Cosmetic Facial Fillers Suzanne K. Freitag, MD Director, Ophthalmic

6/11/12!
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Cosmetic Facial Fillers
Suzanne K. Freitag, M.D.
Director, Ophthalmic Plastic Surgery Service
Massachusetts Eye and Ear Infirmary
Harvard Medical School
Boston, MA
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I have no financial disclosures.
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Learning Objectives
! Aging face
! Facial zones amenable to fillers
! Dermal filler products available
! Facial filler technique
! Before and after pictures
! Risks and risk management
! Video of injection
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Plastic Surgery is Trendy.
Look at these Trend Setters…
Are they enhancing their beauty?
Or will they look back in 10 years and wonder what they
were thinking?
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Joan van Ark
Michaela Romanini
Just when you think you want no part of this …
The Aging Face
! Multifactorial
! Hyperdynamic and static rhytids
! Loss of skin elasticity
! Gravitational descent
! Volume depletion
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! Gravitational descent
! Volume depletion
! Facial aesthetic medicine
has shifted to achieve 3-D
facial rejuvenation.
The Aging Face
! Prominent facial lines and sagging skin can be misinterpreted
as anger, fatigue, sadness.
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Dermal fillers are used for facial contouring and volume
augmentation
Dermal Filler Uses
! “Liquid Facelifts”
! Nice cosmetic benefits
! Little downtime
! Low risk
! Lower cost than surgery
! Do require re-treatment
! Combine with Botox and other treatments
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Ideal Filler Characteristics
! Safe, bio-compatible
! Easy to inject
! Readily prepared
! Easy to store
! Affordable
! Long-lasting effect
! Minimal complications
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“It seems like there are so many products available. This is
what scares me about learning about fillers.”
Fillers - Categorized
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Fillers - Categorized
! Collagen
! CosmoDerm, Cosmoplast, Zyderm, Zyplast, Evolence
! Cadaveric dermis
! Cymetra, Dermalogen, Fascian
! Hyaluronic acid
! Captique, Esthelis, Elevess, Hylaform, Juvederm, Perlane,
Prevelle, Puragen, Restylane
! Calcium Hydroxylapatite
! Radiesse, Radiance
! Polylactic acid
! Sculptra, New-Fill
! PMMA
! Articol, Artefill, Metacrill
! Autologous fat
Fillers - Categorized
! Passive fillers
! Space-filling agents
! Most dermal fillers
! Active fillers
! Capable of increasing fibroblast activity
! Stimulates neocollagenesis
! Calcium hydroxylapatite, poly-L-lactic acid
Next big question –
What filler should I use where ?
Let’s go through each type of filler and then this will become
clear.
Dermal Fillers Overview
! Volume enhancement with autologous fat dates back over a
century
! Bovine collagen used in 1980’s
! Led to explosion of dermal fillers
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! Led to explosion of dermal fillers
! Limited effect and immunologic concerns
! Led to development of human and porcine collagen
products
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Dermal Fillers Overview
! Hyaluronic acid fillers have become the prominent product
! Accounted for >85% of fillers used in 2008
! Originally derived from
rooster combs
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Dermal Fillers Overview
! Longer-acting products are gaining popularity
! Contain calcium hydroxyapatite, silicone, PMMA
! Require more skill for injection and have potential for more
complications
Collagen Fillers
! First fillers FDA approved for use in US
! Gold standard until 2000’s
! Relatively light, non-viscous filler
! Overfill/ overcorrect 1.5 to 2 times
! Saline and lidocaine will absorb within 24 hours
! Short duration of effect
! 3 months
Collagen Fillers
! Bovine: Zyderm, Zyplast
! Risk of hypersensitivity reaction
! Skin testing x 2 a month apart required prior to treatment
! Human: CosmoDerm, Cosmoplast
! Risk of disease transmission
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! Risk of disease transmission
! More cross-linking in Zyplast and Cosmoplast
! slower to degrade, suited for deeper injection
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Hyaluronic Acid Fillers
! Available for use in Europe for decades
! The first to gain FDA approval in US was Restylane in 2003
! Cross-linked HA product from Streptococcus species
biofermentation
! Stored at room temperature
! Lasts 6-9 months
! Depends on amount of dynamic movement in that facial
region
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Hyaluronic Acid
! Forms fluid matrix of connective tissue
! Collagen & elastin are embedded in HA in vivo
! Half-life of several days
! Cross-linked for stability as a filler
! Highly hydrophilic
! Water absorption helps fill tissues
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Hyaluronic Acid Fillers
! Unique property of dynamic viscosity
! Viscosity increases with decreasing shearing force
! Relatively fluid under injection pressure
! Form stable, viscous gel once implanted
! Not likely to migrate
! Larger, more cross-linked products
! Juvederm Ultra Plus, Perlane
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! Juvederm Ultra Plus, Perlane
! For deeper filling
Hyaluronic Acid Fillers
! Now are many HA products in US
! Vary by viscosity, particle size, concentration
! Manifest as variability of ease of injection, recommended
depth of injection, longevity of effect, local reactions
Injection technique
! Inject material into middle dermis
! Deep injection
! Minimal cosmetic result
! Superficial injection
! Blanching of skin noted
! Uneven contouring
! Gentle massage immediately after injection to smooth lumps
Touch-up may be performed several weeks later.
