W ithin the last couple of years, we’ve seen the filler menu expand extensively with choices we’ve never had before. Restylane, Captique and Sculptra, are but a few of the fillers available, and they have given us the ability to expand our practices exponentially. In this article, we’ll explore some of the newer filler options and tackle the question many practitioners want to know: Can one filler do it all? The Skin We’re Aging In Collagen, elastin and hyaluronic acid are significantly decreased in aged skin, resulting in a less youthful skin appearance. As you know, collagen, which makes up 70% to 80% of the dry weight of the skin, gives the dermis its mechanical and structural integrity. Hyaluronic acid, or hyaluronan, helps maintain salt and water balance because it strongly binds water, drawing it into the skin, and leaving the skin plump, soft and hydrated. Hyaluronic acid (HA) and dermatan sulfate are the most prevalent of the glycosaminoglycans, which have water binding properties that give the skin its volume. Elastin gives the skin its resilience and ability to bounce back, and, consequently, aged skin is characterized by decreased amounts of HA and collagen, and changes in the elastic fibers known as elastosis.1 Naturally, the goal of dermal fillers is to replace these lost substances, imparting a more youthful look to the skin. At this time, no fillers presently available replace elastin, so we’ll focus on the collagen and HA containing fillers in this article. Collagen Fillers Previously, bovine collagen was the only approved dermal filler in the United States. However, nowadays there are several options available. In March 2003, the FDA approved CosmoDerm and CosmoPlast (Inamed Corporation, Santa Barbara, CA) as the first bioengineered type I/type III human collagen containing fillers for cosmetic indications. The production process starts with dermal fibroblasts, harvested from bioengineered human skin cells. The fibroblasts replicate and secrete collagen and other extracellular matrix proteins. The final collagen products are thoroughly tested for viruses, retroviruses, cell morphology, isoenzymes, and tumorigenicity. This product contains intact triple helix collagen capable of forging noncovalent bonds with hyaluronic acid and other molecules, providing structure to the skin. CosmoDerm and CosmoPlast are the only FDA-approved dermal filling agents that contain human bioengineered collagen and require no skin test prior to treatment.2,3 CosmoDerm contains 35 mg/cc of collagen dispersed in phosphate buffered saline solution and 0.3% lidocaine. CosmoPlast is composed of these ingredients, but is also cross-linked with gluteraldehyde that extends the duration of the cosmetic correction. CosmoDerm is better suited for superficial wrinkles, while CosmoPlast is indicated for the treatment of deeper wrinkles, scars and for enhancing the vermilion border of the lips. When used in combination, CosmoDerm can be layered over CosmoPlast to treat deeper furrows. The Advantages These collagen products have several distinct advantages. Because collagen forms the natural structure of the skin, giving it support, CosmoPlast is the ideal filler when trying to make an area stand up or trying to “give it altitude.” For example, if it is desired to enhance the vermilion border of the lip, CosmoPlast is ideal for getting vermilion to stand proud. The same is true for raising the corners of the mouth. In addition, the collagen contained in these fillers has platelet-aggregating effects that may help decrease bruising.4 Both CosmoDerm and CosmoPlast contain lidocaine, which is believed to be responsible for reducing the incidence of swelling and bruising by inhibiting the activation of eosinophils.5 It is for these reasons that we often treat a particular patient first with CosmoPlast in the mid dermis and then, in the same treatment visit, with a hyaluronic acid filler at the same level in the mid dermis. Hyaluronic Acid Fillers Hyaluronic acid fillers can be used as alternatives to, or in combination with, collagen containing fillers. Several types of commercial HA fillers are now available in many countries. They include Hylaform, Hylaform Plus, Restylane, Perlane, Captique, Juvéderm and others. They have been approved for cosmetic use in several countries, but not all of them are currently approved in the United States. Hylaform, also known as Hylan B, is derived from rooster combs, known to contain a copious supply of HA. Sulfonyl-bis-ethyl cross-links are introduced between hydroxyl groups of the polysaccharide chains of hyaluronan to produce