Dermal fillers in Tunisia

Skin aging is a normal physiological process. Skin aging signs usually show up with wrinkles, loss of volume, the appearance of pits and grooves on the face giving it a tarnished and tired appearance.

Fine lines and face wrinkles, considered as indicators of facial aging are of 2 types: dynamic wrinkles and static wrinkles.

These Types of wrinkles are mainly in the following areas of the face: forehead wrinkles (A), the frown lines (B), the wrinkles of the crow’s feet (C), the nasolabial folds (D) and marionette lines.

In addition to the appearance of wrinkles, there is a loss of facial volume in the cheeks and cheekbones, the valley of tears, the oval of the face, lips, dark circles...

Patients, who the aging signs begin to appear, use the fillers injections for the simplicity and speed of this solution, which aims to correct the unsightly aspects of facial aging, increasing the volume of places where it is necessary.

We can mention four categories correction among the most common:

• Hollowing and lack of volume: the lack of volume at the cheekbones and cheeks, nose, chin, mandibular outlines and scars (trauma, chickenpox, acne ...).
• Lips : represent the hem (the lip), plumping the lips and increase their thickness in case they are too thin.

• Wrinkles and fine lines: "crow's feet" (located at the corners of the eyes) , forehead, "pleated sun" or wrinkles that make the contour of the mouth, chin , "frown lines" ( wrinkles located between the eyebrows) , cheeks ...
• The grooves : marionette lines (located at the corners of the mouth opening on both sides of the chin), lip and chin furrows and nasolabial folds (ranging from the nose sides up at the corner of the mouth)...

Undoubtedly, these disgraces due to skin aging will not be completely removed but will certainly be reduced to the lowest level by the injections. To keep up its positive results, and even improve it, the correction and treatment should be renewed whenever necessary. Obviously hyaluronic acid remains the most requested filling product.

The process of the filler injection procedure is the injection of the product at the skin thickness or under the skin area that aimed to create volume, filling hollows and wrinkles.

• Fat autologous or face lipofilling
• PRP or Platelet Rich Plasma
• Hyaluronic acid (Restylane *, Perlane*, Juvederm *, Hyaluderm*, Hylaform*, Rofilan*, Reviderm*, TEOSYAL* ...) being the most used product, it does not require a test before the injection, it is of synthetic origin and its effect lasts few months (generally known for its effects that have a life somewhat longer than collagen)
• The collagens (Zyderm *, Zyplast * * Résoplast ...): make sure to carry out two successive dermatological tests before performing the injection because there are risks of allergies; collagen is of animal origin; product effect lasts for several months.

• Polylactic acid (New-Fill *): it is synthetic, requires no test, and the results last for a few months.
• Silicone: its injection has been banned since 1997 because it has been proven that it has several side effects that can be harmful.
• Acrylic Hydrogel (Dermalive*) and polymethyl methacrylate (Artecoll*): these synthetic granules that are not biodegradable and are likely to form granulomas.
• Polyacrylamide - (Aquamid * BioAlcamid * Outline *): It is the latest discovery in the market, it is designed so that its effect last for several years and it does not form granulomas at least less than other products.

It is important to know that hyaluronic acid filler is by far the most used and is patient preference almost unanimously, because of several criteria: safety, biodegradable, natural, no allergy, efficient results...

In case where the desired result is to adjust the volume significantly (at the cheekbones or chin, etc.), or if the patient has an allergy, it is appropriate to conduct a discussion with your surgeon Dr.Bouzguenda, to explore the possibility of re-injecting fat taken from the patient himself: lipofilling or face lipostructure.

Hyaluronic acid is a natural constituent of our body, and about 50% total of hyaluronic acid of the body is located in the dermis.

It is thanks to hyaluronic acid that a young skin is plump, fresh and wrinkle free. Indeed, it has the ability to maintain a good level of hydration of the skin and ensure the flexibility and firmness.

However, and from the age of 20, this natural element of the skin gradually decreases. Deprived from hydration, the skin is dry, loose and wrinkled.

There are several types of hyaluronic acid based on several criteria:

• Curing : cross-linked hyaluronic acid is injected into the deep and medium dermis and lasts longer. The little or no cross-linked hyaluronic acid is injected in the superficial wrinkles and dark circles. In its fluid version, it will be injected on the surface to fill wrinkles, like those of the crow's feet, for example
• Density: hyaluronic acid fluid is injected at the superficial wrinkles; very dense to dense hyaluronic acid will be injected at the medium and deep wrinkles level and as volumizer.

Acid injection allows a facelift without surgery, but with limits...

Wrinkle treatment with hyaluronic acid fillers is done using gel injections. The injected gel allows the retention of water. The effects of hyaluronic acid: volume effect and skin hydration to restore skin’s youthfulness, freshness and volume, reducing the wrinkles and fine lines.

Hyaluronic acid is a biodegradable and absorbable product. We must therefore renew the injections regularly for a continuously fresh, youthful appearance.

