The fifth part of Dr. Lee's "Trends in Oculoplastic Surgery" series will discuss trends in dermal fillers.
There are so many dermal filler products on the market — some have come and gone, while others have been around for years.
The most popular dermal fillers are the hyaluronic acids, including the Juvéderm® family of products, the Restylane® family of products, and Belotero®. These fillers differ by many characteristics, but all come from non-animal based bacterial cell walls and consist of a natural polysaccharide found in all living species, so they are very well tolerated. Some are more concentrated than others, some more cross-linked, giving them different rheologic properties such as G’ (lifting capacity) and cohesivity.
About Juvéderm
The Juvéderm family of products come from Allergan, who also produces Botox® and Kybella®. Their products are cross-linked by the proprietary Vycross™ technology.
- Juvéderm Voluma® is relatively new and indicated for the midface. It has a combination of heavy and light chains, has a high G’ and is cohesive. This product is indicated to last up to two years and is a soft product that is easy to inject. Recommended injection patterns follow Hinderer’s Lines starting at the zygoma and marching forward toward the anteromedial cheek with caution so as not to get product into the infraorbital canal or angular artery.
- Juvéderm Ultra Plus XC is a hyaluronic acid that is 24mg/ml and is 90 percent cross-linked. It differs from Ultra XC in that it has a higher degree of cross-linking, making it better used in deeper lines and folds.
- Juvéderm Ultra XC is also 24mg/ml and 90 percent cross-linked, but has a lesser degree of cross-linking when compared to Ultra Plus XC. This product is nice for more shallow lines and folds, as well as the perioral and lip region.
- Juvéderm Volbella® was just released on the market. This hyaluronic acid is only 15 mg/ml and is indicated for the lips and perioral lines. Volbella is a very soft product that is great for defining the lips, rather than volumizing the lips.
About Restylane
The Restylane family of products come from Galderma, who also produces Dysport® and Sculptra®. Their products are cross-linked with the proprietary NASHA™ technology.
- Restylane Lyft is the rebranded Perlane®. This product is 20 mg/ml and is 80 percent cross-linked. The Restylane family of products differ in their particle size. Restylane Lyft is the largest particle size (750 – 1000 um). This product is used for midface lifting and deeper lines and folds. Injection of “tent poles” creates a nice lift in the cheek region.
- Restylane-L is Galderma’s oldest product. It is also 20 mg/ml and 80 percent cross-linked. It is a medium particle size (330 – 500 um). This product is great for mild to moderate lines and wrinkles. Many injectors prefer this product in the tear trough as well, as it produces nice and more predictable results.
- Restylane Silk is the newest of the Restylane products. It is also 20 mg/ml and 80 percent cross-linked, but is the smallest particle size. This product is indicated for the lips. It is best injected in the submucosal plane to minimize swelling and optimize results.
About Belotero
Belotero is a hyaluronic acid that is produced by Merz, the makers of Xeomin® and Radiesse®. This product is 22 mg/ml. It is a mixture of long and short chains to reduce the risk of the Tyndall effect. Because of this feature, Belotero is great for injections into fine, etched lines that require very superficial injections. This product can be injected so superficial that you can see the silver of the needle beneath the skin. Belotero is commonly used also in the lips and tear trough. For glabellar injections, which are notoriously risky given the proximity to the supraorbital and supratrochlear neurovascular bundles, superficial injections are paramount. Belotero should be considered.
Dermal Stimulators
Besides the hyaluronic acid fillers, there are dermal stimulators that are popular. These are effective for large volume deficits and areas that require a lot of volume.
Radiesse and Radiesse (+) are produced by Merz. These products are made of calcium hydroxyapatite. Radiesse was first approved for vocal cord insufficiency, but now has cosmetic indications. Radiesse (+) has lidocaine in it. This product is nice as an injectable implant, for instance in the pre-jowl sulcus, dorsum of the nose or cheeks. Radiesse is indicated for the hands also. Injecting between the tendons can decrease the appearance of aged hands.
Sculptra is poly-L-lactic acid produced by Galderma. Its original indication was for facial lipoatrophy in HIV patients, but now has a cosmetic indication. This product stimulates collagen over time, so requires a series of treatments. It is important to set patients’ expectations with this product, as they will not see results right away. Treatments are spaced at least one month apart, and patients will notice a gradual and natural result.
For injectors who provide dermal filler treatments in their office, it is extremely important to have a “filler crash cart” nearby. This should include hot compresses, which can be used to dilate vessels in the case of embolism. Nitropaste is controversial — some think that dilating the artery may increase the chance that the embolism will dislodge further.
The most important item to have in the filler crash cart is hyaluronidase. This enzyme comes in bovine form (Vitrase) or human recombinant (Hylenex®). Use of hyaluronidase in the face of necrosis, lumps and bumps will produce results within 24 hours. In the case of a central retinal artery occlusion, avoidance is key as treatments have not yet proven to be effective.
Conclusion
Each of the different products discussed above serve various but overlapping purposes. It is important for injectors to learn the differences and nuances of each so that the appropriate choices are made for the patients. Different products can definitely be used in combination to provide optimal results.