Update on Dermal Fillers. Joely Kaufman, MD Voluntary Assistant Professor Dermatology University of Miami Miller School of Medicine

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1 Update on Dermal Fillers Joely Kaufman, MD Voluntary Assistant Professor Dermatology University of Miami Miller School of Medicine

2 Relevant Disclosures Contracted Research: Merz Pharmaceuticals; Revance Advisory Board: Allergan; Merz Pharmaceuticals

3 Pathophysiology of aging Dermal loss of: Collagen Elastin Glycosaminoglycans Subcutaneous loss of: Fat Bone resorption

4 Temporary fillers of the world AcHyal Atlean Belotero Cosmetalife Cosmoderm Cosmoplast DermiCol Evolence & evolence breeze Emervel Esthelis Fibrel Procine Collagen Fibroquel Hyal 2000 Injection Hyacell Hydrafill Hydrafill Coftline Hylaform Hylan Dex Hylan SeS Hyruan Injection Isologen Juvederm 18, 24, 30 Koken Autocollagen MacDermol S Macdermol R Matrigel Martidex Matridur Matrex Newfill Polylactic acid Perlane Permicoll Permacoll Plasma Gel Purogen Prevelle Radiesse Resoplast Resylane Restylane fine line Restylane vitale Restylane lip Reviderm Intra Rhegecoll Rofilan Hylan Gel Sculptra Teosyal Uma Jeunesse Varioderm Voluma Zyderm I Zyderm II Zyplast Bovine Collagen

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6 FDA approved fillers Zyplast Zyderm 1 & 2 Cosmoplast Cosmoderm 1 & 2 Evolence Autologous fat Artefill Restylane Captique Hylaform Hylaform Plus Juvederm Ultra, Plus Perlane Prevelle Belotero Voluma Sculptra Radiesse

7 Filler Choices Duration Temporary (2-9 months) Semi-permanent (>9 months) Permanent Properties Density/Viscosity Purpose Filling Fine lines Deep lines Sculpting Placement Superficial Mid Deep

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9 Update on Fillers: Lecture outline Update on products, uses Hyaluronic acids Polylactic acid Calcium hydroxylapetite Injection techniques: Canulas Specific areas, specific techniques

10 Hyaluronic acids Most versatile fillers on the market Excellent safety profile HA is chemically identical across species Less chance of antigenicity

11 Hyaluronic Acid Polymer of disaccharides linked via glycosidic bonds Carbohydrate (polysaccharide) portion of the extracellular matrix

12 Identical in all species Hyaluronic acid Able to bind 100x its weight in water Used as a cushion and lubricant in tissues- in joints/synovial fluid, cartilage, dermis of skin

13 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

14 Hyaluronic Acid Fillers Binding with water yields a plumping effect Reversible with hyaluronidase

15 Hyaluronic Acids Non-animal source (NASHA) Captique Restylene Juvederm Perlane Belotero Voluma

16 Hyaluronic acids

17 Physical Differences between HAs Cross linking Method (ether, ester) Type (BDDE) Amount Double cross-link Concentration of HA 5-30mg/ml Particle size 10, ,000 gel particles/ml (biphasic) Uniform gel, nonparticle (monophasic) Size of HA chain

18 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

19 Product Concentration Particle or homogenous gel Juvederm ultra Homogenous gel Juvederm ultra plus Homogenous gel Belotero 22.5mg/mL Homogenous gel BDDE cross linking Voluma

20 Voluma FDA approval 2013 Indicated for deep (subcutaneous and/or supraperiosteal) injection for cheek augmentation to correct age-related volume deficit in the midface in adults over the age of 21

21 Belotero

22 Tan Delta (tan ) of HA Fillers 0.8 Cohesive Polydensified Gel 0.7 Cohesive Gel Particulate Gel Restylane Restylane-L Perlane Perlane-L Juvederm Ultra *Homogenous gel, 22.5 mg/ml HA manufactured by Anteis S.A. tan = Measures presence and extent of elasticity Juvederm Ultra XC Belotero Balance * Measured at 0.7 Hz Data on File, Merz Aesthetics, Inc

23 Cohesivity Evaluation BELOTERO BALANCE Restylane BELOTERO BALANCE Restylane-L BELOTERO BALANCE Perlane *Homogenous gel, 22.5 mg/ml HA manufactured by Anteis S.A. BELOTERO BALANCE Perlane-L 8 mm plate separation Data on File, Merz Aesthetics, Inc

24 HA Distribution in the Dermis BELOTERO BASIC* Juvéderm Restylane Day 7 Blue = HA Day 114 *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

25 700 Particulate Gel Cohesive Gel Cohesive Polydensified Gel 0 Restylane Restylane-L Perlane Perlane-L Juvederm Ultra Elastic Modulus = G Measures ability to resist outside forces Juvederm Ultra XC Belotero Balance Measured at 0.7 Hz Data on File, Merz Aesthetics, Inc

26 Physical Differences between HAs Already fully saturated with water in syringe Captique Hylaform Result: less expansion after injection (less swelling) Not fully saturated with water in syringe Juvederm Restylane Unmodified HA is added to increase fluidity Result: Some expansion after injection. Ease on injection. Not all HA is crosslinked.