the filler material.6 The modified material forms a gel-like substance, which is then extruded through a sieve. The smallest resulting particles are packaged as the low-density dermal filler sold as Hylaform Fine Line; medium-sized particles as Hylaform; and the large particles form the high-density product as Hylaform Plus. At this time, Hylaform and Hylaform Plus are approved by the FDA. These product are the softest of the HA filler choices and leave a natural feeling when injected into the dermis or the body of the lips.7,8 Hylaform is often used alone in the body of the lips, or in combination with CosmoPlast in mild or moderately deep wrinkles. When used in combination with CosmoPlast, the CosmoPlast is injected first and then Hylaform is layered in the same plane. This layering technique has the perceived (but not yet proven) advantages of less bruising and increased longevity of the correction. Hylaform can also be used under the eyes in the tear trough area; however, this area frequently bruises and patients should be forewarned. Hylaform Plus is often used layered over CosmoPlast in deep wrinkles or alone over large areas needing volume such as the cheekbones, hollows of the cheeks and the pre-jowl hollow. The softness of Hylaform Plus gives it a soft, natural feel even when used in large quantities in these areas. In addition, many dermatologists choose to use Hylaform Plus in the body of the lips. Restylane (Q-med, Uppsala, Sweden) is produced through bacterial fermentation (streptococci) and stabilized by cross-link using a butanediol diglycidyl ether (BDDE). The resulting product is then broken down into smaller pieces, similar to Hylaform. The smallest particles are packaged as Restylane Fine Line, which is indicated for the upper or papillary dermis and, therefore, appropriate for treating small lines, for example, crow’s feet and vertical lip wrinkles. The medium-size particles are Restylane, which is intended for the mid-dermis. The largest particles are sold as Perlane, which is indicated for treatment of the deep dermis. The FDA approved Restylane for cosmetic use in December 2003. Restylane is the stiffest of the available HA products, which makes it a good choice for deep wrinkles, the vermilion border, shaping the nose and treatment of acne scars. Captique is the newest non-animal stabilized hyaluronic acid-based dermal filler to be FDA-approved in the United States on December 2004. Captique is manufactured in the same manner as Hylaform (hylan B gel) with the exception that hyaluronan is derived from a bacterial source rather than an avian source. The chains of HA derived from the bacteria have a shorter chain length than those of Hylaform, making this product slightly stiffer than Hylaform. Captique is very versatile and can be used as a wrinkle corrector or as a facial sculpting material. Its consistency and feel make it ideal for the “smoker’s lines” around the mouth, and as a filler for moderately deep wrinkles. It can also be injected along the lateral portion of the eyebrow to give an eye lift, and is ideal in the pre-jowl hollow. Juvéderm is obtained by bacterial fermentation process similar to the one used in the manufacture of Restylane. Heat destroys the streptococci and it is eliminated by filtration. BDDE, the cross-linking agent used in Restylane, is used to cross-link the strands of HA in Juvéderm. Juvéderm differs from Hylaform and Restylane because instead of being a gel broken into smaller particles, it is a homogenous gel. The Juvéderm line of products contains several variations that differ by the amount of HA per cc and the amount of cross-linking of the product, and the regularity of the cross-linking of the product. The “non HV” products (Juvéderm 18, 24 and 30) tend to stay where you inject them while the “HV” products (Juvéderm 24 HV and 30 HV) tend to diffuse. Juvéderm 18 is indicated for fine lines such as crow’s feet. Juvéderm 24 and Juvéderm 24 HV are used for moderately deep wrinkles such as nasolabial folds, glabellar lines and oral commisures. Juvéderm 30 is used for deeper lines and wrinkles. Juvéderm 24 or 30 can be used in the vermilion border, while Juvéderm 24 HV and 30 HV are ideal for the body of the lip. The Juvéderm line of products is available in many countries in Europe and South America, but are not yet approved by the FDA in the United States. Phase III trials are currently ongoing. Dermal Stimulators The above-mentioned products fill wrinkles and provide immediate gratification. However, a new product will stimulate the native fibroblast to make collagen, resulting