Many patients call to inquire about breast augmentation by the injection of hyaluronic acid «breast augmentation without surgery," an alternative that they prefer to breast augmentation with implants or breast lipofilling. But be aware that breast augmentation by injection of hyaluronic acid was banned in France August 26, 2016.

Macrolane , highly volumizing hyaluronic acid allows buttocks augmentation without surgery and without scars. Another option is to increase the buttocks through lipofilling.

The calves augmentation can be achieved without surgery and without scarring, using the injection of hyaluronic acid at the calf, Macrolane, but for a transitional period. Whereas the calf Lipofilling, increase the calf permanently.

The filling injections technique requires no preoperative procedure.

All they only have to appear without makeup on the day of the act of filling wrinkles or remove make-up and there is no need to fasting.

Almost like all aesthetic medicine procedures, the surgeon will proscribe you the minimum aspirin 15 days before the procedure and 15 days after, because it reduces the risk of bleeding in the treated areas.

It is also recommended to avoid taking alcohol and also avoid sun exposure one day before and after the filling process.

It is rumored that the filler injection is performed without anesthesia. However, anesthesia is performed in the case of the use of some products that are more painful compared to the other and when the patient is a little more sensitive. The surgeon also uses anesthesia when it comes to sensitive areas to be treated, such as the lips and around the mouth.

When speaking of anesthesia, we particularly evoke two different ways:

• The anesthetic cream EMLA, which applies in abundance on the area to be treated minimum 60 minutes before the injection. The patient will see a decrease
• The real local anesthesia, the surgeon injects the anesthetic to trigger the session, which will provide a total insensitivity to pain.

The injection of dermal filler can be done in the office of a plastic surgeon.

The procedure itself takes only few minutes. The injection of dermal fillers can be made using several techniques that change from one doctor to another. At each method it adopts and applies to each patient to ensure the desired result.

The number of injections performed per patient always depends on the number of areas to be treated: more areas that are treated the more are the product to be injected. A preliminary assessment of the amount will be made for more precision.

Filling techniques may be different from one surgeon to another

1. The injection technique can be retro
2. Linear plotting (1)
3. The injection technique can be done with multipunctures (2)
4. The injection technique may be fan (3)
5. The injection technique can be done by topping (4)

Depending on the area to be treated and the depth of the wrinkle , hyaluronic acid can be injected at a level of different depths :

After performing the injection session, it is recommended to maintain your calm and rest, avoiding the slightest physical effort, for about 6 hours.

Preferably, the patient should rest the facial expressions and immobilize (avoid mimicry; minimize maximum gestures, speech and smiles).

For the first period of the first days, patients will better stop alcohol, aspirin and anti-inflammatory drugs, and exposure to the sun and saunas.

Regarding the consequences of the injection session, usually the patients experience swelling, the appearance of redness, itching, a little paleness, hyperpigmentation or temporary edema.

It is known that the sequences for the injection of products fade within 3 days. It is also important to realize that the suites can however leave temporarily because of the regularity distribution of edema is not homogeneous, or correction will be a relief appearance. These irregularities will fade and disappear gradually.

After few days, the patient can enjoy the final result. This period is essential for the integration of the product in the treated area and the disappearance of edema, also for the fabrics to find their flexibility.

The fillers injection treatment usually mitigates the misfortunes but they do not disappear completely. It depends on the area treated and the depth and length of wrinkles, because some areas are already more resistant than others and wrinkles are more difficult to make them disappear when they are older.

These injections are intended to improve the general appearance of the face, not to improve it. So if you keep in mind realistic results, you will be very satisfied.

The effect of the injection of hyaluronic acid lasts from 6 to 9 months. So the result is only temporary and the session must be followed by a maintenance session to keep the maximum of the acid action.

Whichever the medical procedure done, there is always a share of hazards that accompanies it. Always be aware of the risks of each medical procedure performed.

Although the injection procedure of hyaluronic acid is minimal risk, you still have to take care to choose a qualified practitioner who has received specific training in injection techniques, and also choose the filler to inject that is best suitable to you to minimize the chances of occurrence of these risks to the maximum.

In general, the majority of troubles that may happen are related to the product itself, it may precisely be the cause of several reactions:

• Allergies: they manifest following collagen characteristics, and it is possible to escape by preliminary tests.
• All local reactions after the injections: swelling, redness, pale skin, irregularities, tenderness, itching and appearance of bruises. The duration of these reactions is only temporary and will fade in time.
• Herpes appearance at the mouth in predisposed individuals.
• Acute or chronic inflammation: can occur following secondary injection of the same area that has been injected with different products especially when they are non-absorbable.
• granulomas: the appearance of small indurated nodules, which are delicate and perceptible to the touch. Sometimes they are obvious and unpleasant. The chance of occurrence is very limited and exceptional when it comes to injecting hyaluronic acids.
• rare and exceptional complications: It was reported a few cases where the redness persisted for weeks or abscesses and skin necrosis were located in the same area of the injection site.

This said, the act of filling wrinkles by hyaluronic acid injection is always an act whose risks are very limited and that we should not overstate. In general, we must seek to learn about the risks of all medical procedures as minimal or simple they are, even when it is nonsurgical.