solutions or lipsticks that produce hydration and are often used by patients. , on the grounds that “it is difficult for me to drink water; I can't drink water or I don't have time to drink water ". Our advice in these conditions is to try to use a mobile application, or any reminder that reminds them to drink water from time to time on a specific scheme.. If the tissue is dehydrated, it will not be able to produce a localized water retention and thus its retention would be lower in the long run.The second type of hyaluronic acid that we can refer to in this regard is the micromolecular one, ie it has a structure based on small particles, which cannot expand on contact with water. In other words, for this type of hyaluronic acid, the patient does not need to be well hydrated, because it does not base it’s principle on binding with water. In this case, you will get an effect of "What you see is what you have" .Often in our decisions comes the experience and medical flair of each doctor, who can sometimes dictate a slightly different solution from the recommendations of the company producing hyaluronic acid. For example, there are some patients who want a lip augmentation procedure with hyaluronic acid and confirm from the beginning that they do not want big lips and that they do not drink water at all during a day. Therefore, in this situation we should choose a micromolecular hyaluronic acid - which does not attract water, it does not produce the appearance of fluffy or larger lips, but the appearance of discreet lips. Frequently in our daily practice it happens to us that a patient of this kind comes to tell us at the next hyaluronic acid injection session, for lip augmentation, after she already has experience with both types, that she prefers the product that attracts water. because she likes more what shape and volume the lips have and especially, that it would last longer than the one that does not attract water, although it does not consume a sufficient amount of water, so that this hyaluronic acid has a good indication . So in the end, it all depends on how the patient's tissues support, accept and maintain hyaluronic acid over time. That's why we sometimes tell patients that they may end up trying more products until they know which one is best for them. The second type of classification is- Depending on the degree of viscosity.That is, to fill the tear troughs, we will use only a certain type of acid and the same is true when we talk about temples, cheeks or jaw line. What we will never do is we will not use to fill the tear troughs, what we use to enlarge the cheekbones, fill the nasolabial folds or correct the mandible line, which are practically treatments located at the opposite pole for the viscosity of hyaluronic acid.This would mean a customized treatment depending on the patient's needs.

Always, first of all, we consider that a clinical examination of the aesthetic units of the face is needed and then the complete evaluation of the face as a whole. Following this, it can be decided whether a certain treatment is good or not, according to the patients' wishes, or what the doctor says it should or can be obtained. Sometimes the indication may be surgical in nature. We cannot treat any deformity or defect with hyaluronic acid alone. When the laxity of the skin of the eyelids, cheeks or jaw line is extremely loose, a blepharoplasty or a facelift will most likely be needed. The principle of injecting hyaluronic acid or even fat is based on the possibility of creating a lifting effect of the tissues, by expanding them due to the filling process. Therefore, we will never be able to create a surgical facelift effect using hyaluronic acid when the indication is clear for a surgical procedure. Eventually we can improve the appearance using hyaluronic acid treatments for patients who do not want to opt for a surgical procedure, do not have a clear indication for this due to comorbidities that may adversely affect the result, or do not have the necessary budget for it. This improvement that can be offered with hyaluronic acid can be considered only in the case of a patient who also needs a restoration of the volume of the face, because in the case of those who already have a consistent volume, the procedure does not have a clear indication. The idea of ​​filling is not good at all if the tissue needs more repositioning. For example, here we are talking about tissues such as eyebrows, tear troughs or cheeks. If there is a ptosis or a falling down effect of the skin to a certain degree and there is already a substantial volume of subcutaneous tissue, the injection of hyaluronic acid will not solve the patient's requirement in any way. More specifically, if the patient complains about the bags under the eyes and especially the tear troughs that are deepened and there is also a laxity of the skin, the injection of hyaluronic acid is not a good idea. In this case the solution is most often transconjunctival or transcutaneous blepharoplasty with transposition or removal of fat deposits from the 3 internal compartments of the lower eyelid to the marginal arch, after the orbito-malar ligament has been severed from the bony surface. Trying not to do surgery and injecting hyaluronic acid over the marginal arch just to fill the area and create a smoother transition between the skin of the eyelid itself and the junction between the eyelid and cheekbones is not a good idea because it can cause quite a lot of discomfort. This is just a fairly common example in cases where patients do not want surgery and the doctor does not know which is the correct indication and responds to the patient's request.

Everything is done with an indication, depending on the needs of the patient's tissues.