in wrinkle correction over time. Sculptra, formerly New Fill (Dermik Laboratories, Sanofi-Aventis Group) as of August 2004 was approved by the FDA as a treatment of lipoatrophy. It is used off-label as a treatment of facial wrinkles and volume loss due to aging. This product is composed of Poly-L-lactic acid (PLLA), a synthetic polymer that is biocompatible, biode-gradable, immunologically inert, and free from toxicity. PLLA is injected into the deep dermis or into the subcutaneous tissue (superficial injections should be avoided). The injections are spaced at 2- to 4-week intervals. After two or three injection sessions, results are appreciable. Once the desired results are achieved, the results may last up to 2 years. The novel technique and mechanism of action of this product require physicians to adjust their practice of treating a specific wrinkle and instead focus on returning volume to the face. Sculptra has been used successfully for the correction of nasolabial folds, mid and lower facial volume loss, jawline laxity, and other signs of facial aging.10-12 Improper dilution of the product, improper preparation of the product or incorrect injection of the product can result in granuloma formation. Therefore, proper physician training is paramount prior to the use of this product. It is possible to combine this product with collagen and/or HA containing fillers in patients who prefer an immediate result. The “Best” Filler There is no one perfect filler. Each of the available fillers has unique characteristics that give them both advantages and disadvantages. When deciding which filler to use, base your decision on the following: • the site to be treated • your comfort level and experience with the filler • the patient’s desires, experience, and needs • the patient’s budget • how long the patient is willing to wait for the result and how long the patient wants the filler to last. Some fillers are better on fine lines, others on deeper ones; some are stiffer and some are softer; some have more bruising and swelling and some have less down time. For example, if a patient has a wedding in 5 days and wants to correct the nasolabial folds with minimal down time and an immediate result, CosmoPlast would be the filler of choice. If a patient is willing to wait 3 months for the result and undergo two to three injections, but does not want to worry about being re-injected again for several years, Sculptra would be the filler of choice. If a patient has a large budget, can afford the possibility of 2 to 10 days of bruising, and needs a natural result and superior facial sculpting, several of these fillers would be used in combination. The field of dermal fillers has become an art as well as a science. To be a leader in the field, one must combine meticulous patient evaluation and knowledge of the attributes of each product with artistic skill.
Can One Filler Do It All?
W ithin the last couple of years, we’ve seen the filler menu expand extensively with choices we’ve never had before. Restylane, Captique and Sculptra, are but a few of the fillers available, and they have given us the ability to expand our practices exponentially. In this article, we’ll explore some of the newer filler options and tackle the question many practitioners want to know: Can one filler do it all? The Skin We’re Aging In Collagen, elastin and hyaluronic acid are significantly decreased in aged skin, resulting in a less youthful skin appearance. As you know, collagen, which makes up 70% to 80% of the dry weight of the skin, gives the dermis its mechanical and structural integrity. Hyaluronic acid, or hyaluronan, helps maintain salt and water balance because it strongly binds water, drawing it into the skin, and leaving the skin plump, soft and hydrated. Hyaluronic acid (HA) and dermatan sulfate are the most prevalent of the glycosaminoglycans, which have water binding properties that give the skin its volume. Elastin gives the skin its resilience and ability to bounce back, and, consequently, aged skin is characterized by decreased amounts of HA and collagen, and changes in the elastic fibers known as elastosis.1 Naturally, the goal of dermal fillers is to replace these lost substances, imparting a more youthful look to the skin. At this time, no fillers presently available replace elastin, so we’ll focus on the collagen and HA containing fillers in this article. Collagen Fillers Previously, bovine collagen was the only approved dermal filler in the United States. However, nowadays there are several options available. In March 2003, the FDA approved CosmoDerm and CosmoPlast (Inamed Corporation, Santa Barbara, CA) as the first bioengineered type I/type III human collagen containing fillers for cosmetic indications. The production process starts with dermal fibroblasts, harvested from bioengineered human skin cells. The fibroblasts replicate and secrete collagen and other extracellular matrix proteins. The final collagen products are thoroughly tested for viruses, retroviruses, cell morphology, isoenzymes, and tumorigenicity. This product contains intact triple helix collagen capable of forging noncovalent bonds with hyaluronic acid and other molecules, providing structure to the skin. CosmoDerm and CosmoPlast are the only FDA-approved dermal filling agents that contain human bioengineered collagen and require no skin test prior to treatment.2,3 CosmoDerm contains 35 mg/cc of collagen dispersed in phosphate buffered saline solution and 0.3% lidocaine. CosmoPlast is composed of these ingredients, but is also cross-linked with gluteraldehyde that extends the duration of the cosmetic correction. CosmoDerm is better suited for superficial wrinkles, while CosmoPlast is indicated for the treatment of deeper wrinkles, scars and for enhancing the vermilion border of the lips. When used in combination, CosmoDerm can be layered over CosmoPlast to treat deeper furrows. The Advantages These collagen products have several distinct advantages. Because collagen forms the natural structure of the skin, giving it support, CosmoPlast is the ideal filler when trying to make an area stand up or trying to “give it altitude.” For example, if it is desired to enhance the vermilion border of the lip, CosmoPlast is ideal for getting vermilion to stand proud. The same is true for raising the corners of the mouth. In addition, the collagen contained in these fillers has platelet-aggregating effects that may help decrease bruising.4 Both CosmoDerm and CosmoPlast contain lidocaine, which is believed to be responsible for reducing the incidence of swelling and bruising by inhibiting the activation of eosinophils.5 It is for these reasons that we often treat a particular patient first with CosmoPlast in the mid dermis and then, in the same treatment visit, with a hyaluronic acid filler at the same level in the mid dermis. Hyaluronic Acid Fillers Hyaluronic acid fillers can be used as alternatives to, or in combination with, collagen containing fillers. Several types of commercial HA fillers are now available in many countries. They include Hylaform, Hylaform Plus, Restylane, Perlane, Captique, Juvéderm and others. They have been approved for cosmetic use in several countries, but not all of them are currently approved in the United States. Hylaform, also known as Hylan B, is derived from rooster combs, known to contain a copious supply of HA. Sulfonyl-bis-ethyl cross-links are introduced between hydroxyl groups of the polysaccharide chains of hyaluronan to produce the filler material.6 The modified material forms a gel-like substance, which is then extruded through a sieve. The smallest resulting particles are packaged as the low-density dermal filler sold as Hylaform Fine Line; medium-sized particles as Hylaform; and the large particles form the high-density product as Hylaform Plus. At this time, Hylaform and Hylaform Plus are approved by the FDA. These product are the softest of the HA filler choices and leave a natural feeling when injected into the dermis or the body of the lips.7,8 Hylaform is often used alone in the body of the lips, or in combination with CosmoPlast in mild or moderately deep wrinkles. When used in combination with CosmoPlast, the CosmoPlast is injected first and then Hylaform is layered in the same plane. This layering technique has the perceived (but not yet proven) advantages of less bruising and increased longevity of the correction. Hylaform can also be used under the eyes in the tear trough area; however, this area frequently bruises and patients should be forewarned. Hylaform Plus is often used layered over CosmoPlast in deep wrinkles or alone over large areas needing volume such as the cheekbones, hollows of the cheeks and the pre-jowl hollow. The softness of Hylaform Plus gives it a soft, natural feel even when used in large quantities in these areas. In addition, many dermatologists choose to use Hylaform Plus in the body of the lips. Restylane (Q-med, Uppsala, Sweden) is produced through bacterial fermentation (streptococci) and stabilized by cross-link using a butanediol diglycidyl ether (BDDE). The resulting product is then broken down into smaller pieces, similar to Hylaform. The smallest particles