Dr. Sam Lam Plastic Surgery Forum

Hi Dr.Lam, how are you?

I heard fillers are not as good as doctors claim they are and many patients (especially the ones in the forums) complained about mishappenings and bad side effects,

Here dr Toriumi addresses this issue with photos illustrated on the bottom of the page on how he had to remove the fillers that caused a lot of damage...

http://deantoriumi.com/issue1-1.asp

im wondering what are your thoughts about this?

How long have u been doing fillers? Besides silicone, what other fillers have u been using? have u been monitoring your patients with nasal fillers, if so for how many years and what have u observed as far as infection, migration and other side effects are concerned?

Happy new year,

Regards

Exellent questions. I have heard Dr T talk so I know his opinion, and he is right in many counts. It is very hard to operate in a patient with Radiesse placed in the nose before if they require extensive revision as it tends to stick everywhere. That is why if you read a previous forum question (I believe it was a previous forum question and not a private email) I suggested to a patient who wanted a "non-surgical rhinoplasty" I think from California not to have Radiesse if he or she was contemplating having a real rhinoplasty.

That being said, I no longer use Radiesse in the nose. I personally still think Radiesse is a very safe product in the nose in the right hands if you are a) not planning a revision rhinoplasty, b) are using it to touch up a rhinoplasty or perform non-surgical rhinoplasty and not planning a rhinoplasty in the future c) not dealing with thinned out skin.

Let's now address his concern about thinned out skin. Yes, this can be a problem in rhinoplasty if the skin is thinned out and you are trying to peel it out from under there or are putting a lot of material in to an area with thinned out skin. That is why judgment is so important. However, here is my feeling, if you have a patient with thinned out skin and you are going to need another implant in there, I think you risk necrosis and real skin problems with another solid implant than with a few liquid drops because there is a complete barrier between the blood supply to the skin and the deeper tissues. A little liquid silicone built slowly over time can provide much better blood supply to the overlying tissue than a big solid implant can.

Now what is the track record of silicone and how long have I been doing it. I have been doing it for close to 5 years now. I have never encountered serious problems with it with close to a 1000 patients. Now, you say, what about long-term safety? I have trained with surgeons (facial plastic surgeons) and physicians (dermatologists) who have worked with the product close to 40 years. Now tell me a product on the cosmetic market that has been around with a long-term safety record of 40 years? You can't because only silicone has been around that long. What product has been around close to that? Botox. That has been around 30 plus years.

Finally, I would like to address Artefill one more time. I will not plan on using Artefill because of the innumerable problems with the product in its two previous incarnations: Arteplast and Artecoll. If people say, oh Arteplast was different, Artecoll is very close to Artefill and there are numerous problems in Europe with this product. If you are going to do permanent filler would you want one with a safety record of 40 years or one that has a checkered past of less than 10.

Remember that any product can have bad press if it is badly injected (including silicone). Or if the product is an adulterated form. I personally have had to take out bad silicone from lips because the way that it was injected (big injections in 1 session) is nothing short of being frightening. So be careful when you choose the injectable product but be as equally careful when you choose the injector from a vantage of experience, technique, judgment, and artistic sensibility.

Hope that helps,
SML

thanks for the quick reply,
So silicone's been around for 40 years and so far u've never had any serious problems with it in the 5 years. But if there were problems at all, what kind of problems were there? And what are the possible risks associated with silicone injections?

Do silicone injections look and feel natural? Can you only do 'so much' with silicone injections as far as building the bridge goes?

What's the level of difficulty in removing the silicone injections from the nose in case of complications?

WIth implants your nose will be put through trauma and the strength in the nose will not be as strong as before because u basically permanently damage ur nose when u alter it in anyway by cutting and inserting a foreign object. Which means you can't rub your nose as hard as you used to because the fear of infection spreading from your fingers through your skin to your implant and ur nose will be extra vulnerable to things than your pre=op nose,

What advantage does the silicone injections have over the implant given the risks given above?

and last but not least... Im in the new york area and was wondering if you could recommend any doctors in my area that are at least as good as u are? Anyone u've worked with, admire, or heard about?