Our rule assumes that when the patient is with us for the first time, no matter how minimalist or extensive the request is, a rigorous meticulous examination of the face is necessary and also to show the patient in the mirror  each aspect that we explain and what the indication is for this.

The clinical examination evaluates the three facial zones cranio-caudally  and the relationship between them, so that patients understand where the problem is and if and how it can be solved with hyaluronic acid. Those 3 zones would mean the upper third- from the hairline to the corners of the eyes, the middle third from the corners of the eyes to the corner of the mouth and the middle third is from the corner of the mouth to the inferior cervical zone and this would encompass the superior part of the neck.

Being a plastic surgery clinic, we do not only do beauty treatments with hyaluronic acid or neuromodulators, so that patients have the benefit of being explained the aging process, where are the facial anatomical structures that are distorted or deficient and what solutions are to solve or improve them, even if they involve surgery or surgical techniques, such as blepharoplasty or facelift. Always in medicine or especially in cosmetic surgery, the situation must be analyzed from all points of view, because there is no single key for all locks. Our goal and desire is that at the end of the consultation, patients be correctly informed about their particular situation and what the techniques we recommend, would involve. Only in this way  we are convinced that their decisions will produce spectacular results, in accordance with the rigors of aesthetics and beauty.

Even if the request will only be for lip augmentation, it is extremely important for the patient to understand the relationship between lips and chin, nose, forehead, cheekbones, etc. Everything must be in harmony with the rest of the face and the patient must understand this relationship, because this will lead to a delightful aesthetic result, unlike patients who require large volumes because they have seen in other people and more, the doctor accepts and responds to the patient's request. Then the results can be disastrous both aesthetically and functionally.

Personally, we do not prefer to do a treatment only according to the patient's request: e.g. I'm bothered by the nasolabial folds and I came to fill them. It's like going to the market and you want to negotiate with that trader for a certain amount of vegetables or fruits. Maybe there too that trader will explain to you another one about the products he sells, what to do and what not to do with them when you want to plant them, for example.

We try to explain to patients after an examination of the face, which would be the medical indication, what it entails and finally we teach them to try to establish a semester or annual budget, because these treatments require repetition, even if sometimes for a long time between the sessions. In this way the patient will be satisfied with the decision she or he has made from all points of view.

Therefore, the conclusion to how we approach the patient is: Consultation that includes the anamnesis about the medical history, the clinical examination of the face associated with the necessary indications and the establishment of a semester or annual budget, depending on the wishes or needs of the patients.

Acid is a gelatinous, crystalloid product, in the form of a gel, with a different viscosity, which has the role of filling the grooves, depressions, wrinkles, lips, cheekbones, forehead, chin and so on and thus restore the lost volume or prevent the effects of aging by maintaining the expansion of tissues as they appeared in youth. The difference between the hyaluronic acid that we use in our practice and the standard one that is not for medical use, is that the former is purified thousands of times until it reaches a form very close and compatible with that of human tissues. Its degree of maintenance is due to this biocompatibility, which is good to be as high as possible, even if the acid is not maintained as much as we would like.

The hyaluronic acid gel, once injected at the desired tissue level and in the corresponding plane, will produce a stabilization of its collagen bonds and at the same time will produce an expansion and sometimes even a rearrangement of the tissues. It is a filling product, not a muscle relaxant as is the case with neuromodulators. Our recommendation is that the treatment be done in stages, until a volume agreed by the doctor and patient is reached. On the other hand, it is very important that both the patient and the doctor are extremely careful and reasonable with the volumes and do not exceed the barrier of common sense, producing an unsightly and artificial appearance. This does not mean that if 6-8 ml of hyaluronic acid is used in a facial volumization session, it is a mistake or too much product is used, because with these volumes the temples can be improved, wrinkles or depressions on the forehead can be filled, tear troughs can be filled , cheeks can be filled, fill the nasolabial folds, correct wrinkles around the mouth, fill the lips, augment the chin, redefine the jaw line, etc. and so the dispersion of hyaluronic acid was made on a fairly large area. In this way even an amount that at first sight seems large, in fact it is not. The artificial appearance or sometimes even some complications, can occur when using a large amount in the same region: example - over 1 ml of macromolecular hyaluronic acid at the level lips in a single session, or over 2-3 ml of volumizing hyaluronic acid in the cheekbones in a single session. In the end, these mentions also have a certain subjectivism, because everything depends on what the patient needs and what is the doctor's recommendation related to obtaining a result as natural as possible.