Joely Kaufman, MDVoluntary Assistant Professor Dermatology
University of MiamiMiller School of Medicine
Update on Dermal Fillers
Relevant Disclosures
Contracted Research: Merz Pharmaceuticals; RevanceAdvisory Board: Allergan; Merz Pharmaceuticals
Pathophysiology of aging
Dermal loss of:CollagenElastinGlycosaminoglycans
Subcutaneous loss of:
FatBone resorption
Temporary fillers of the worldHylaformHylan DexHylan SeSHyruan InjectionIsologenJuvederm 18, 24, 30Koken AutocollagenMacDermol SMacdermol RMatrigelMartidexMatridurMatrexNewfill Polylactic acidPerlanePermicollPermacollPlasma GelPurogen
AcHyalAtleanBeloteroCosmetalifeCosmodermCosmoplastDermiColEvolence & evolence breezeEmervel EsthelisFibrel Procine CollagenFibroquelHyal 2000 InjectionHyacellHydrafillHydrafill Coftline
PrevelleRadiesseResoplastResylaneRestylane fine lineRestylane vitaleRestylane lipReviderm IntraRhegecollRofilan Hylan GelSculptraTeosyalUma JeunesseVariodermVolumaZyderm IZyderm IIZyplast Bovine Collagen
FDA approved fillersZyplastZyderm 1 & 2CosmoplastCosmoderm 1 & 2Evolence
Autologous fat
Artefill
RestylaneCaptiqueHylaformHylaform PlusJuvederm Ultra, PlusPerlanePrevelleBeloteroVoluma
SculptraRadiesse
Filler Choices
DurationTemporary (2-9months)Semi-permanent (>9 months)Permanent
PropertiesDensity/Viscosity
PurposeFilling
Fine linesDeep lines
Sculpting
PlacementSuperficialMidDeep
Update on Fillers: Lecture outline
Update on products, usesHyaluronic acidsPolylactic acidCalcium hydroxylapetite
Injection techniques:CanulasSpecific areas, specific techniques
Hyaluronic acids
Most versatile fillers on the marketExcellent safety profileHA is chemically identical across species
Less chance of antigenicity
Hyaluronic Acid
Polymer of disaccharides linked via glycosidic bonds
Carbohydrate (polysaccharide) portion of the extracellular matrix
Hyaluronic acidIdentical in all species
Able to bind 100x its weight in water
Used as a cushion and lubricant in tissues- in joints/synovial fluid, cartilage, dermis of skin
Hyaluronic acid fillers
Currently the most popular filler category in US
Can be placed in mid or deep dermis/ subdermal plane, or supraperiostial
Very soft
Hyaluronic Acid Fillers
Binding with water yields a plumping effect
Reversible with hyaluronidase
Hyaluronic Acids
Non-animal source (NASHA)
CaptiqueRestyleneJuvedermPerlaneBeloteroVoluma
Hyaluronic acids
Physical Differences between HAs
Cross linkingMethod (ether, ester)Type (BDDE)Amount Double cross-link
Concentration of HA
5-30mg/ml
Particle size10,000-200,000 gel particles/ml (biphasic)Uniform gel, non-particle (monophasic)
Size of HA chain
Product Concentration Particle size
Restylane fine line
20mg/ml 200,000 gel particles/ml
Restylane 20mg/ml 100,000 gel particles/ml
Perlane 20mg/ml 10,000 gel particles/ml
Restylane subQ 20mg/ml 1,000 gel particles/ml
Product Concentration Particle or homogenousgel
Juvederm ultra Homogenous gel
Juvederm ultra plus Homogenous gel
Belotero 22.5mg/mL Homogenous gelBDDE cross linking
Voluma
VolumaFDA approval 2013
Indicated for deep (subcutaneous and/or supraperiosteal) injection for cheek augmentation to correct age-related volume deficit in the mid-face in adults over the age of 21
Belotero
Tan Delta (tan ) of HA Fillers
Measured at 0.7 Hz*Homogenous gel, 22.5 mg/mL HA manufactured by Anteis S.A.
*
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
Restylane Restylane-L Perlane Perlane-L Juvederm Ultra
Juvederm Ultra XC
Belotero Balance
Particulate Gel
Cohesive Polydensified Gel
Cohesive Gel
tan =Measures presence and extent of elasticity
Data on File, Merz Aesthetics, Inc. 2012.
Cohesivity Evaluation
*Homogenous gel, 22.5 mg/mL HA manufactured by Anteis S.A.
Restylane-LBELOTEROBALANCE
R t l LBELOTERORestylaneBELOTEROBALANCE
Perlane-LBELOTEROBALANCE
PerlaneBELOTEROBALANCE
8 mm plate separation
Data on File, Merz Aesthetics, Inc. 2012.
HA Distribution in the Dermis
Blue = HA
Day 7
Day 114
RestylaneJuvédermBELOTERO BASIC*
*Homogenous gel, 22.5 mg/mL HA manufactured by Anteis S.A.
Courtesy of Dr. Patrick Micheels and HCU Geneva, Dr. Salomon, University of Geneva / Anteis
0
100
200
300
400
500
600
700
Restylane Restylane-L Perlane Perlane-L Juvederm Ultra
Juvederm Ultra XC
Belotero Balance
Particulate Gel
Cohesive Polydensified Gel
Cohesive Gel
Elastic Modulus = G Measures ability to resist outside forces
Data on File, Merz Aesthetics, Inc. 2012.