27 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

28 Sculptra (Newfill) Poly L-lactic acid Long lasting, nonpermanent filler Approved by FDA for facial lipoatrophy in immunocompromise d patients in 2004

29 Sculptra Comes in vial as powdered substance Reconstitute with saline and lidocaine Wait at least 3 hours after reconstitution Injections/substance stimulates collagen formation Injections should be placed in deep dermis or subcutaneous tissue

30 Industry-provided image for educational purposes only.

31 Sculptra + s and s Duration Natural looking results Forgiving if placed in SQ Not plumping Reconstitution 26 gauge needle that sometimes clogs Results are not immediate Multiple treatments SQ papules

32 Sculptra 1.5 vials Photo courtesy of Steve Mandy, MD

33 Sculptra photo cheek

34 Sculptra update Dilutions started around 6cc of dilutent Gradually have increased 8cc of saline and 2cc of lidocaine Off face dilutions of 15cc

35 Synthetic Calcium Hydroxylapatite microspheres [30%] suspended in a carboxymethylcellulose resorbable aqueous gel carrier [70%] Radiesse

36 Radiesse When placed into soft tissue, Radiesse provides immediate correction Gel + CaHA Particles Over time the gel is resorbed and the CaHA particles stimulate the body to produce collagen Decalcified 25μm to 45 μm particles

37 Radiesse Radiesse stimulates collagen production The CaHA microspheres are synthetically derived and break down naturally over time by the body s own metabolic processes into Ca 2+ and PO 3 2+ ions. No ossification or calcification of CaHA has been reported in over 6 years of clinical use and >400,000 syringes injected

38 Radiesse + and -s 27g needle Post injection edema Firm for a couple of weeks after injection Product clumps in lips Mixed in office with lidocaine Long duration (>12 mo) More filler per cc of product Immediate results Safety profile

39 Patient Satisfaction Radiesse vs. Restylane % of Patients That are Satisfied & Extremely Satisfied* 89% 96% Radiesse Restylane 61% 58% More patients were Satisfied with Radiesse than were with Restylane Even at 6 Months 6 Months 9 Months Time post 2nd Injection

40 Radiesse vs. Restylane 6 months post second treatment Restylane Radiesse Volume 1.20cc Volume 0.80cc

41 Nasolabial fold correction Before Radiesse 12 weeks after Radiesse

42 Anatomic considerations must 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

43 Depth of injection is dependent on area being augmented Deep dermis/subdermal plane for treating lines Nasolabial 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

44 Structural Aging The 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, Fitzgerald et al. Aesthetic Surg Journal, July/August 2010.

45 Structural Aging Facial bony structures remodel throughout adulthood Facial frontal bone moves anteriorly and inferiorly Maxillary bone moves posteriorly and superiorly Maxillary regression- NLF Changes in mandible and teeth Pessa et al. Plastic Reconstr Surg, 1998.

46 Perioral Aging Marionette lines Down turn angle of mouth Fine radial lines Deflation of vermillion border Flattening of cupids bow, philtrum Chin dimpling

47 Perioral Aging

48 Marionette lines Deep placement Correct structural defect Superficial placement Correct dermal defect

49 Cannula

50 Perioral Rejuvenation 27g, 37mm cannula 30g, 27mm cannula Insertion opening with 26g

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54 Deposition point to turn up angle of mouth

55 Perioral Rejuvenation

56 Perioral rejuvenation

57 Perioral: Fine lines Juvederm.4 cc syringe diluted with.3cc saline

58 Perioral: Fine lines Belotero Balance

59 Perioral: Fine lines Fine radial lines: Serial puncture technique 32 gauge needle Intradermal If using diluted product, slight overcorrection Vermillion threading 30 gauge

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61 Perioral: fine lines

62 Perioral Jeremy Green, MD

63 Perioral Rejuvenation Etiology is multifactorial Do not disregard the structural abnormalities

64 Thank You!

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