are packaged as Restylane Fine Line, which is indicated for the upper or papillary dermis and, therefore, appropriate for treating small lines, for example, crow’s feet and vertical lip wrinkles. The medium-size particles are Restylane, which is intended for the mid-dermis. The largest particles are sold as Perlane, which is indicated for treatment of the deep dermis. The FDA approved Restylane for cosmetic use in December 2003. Restylane is the stiffest of the available HA products, which makes it a good choice for deep wrinkles, the vermilion border, shaping the nose and treatment of acne scars. Captique is the newest non-animal stabilized hyaluronic acid-based dermal filler to be FDA-approved in the United States on December 2004. Captique is manufactured in the same manner as Hylaform (hylan B gel) with the exception that hyaluronan is derived from a bacterial source rather than an avian source. The chains of HA derived from the bacteria have a shorter chain length than those of Hylaform, making this product slightly stiffer than Hylaform. Captique is very versatile and can be used as a wrinkle corrector or as a facial sculpting material. Its consistency and feel make it ideal for the “smoker’s lines” around the mouth, and as a filler for moderately deep wrinkles. It can also be injected along the lateral portion of the eyebrow to give an eye lift, and is ideal in the pre-jowl hollow. Juvéderm is obtained by bacterial fermentation process similar to the one used in the manufacture of Restylane. Heat destroys the streptococci and it is eliminated by filtration. BDDE, the cross-linking agent used in Restylane, is used to cross-link the strands of HA in Juvéderm. Juvéderm differs from Hylaform and Restylane because instead of being a gel broken into smaller particles, it is a homogenous gel. The Juvéderm line of products contains several variations that differ by the amount of HA per cc and the amount of cross-linking of the product, and the regularity of the cross-linking of the product. The “non HV” products (Juvéderm 18, 24 and 30) tend to stay where you inject them while the “HV” products (Juvéderm 24 HV and 30 HV) tend to diffuse. Juvéderm 18 is indicated for fine lines such as crow’s feet. Juvéderm 24 and Juvéderm 24 HV are used for moderately deep wrinkles such as nasolabial folds, glabellar lines and oral commisures. Juvéderm 30 is used for deeper lines and wrinkles. Juvéderm 24 or 30 can be used in the vermilion border, while Juvéderm 24 HV and 30 HV are ideal for the body of the lip. The Juvéderm line of products is available in many countries in Europe and South America, but are not yet approved by the FDA in the United States. Phase III trials are currently ongoing. Dermal Stimulators The above-mentioned products fill wrinkles and provide immediate gratification. However, a new product will stimulate the native fibroblast to make collagen, resulting in wrinkle correction over time. Sculptra, formerly New Fill (Dermik Laboratories, Sanofi-Aventis Group) as of August 2004 was approved by the FDA as a treatment of lipoatrophy. It is used off-label as a treatment of facial wrinkles and volume loss due to aging. This product is composed of Poly-L-lactic acid (PLLA), a synthetic polymer that is biocompatible, biode-gradable, immunologically inert, and free from toxicity. PLLA is injected into the deep dermis or into the subcutaneous tissue (superficial injections should be avoided). The injections are spaced at 2- to 4-week intervals. After two or three injection sessions, results are appreciable. Once the desired results are achieved, the results may last up to 2 years. The novel technique and mechanism of action of this product require physicians to adjust their practice of treating a specific wrinkle and instead focus on returning volume to the face. Sculptra has been used successfully for the correction of nasolabial folds, mid and lower facial volume loss, jawline laxity, and other signs of facial aging.10-12 Improper dilution of the product, improper preparation of the product or incorrect injection of the product can result in granuloma formation. Therefore, proper physician training is paramount prior to the use of this product. It is possible to combine this product with collagen and/or HA containing fillers in patients who prefer an immediate result. The “Best” Filler There is no one perfect filler. Each of the available fillers has unique characteristics that give them both advantages and disadvantages. When deciding which filler to use, base your decision on the following: • the site to be treated • your comfort level