Since our first edition of the book Injectable Fillers in Aesthetic Medicine, we have pointed out in the first chapter by “At the moment new injectable fillers are popping up like daisies” that we have an abundance of fillers. Specifically for Europe and Latin America, the situation is not much different by now. Fortunately for some products we do know now at least something about their clinical behavior. Nevertheless, there are still unanswered questions even for those specifically when it comes to the understanding of the long-term behavior.

We started with silicone, PMMA, methyl methacrylates, polyacrylamides, collagens (bovine and later porcine), poly-l-lactic acid, hydroxylapatite, and HAs. Lately we seem to be focusing mostly on HA-based fillers and HA-based volumizers. However, within the HAs themselves it is easy to get confused as industry gives us different names (all the brands), types (mono- and biphasic), as well as cross-linkers that initially made us curious but finally ends up making us more and more confused. We have now products for fine lines, folds, lips, cheekbones, jawline, etc., with and without lidocaine. These products have helped us to achieve many incredible results in an individual patient but also make it sometimes difficult for us to position a specific product. For example, can we or can we not use a product that was designed to be used in lips and nasolabial folds? The answers are not so simple.

There are indeed products that perform well in different areas and are very much versatile when it comes to different indications. There are other products that are obviously only suitable for a specific area such as a fine line product (i.e., low-density HA) which does not make a lot of sense to be injected into the chin area for projection and volumization as well as a volumizer (i.e., high-density HA) to be used in the fine lines of the lower eyelid – which might end up in an aesthetic challenge (e.g., a very visible HA roll).

Sometimes a specific product is designed and clinically investigated by good trials for a specific indication in a specific way, and we discover in our practice that there is another way to inject it (e.g., with a cannula instead of a needle) or that a different indication can be treated (e.g., a volumizer that was designed to be injected down deep to the bone and found useful in treating folds in a more superficial, e.g., subcutaneous mode) (Table 4.1). If we are working with a versatile HA product, we may obtain an accurate response of this product regardless of the area we are injecting it as long as we respect its limits. If we are working with a less versatile product, there might be still some variability. We may use a volumizer (degree 1) to treat a prominent nasolabial fold as long as they are injected subdermally. By using such a filler, less volume compared to a standard filler might be needed. On the other side a very-low-viscosity product (degree 0) may also be injected into a deep fold but with the certain disadvantage of using more volume and a shorter durability.

The performance of a product also depends on the experience that we develop by injecting it over the years. The same product may perform differently in different patients and among different injectors. So, it is basically quite important to keep a clear and critical mind to be aware of the product as well as the injection technique for the benefit of the patients and us.

We will be constantly invited to try different products and requested by patients to inject new areas. We have to remember that respecting the science behind the products and our learning curve is of utmost importance to protect our patient and also us against avoidable reactions from both products and techniques. We have to try to be as good as possible when it comes to new challenges, and we have to be very careful with new products specifically when treating new areas (Table 4.2).

Another barrier to overcome when putting a treatment plan together may be the patient-injector relationship. As discussed before, when it comes to aesthetic procedures, patients have a stronger influence on treatment decision when compared to other medical fields. Sometimes one may wonder if medical aesthetics is not closely associated to buying/selling a car than to health care.

There are patients that are very much aware of their needs and open to listen to advice. These are considered the ideal patients. But unfortunately it is not the rule. There are many patients that will not listen to the physicians’ opinions and only see the injector as a “deliverer” of their wishes. That would be acceptable if the patients’ perceptions were always accurate – which is of course not always the case. Patients usually tend to look at themselves in the mirror in the frontal view and their complaints are usually focused on the glabella, tired eyes, and nasolabial folds. They only see what can be seen in the frontal view and this is not necessarily what makes them look more exhausted or older (Rzany et al. 2012). In society, however, we do not look at each other frontal to frontal – which is considered confronting – but instead we look at each other more in the oblique view which is softer and nicer. Only by this can we see a discrepancy of analysis and perception between patient and physician.