Measured at 0.7 Hz
Physical Differences between HAs
Already fully saturated with water in syringeCaptiqueHylaform
Result: less expansion after injection (less swelling)
Not fully saturated with water in syringeJuvedermRestylaneUnmodified HA is added to increase fluidity
Result: Some expansion after injection. Ease on injection. Not all HA is crosslinked.
Physical Differences between HAs
Higher concentration HA requires larger gauge needed and more injection pressure
Larger particles firmer filler, longer duration?
Higher G prime more stiffness
Sculptra (Newfill)Poly L-lactic acidLong lasting, non-permanent fillerApproved by FDA for facial lipoatrophy inimmunocompromised patients in 2004
SculptraComes in vial as powdered substanceReconstitute with saline and lidocaineWait at least 3 hours after reconstitutionInjections/substance stimulates collagen formationInjections should be placed in deep dermis or subcutaneous tissue
Industry-provided image for educational purposes only.
Sculptra +’s and –’s
Reconstitution26 gauge needle that sometimes clogsResults are not immediateMultiple treatmentsSQ papules
DurationNatural looking resultsForgiving if placed in SQNot ‘plumping’
Sculptra 1.5 vials
Photo courtesy of Steve Mandy, MD
Sculptra photo cheek
Sculptra update
Dilutions started around 6cc of dilutentGradually have increased
8cc of saline and 2cc of lidocaineOff face dilutions of 15cc
RadiesseSynthetic Calcium Hydroxylapatite microspheres [30%] suspended in a carboxy-methylcellulose resorbable aqueous gel carrier [70%]
Decalcified 25μm to 45 μm particles
Radiesse When placed into soft tissue, Radiesse provides immediate correction
Gel + CaHA ParticlesOver time the gel is resorbed and the CaHA particles stimulate the body to produce collagen
Radiesse
Radiesse stimulates collagen productionThe CaHA microspheres are synthetically derived and break down naturally over time by the body’s own metabolic processes into Ca2+ and PO3
2+
ions.No ossification or calcification of CaHA has been reported in over 6 years of clinical use and >400,000 syringes injected
27g needlePost injection edemaFirm for a couple of weeks after injectionProduct clumps in lipsMixed in office with lidocaine
Long duration (>12 mo) More filler per cc of productImmediate resultsSafety profile
Radiesse + and -s
Patient SatisfactionRadiesse vs. Restylane
More patients were Satisfied with Radiesse than were with RestylaneEven at 6 Months
% of Patients That are Satisfied & Extremely Satisfied*
89%
61% 58%
96%
6 Months 9 MonthsTime post 2nd Injection
RadiesseRestylane
Restylane
Volume 1.20cc Volume 0.80cc
Radiesse vs. Restylane6 months post second
treatment
Radiesse
Nasolabial fold correctionBefore Radiesse 12 weeks after Radiesse
Anatomic considerationsmust not be injected into blood vessels and should not be used in vascular-rich areas. Use in these areas, such as glabella and nose, has resulted in cases of vascular embolization, occlusion of the vessels, ischemia or infarction, or blindness. Symptoms of vessel occlusion and embolization include pain that is disproportionate to the procedure or remote to the injection site, immediate blanching extending beyond the injected area, and color changes that reflect ischemic tissue such as a dusky or reticular appearance
Depth of injection is dependenton area being augmented
Deep dermis/subdermal plane for treating linesNasolabial folds, marionette lines, mental crease, etc.Retrograde linear threading of material
Subcutaneous/supraperiosteal for restoring volume resulting from skeletal loss or if placing material against bone
Mid-face: infraorbital and malar, submalar, chin, nose, pre-jowl sulcus, etc.Retrograde linear threading or bolus injections
Structural AgingThe facial recurve concept:
Young facial musculature has a convex configuration with facial fat pads deep to the muscle
The facial musculature of older patients has shorter and flatter appearance by MRI
LeLouarn et al. Aesthet Plastic Surg, 2007.Fitzgerald et al. Aesthetic Surg Journal, July/August 2010.
Structural AgingFacial bony structures remodel throughout adulthood
Facial frontal bone moves anteriorly and inferiorlyMaxillary bone moves posteriorly and superiorly
Maxillary regression- NLFChanges in mandible and teeth
Pessa et al. Plastic Reconstr Surg, 1998.
Perioral Aging
Marionette linesDown turn angle of mouthFine radial linesDeflation of vermillion borderFlattening of cupids bow, philtrumChin dimpling
Perioral Aging
Marionette linesDeep placement
Correct structural defect
Superficial placement Correct dermal defect
Cannula
Perioral Rejuvenation27g, 37mm cannula30g, 27mm cannula
Insertion opening with 26g
Deposition point to turn up angle of mouth
Perioral Rejuvenation
Perioral rejuvenation
Perioral: Fine lines
Juvederm .4 cc syringe diluted with .3cc saline
Perioral: Fine lines
Belotero Balance
Perioral: Fine lines
Fine radial lines:Serial puncture technique32 gauge needleIntradermalIf using diluted product, slight overcorrection
Vermillion threading30 gauge
Perioral: fine lines
Perioral
Jeremy Green, MD
Perioral Rejuvenation
Etiology is multifactorialDo not disregard the structural abnormalities
Thank You! [email protected]