Hyalunoric Acid Fillers
! May be instantly erased with hyaluronidase (Wydase)
! Useful when
! Concern for ischemia
! Patient is unhappy
Before and After
Before and After
Before and After
Calcium Hydroxylapatite Filler
! Radiesse is representative of this group
! Hydroxylapatite microspheres in glycerin base
! CaHA is primary mineral component of bone
! Particle size ranges from 25-45 microns
! Inject with 25-27 gauge needle
! Inject into deep dermis, or for volume below dermalsubcutaneous junction
Deep Injection
Calcium Hydroxylapatite Filler
! Initially both CaHA and gel act as filler
! After 2-3 months, water-based gel degrades
! Leaves behind CaHA microspheres
! Stimulate neocollagenesis
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! Leaves behind CaHA microspheres
! Stimulate neocollagenesis
! FDA approved for correction of moderate to severe facial
wrinkles
Calcium Hydroxylapatite Filler
Calcium Hydroxylapatite Filler
Radiesse
Poly-L-lactic Acid Filler
! Sculptra is example of this type of deep dermal filler
! Injectable poly-L-lactic acid in the form of a sterile lyophilized
cake
! Biocompatible, biodegradable synthetic polymer from alphahydroxy-acid family
! Originally FDA approved for correction of lipoatrophy in HIV
patients
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Poly-L-lactic Acid Filler
! Lasts 18-24 months
! Slow degradation of large, irregularly shaped PLLA particles
! 40-63 microns
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Poly-L-lactic Acid Filler
! Supplied as sterile, freeze-dried powder with 2 year shelf-life
! Reconstitute 24 hours prior to injection with 25 gauge needle
! Add lido just before use
! May then be stored at room temperature for 30 days
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Poly-L-lactic Acid Filler
! Mantra of PLLA injection technique
! “Treat, wait, assess”
! Do not overfill
! Neocollagenesis will take over after vehicle is absorbed
! “semi-permanent” filler
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Sculptra
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Sculptra
Sculptra (cosmetic)
Autologous Fat
! Pros
! May be permanent
! No cost for product
! No risk for hypersensitivity or adverse reaction
! Cons
! Highly unpredictable longevity
! Relatively complicated process to harvest and prepare
! Highly unpredictable results
! May all die or may hypertrophy
Autologous Fat
Autologous Fat
Autologous Fat
Fillers General Principles
! Products with smaller particles are used superficially for fine
lines
! Will “get lost” if used deep
! Products with larger particles are used for deeper lines and to
replace volume loss
! Will leave visible lumps if superficial
Fillers General Principles
! Layering multiple products is useful in areas requiring both
volume enhancement and fine wrinkle reduction
! Thinner products last about 6 months
! Larger particle products last 6-12 months
Preinjection Anesthesia
! Varies widely among MD’s
! Topical anesthetic creams
! Ice packs
! Chilled air
! Regional nerve block
! Dental block for lips
! Many products now have lidocaine mixed in the syringe
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! Many products now have lidocaine mixed in the syringe
Injection Technique
! Most can be injected with 30-gauge needle
! some require a 27-gauge because of particle size
! Package insert will recommend a needle
! Most products come pre-loaded in syringe and a stopper is
removed and needle attached prior to injection
! Stop blood thinners for 1-2 weeks prior to injecting
Injection Technique
! Injecting too superficially results in bluish discoloration of
treated area
! Tyndall effect
! Massage any lumps immediately after treatment
! Ice packs minimize pain and swelling
! Save leftover in refrigerator and offer for patient to return in 1-2
weeks for touch-up or more volume
Injection Technique
! Retrograde linear threading
! Anterograde linear threading
! Serial puncture
! Fanning
! Crosshatching
Retrograde Linear Threading
! Needle enters skin bevel up at 30 to 45 degree angle
! Insert to the hub at desired depth
! Inject uniformly as needle is withdrawn
! Stop injecting just before needle withdrawn
! Prevents waste and superficial nodules
Retrograde Linear Threading
Anterograde Linear Threading
! Same as retrograde except filler is injected as needle is
carefully inserted and advanced at desired depth
Serial Puncture
! Line to be injected is held taut with non-dominant hand
! Needle tip, bevel up, inserted into dermis
! Small aliquot of product is delivered and needle withdrawn
! Repeat along length of wrinkle
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! Repeat along length of wrinkle
! Massage immediately after injection
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Serial Puncture
Fanning Technique
! Used for global volumetric enhancement of lower 2/3 of face
! Needle inserted, bevel up, through one point
! Needle is pivoted to create series of linear tunnels in a fanlike
formation
! Inject in retrograde fashion
! Taper volume as reach pivot point to minimize excess in this
area
Fanning Technique
Cross-Hatching Technique
! Injections are placed in grid pattern for large areas of
volumetric filling
! Cross-fanning perpendicular to original tunnels may be done
as a modification
! Less puncture sites
Injection Considerations
! DEPTH, VOLUME and DISTRIBUTION
! Is the target area a fine line versus a large area of volume
loss?
