Update on Dermal Fillers Joely Kaufman, MD Voluntary Assistant Professor Dermatology University of Miami Miller School of Medicine
Relevant Disclosures Contracted Research: Merz Pharmaceuticals; Revance Advisory Board: Allergan; Merz Pharmaceuticals
Pathophysiology of aging Dermal loss of: Collagen Elastin Glycosaminoglycans Subcutaneous loss of: Fat Bone resorption
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
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
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
Update on Fillers: Lecture outline Update on products, uses Hyaluronic acids Polylactic acid Calcium hydroxylapetite Injection techniques: Canulas Specific areas, specific techniques
Hyaluronic acids Most versatile fillers on the market Excellent safety profile HA 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
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
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) Captique Restylene Juvederm Perlane Belotero Voluma
Hyaluronic acids
Physical Differences between HAs Cross linking Method (ether, ester) Type (BDDE) Amount Double cross-link Concentration of HA 5-30mg/ml Particle size 10,000-200,000 gel particles/ml (biphasic) Uniform gel, nonparticle (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 homogenous gel Juvederm ultra Homogenous gel Juvederm ultra plus Homogenous gel Belotero 22.5mg/mL Homogenous gel BDDE cross linking Voluma
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
Belotero
Tan Delta (tan ) of HA Fillers 0.8 Cohesive Polydensified Gel 0.7 Cohesive Gel 0.6 0.5 0.4 0.3 Particulate Gel 0.2 0.1 0 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. 2012.
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. 2012.
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
700 Particulate Gel 600 500 400 300 200 100 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. 2012.
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.
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 acid Long lasting, nonpermanent filler Approved by FDA for facial lipoatrophy in immunocompromise d patients in 2004
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
Industry-provided image for educational purposes only.
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
Sculptra 1.5 vials Photo courtesy of Steve Mandy, MD
Sculptra photo cheek
Sculptra update Dilutions started around 6cc of dilutent Gradually have increased 8cc of saline and 2cc of lidocaine Off face dilutions of 15cc
Synthetic Calcium Hydroxylapatite microspheres [30%] suspended in a carboxymethylcellulose resorbable aqueous gel carrier [70%] Radiesse
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
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
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
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
Radiesse vs. Restylane 6 months post second treatment Restylane Radiesse Volume 1.20cc Volume 0.80cc
Nasolabial fold correction Before Radiesse 12 weeks after Radiesse
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
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
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, 2007. Fitzgerald et al. Aesthetic Surg Journal, July/August 2010.
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.
Perioral Aging Marionette lines Down turn angle of mouth Fine radial lines Deflation of vermillion border Flattening of cupids bow, philtrum Chin dimpling
Perioral Aging
Marionette lines Deep placement Correct structural defect Superficial placement Correct dermal defect
Cannula
Perioral Rejuvenation 27g, 37mm cannula 30g, 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 technique 32 gauge needle Intradermal If using diluted product, slight overcorrection Vermillion threading 30 gauge
Perioral: fine lines
Perioral Jeremy Green, MD
Perioral Rejuvenation Etiology is multifactorial Do not disregard the structural abnormalities
Thank You! JKAUFMAN@MED.MIAMI.EDU