Thanks

with pure silicone and good technique, i have not heard of any side effects. with bad technique, injecting too much too quickly (that is why i use a microdroplet technique and spread my injections as needed over a few months).

i don't have an "amount" of silicone that i use at which i stop but, in general, i use it to provide subtle changes and to correct small defects. for rapid and smooth bridge augmentation that requires more strucutral building like in a low-profile asian nose, i tend to use gore-tex sheets. small adjustments can be made with silicone.

you cannot feel silicone. that is one of the superlative attributes of the product. if done right in the lips, you cannot feel anything. that in particular is why i love it for lips, as you can imagine solid implants in lips feel like rocks. even juvederm and restylane are very hard in the lips.

silicone cannot be removed. it is virtually impossible. that is why you must go to an experienced injector who is using only pure medical-grade product and proper technique. for example, in women who have had terrible deforming lip augmentation, i have had to literally cut half the lip out (see my lip gallery before and after) to fix the problem since manual extraction of silicone is not possible.

i can't advise you for any surgeons in new york. every surgeon is different and you will have to investigate which surgeon fits your aesthetic needs. i perform a good number of patients from out of town, about 20% of my patients fly in for my services.

do silicone droplets in a nose have a timeframe where there is a migration risk? i.e. within 3 months post-op?

I have never heard of goretex sheets before.. do these sheets allow you to gradually build your bridge for a natural look so it won't stick out with sharp edges and look unnatural like an implant?

I've also heard about doctors in Asia with a lower revision rate because they are more experienced with asian noses etc... do u think there are more experienced docs in Asia or do u think dr's in America are just as experienced considering the fact that most ps here are caucasian and rarely do ethnic noses?

1. silicone should not migrate when performing the correct microdroplet technique. microdroplets are placed in a conservative fashion then a month is allowed between treatments so that each micro-particle of silicone is walled off by your own collagen so that it should not migrate ever. that is why microdroplets and a full 30 days waiting period is required to attain safe silicone results.
2. gore-tex sheets are not perfect but they allow in most cases to create a much softer bridge augmentation than silicone for a lot of reasons. please search my archives of this forum for a very detailed comparison between the two types of solid implants. in short, gore-tex is opaque (less chance of see through), lighter (less chance of slippage), thinner and softer (less chance of visiblity) than silicone. In addition, I use only the gore-tex sheets not solid blocks since the sheets are softer than even the blocks. Plus I crimp the edges of the sheets to make the transition over to your unaugmented nose more seamless.
3. Yes, experience of course counts a lot. I do a lot of Asian noses and I think a strong aesthetic eye is important. I find that a lot of Asian surgeons make noses too high because they use solid silicone which by its very nature can make the nose way to high even with very slim implants. I find the same problem in Caucasian surgeons who use gore-tex, rib, and cartilage grafts because they build the nose too high simply because they are using Western standards. For example, I believe that the nasal bridge should start roughly in the middle of the eye if the eye is divided vertically from top to bottom. Many caucasian surgeons will try to make the bridge too high toward the eye crease, which is what I do for Caucasian patients. It looks artificial at this height. In addition, traditional Western techniques for the Asian nose can oftentimes fail. Tying the "domes" together (read my glossary for explanation) can rotate the nose up and lead to nostril show, which is both a culturally and aesthetically unattractive result. That brings me to the point of not only ethnic sensitivity but cultural sensitivity. You should listen to my lectures on understanding Asian culture. That would really refer to Asians who live abroad in Asia or who have recently immigrated here to the U.S. Another technical problem is doing "osteostomies" or breaking the bones. That is a great technique that I use in almost every Caucasian but almost never perform in the Asian nose for two reasons. It over narrows the bridge to make the tip flare out more plus the implant can be destabilized.

Okay, hopefully that is somewhat helpful.