! Choose a filler based on its particle size, viscosity, depth of
implantation needed
!  for lips and lower eyelids use HA
! Consider layering fillers
! Fill deeper portions in first treatment
! Fill finer superficial lines subsequently
Consideration of Facial Region
! In general
! Upper face – botulinum toxin
! Repetitive small muscle movement
! Hyperdynamic lines in forehead and glabella
! Mid and lower face – fillers
! Gravitational descent and volume loss
! Malar projection, nasolabial fold, tear trough, lips,
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! Gravitational descent and volume loss
! Malar projection, nasolabial fold, tear trough, lips,
marionette lines
! Use large-particle product for deeper and HA for
superficial
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Nasolabial Folds
! Malar descent with aging exaggerates folds
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Nasolabial Folds
Marionette Lines
! Superficial extension of nasolabial folds
! Use mid- to deep dermal injection via linear threading or serial
puncture
Glabella
! Treat primarily with botulinum toxin
! If lines present after paralysis, consider filler
! Risk of emboli to eye/orbit
! May avoid with special technique
! Use larger needle to sweep and create pocket, then inject
filler into pocket
! High risk for pressure necrosis
! Use only thin fillers such as HA
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Glabella Filler
Lips
! Aging lips
! Loss of turgor
! Loss of forward projection
! Loss of volume
! Vermillion border, white roll, red lip
! One of the most commonly filled areas
! Linear threading/ serial puncture
! Use only HA products
! High risk for nodularity
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! High risk for nodularity
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Lips
! First augment vermillion border/ white roll lateral to philtrum
! Massage often to keep smooth
! Insert fingers inside mouth and thumb outside for best
results
! Then fill opposite side for symmetry
! Next fill Cupid’s bow +/- red lip
! Next fill lower lip
! Vertical height of upper and lower lip should be same
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Lip Filler with Juvederm
Lips
Lips
Lips
Tear Trough/ Lower Eyelid
! Special considerations
! Injection should be posterior to orbicularis muscle
! There is no subcutaneous fat under eyelid skin
! Avoid severe Tyndall effect
! Avoid lumpiness
! Injection should be anterior to septum
! Deep injection may cause fat pads to prolapse
! I inject just anterior and superior to rim
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Lower Eyelid Selphyll
Malar Augmentation
Other options for fillers
! Chin crease
! Chin augmentation
! Acne scars
! Nasal bridge deformities
! Lipstick lines
Hand Filler
Complications
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Hand Filler
Complications
! Ecchymosis, erythema, edema
! Hypersensitivity reaction
! Asymmetry
! Lumpiness
! Granuloma formation
! Vascular compromise
Granuloma Formation
Vascular Compromise
! Soft tissue necrosis
! Direct arterial embolization
! May result in blindness, if in periocular area
! Venous obstruction
! Local pressure-related mechanisms
! Most often reported in glabellar area
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Vascular Compromise
! Signs and symptoms
! Skin blanching
! Unexpected level of pain
! Violaceous discoloration of treatment area
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Vascular Compromise
! Management
! Stop injecting
! Aspirate any filler possible
! Vigorous massage
! Warm compresses
! 2% nitroglycerine paste
! Should have this in your office if you do fillers
! Causes local vasodilation
! Local injection of hyaluronidase
! Dissolves HA fillers
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Lower eyelid complication
How to get started
! HA is very forgiving – start here
! Buy a few syringes and treat people you know well first
! Then move to a thicker, deeper product
! Next have one product from each category in your
armamentarium
! When you are really an expert, have more options for patients
How to get started
Now that you are experts,
Where to start?!
Thank you
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