The “blind spot” definition presented in the chapter “Patient Selection” is another important aspect to be considered. We defined “blind spot” as the area/areas that untreated worsen the patients’ appearance. Usually the patients are unaware of these areas – that are mainly determined by the patients’ genetics, for example, very small chin, sunken eyes, and asymmetries. Patients usually complain and request treatment of the areas that worsen with aging. So patients may be biased toward aging signs and will disregard their “blind spots” completely. In fact this would be adequate if these patients only want to look younger but not more attractive. Bringing awareness to the “blind spots” must be handled with care as it may lead up to the patient’s frustration especially when we cannot or can only with great difficulties or expenses improve or solve the underlying defects. A careful way to help patients discover their “blind spots” is to show their pictures in different positions (frontal, oblique, profile, leaning forward) in different situations (at rest, full smile, angry, kissing, etc.) and ask them what they like and dislike when they see their pictures. At this moment we may find people that will get frightened by their look and even patients that are really becoming distressed. For those patients that feel severely impaired and depressed with their looks, we advise to stop the photo analysis and proceed to treatment options, and for those patients that are completely blind and cannot establish an adequate analysis, we should try to help them see their aesthetic problems and monitor and control their reaction.

The interaction between patients and injectors may also be a challenge and may differ depending on cultural aspects. We may separate those patients that are aware of what they want and seek for advice and those patients that are unaware of what they want and seek for advice and in whom the injector is unable to promote a treatment plan (Table 4.3).

Female patients might be highly influenced by the media and celebrities. It is not uncommon to have a patient asking an injector for Angelina Jolie’s lips. But what she is unaware of is that those lips will only be suitable on her face if she has similar facial structure as Angelina. As a result of this misconception, many distracting lips are seen in real life as well as on TV. Some other patients feel that they become a more accentuated look when they have their lips injected. The problem is that they request further injections to make their lips even more pronounced and by this (in their view) more attractive. The result is that (in case they find an injector and of course they will) they will do get more attention but not because they look more attractive but because they look weird. Patient education about proportion and beauty is very important to avoid distracting results. A very important rule must be observed here: “the posttreatment photo must be more pleasant to look at than the before-treatment photo.” Obvious as it can be, we might surprise ourselves with the opposite.

This is the most difficult area because injectors also have their “blind spots.” Many aspects may hinder the injector to deliver an accurate treatment plan for their patients. The Greek proverb “In the kingdom of the blind, the one-eyed man is king” teaches us that this is more an opportunity than a barrier. The more we are aware of our abilities and limits, the faster we may try to solve them (Table 4.4).

Technical deficiency is the barrier number one that we have to overcome to evolve as an injector especially if we are interested in delivering a global approach with injectables. The first step it is to be aware of our deficiencies. As otherwise we might continue overtreating an area that we are confident to treat (e.g., the nasolabial folds) instead of treating the area that poses a challenge for us. We may be able to make the proper diagnosis, i.e., sunken temples, but avoid discussing it or indicating it as a treatment option for the patient because of our technical deficiency. In some cases, patients themselves might request such a treatment and we may find us saying that “treating your temples is not important.”

If we are not prepared to successfully inject into an specific area, we should either search for adequate training or refer the patient to a more experienced injector. Sooner or later, all injectors will be able to inject the commonest facial areas. The easiest way to learn is to start by writing down the areas and types of patients that we have difficulty treating and secondly to check if someone is obtaining good results for this indication. Be aware that sometimes, what is difficult for you is difficult for everybody!

Accurate patient assessment and the judgment if that product or technique will work are much more difficult than overcoming technical deficiencies – as incredible as it may seem. Injectors that are not familiar with exercising the assessment process and usually are only used to delivering patients’ requests (usually glabella with BoNT-A and nasolabial fold with dermal fillers) should be aware that patients’ needs are not restricted to these two areas and they may end up suffering from low patient retention. Assessing patients does take time and the speed that we can reach a final conclusion will vary according to our experience and the type of patient we are dealing with. It is also a longtime learning curve and requires exercise.

After solving the two first barriers (technique and assessment), we can really assume that we are now prepared to tackle the last barrier: to build up the treatment plan. The treatment plan is to be programmed according to patients’ social and economic situation, and that is a tremendous opportunity for us to become a long-term trusted cosmetic investment advisor (CIA) for the patient. A CIA is someone that is able to build up consistent treatment plans for their patients along the years and is able to work efficiently with the patients’ budget. One of the biggest challenges of the cosmetic business is patients’ retention. They are looking for someone that is able to help them look better, increase their self-esteem, or rejuvenate. Regardless of their initial request, they will be happy to find an aesthetic physician that they can trust and guide them. That is the gap in the market. Hence, there is the opportunity!