and experience with the filler • the patient’s desires, experience, and needs • the patient’s budget • how long the patient is willing to wait for the result and how long the patient wants the filler to last. Some fillers are better on fine lines, others on deeper ones; some are stiffer and some are softer; some have more bruising and swelling and some have less down time. For example, if a patient has a wedding in 5 days and wants to correct the nasolabial folds with minimal down time and an immediate result, CosmoPlast would be the filler of choice. If a patient is willing to wait 3 months for the result and undergo two to three injections, but does not want to worry about being re-injected again for several years, Sculptra would be the filler of choice. If a patient has a large budget, can afford the possibility of 2 to 10 days of bruising, and needs a natural result and superior facial sculpting, several of these fillers would be used in combination. The field of dermal fillers has become an art as well as a science. To be a leader in the field, one must combine meticulous patient evaluation and knowledge of the attributes of each product with artistic skill.
W ithin the last couple of years, we’ve seen the filler menu expand extensively with choices we’ve never had before. Restylane, Captique and Sculptra, are but a few of the fillers available, and they have given us the ability to expand our practices exponentially. In this article, we’ll explore some of the newer filler options and tackle the question many practitioners want to know: Can one filler do it all? The Skin We’re Aging In Collagen, elastin and hyaluronic acid are significantly decreased in aged skin, resulting in a less youthful skin appearance. As you know, collagen, which makes up 70% to 80% of the dry weight of the skin, gives the dermis its mechanical and structural integrity. Hyaluronic acid, or hyaluronan, helps maintain salt and water balance because it strongly binds water, drawing it into the skin, and leaving the skin plump, soft and hydrated. Hyaluronic acid (HA) and dermatan sulfate are the most prevalent of the glycosaminoglycans, which have water binding properties that give the skin its volume. Elastin gives the skin its resilience and ability to bounce back, and, consequently, aged skin is characterized by decreased amounts of HA and collagen, and changes in the elastic fibers known as elastosis.1 Naturally, the goal of dermal fillers is to replace these lost substances, imparting a more youthful look to the skin. At this time, no fillers presently available replace elastin, so we’ll focus on the collagen and HA containing fillers in this article. Collagen Fillers Previously, bovine collagen was the only approved dermal filler in the United States. However, nowadays there are several options available. In March 2003, the FDA approved CosmoDerm and CosmoPlast (Inamed Corporation, Santa Barbara, CA) as the first bioengineered type I/type III human collagen containing fillers for cosmetic indications. The production process starts with dermal fibroblasts, harvested from bioengineered human skin cells. The fibroblasts replicate and secrete collagen and other extracellular matrix proteins. The final collagen products are thoroughly tested for viruses, retroviruses, cell morphology, isoenzymes, and tumorigenicity. This product contains intact triple helix collagen capable of forging noncovalent bonds with hyaluronic acid and other molecules, providing structure to the skin. CosmoDerm and CosmoPlast are the only FDA-approved dermal filling agents that contain human bioengineered collagen and require no skin test prior to treatment.2,3 CosmoDerm contains 35 mg/cc of collagen dispersed in phosphate buffered saline solution and 0.3% lidocaine. CosmoPlast is composed of these ingredients, but is also cross-linked with gluteraldehyde that extends the duration of the cosmetic correction. CosmoDerm is better suited for superficial wrinkles, while CosmoPlast is indicated for the treatment of deeper wrinkles, scars and for enhancing the vermilion border of the lips. When used in combination, CosmoDerm can be layered over CosmoPlast to treat deeper furrows. The Advantages These collagen products have several distinct advantages. Because collagen forms the natural structure of the skin, giving it support, CosmoPlast is the ideal filler when trying to make an area stand up or trying to “give it altitude.” For example, if it is desired to enhance the vermilion border of the lip, CosmoPlast is ideal for getting vermilion to stand proud. The same is true for raising the corners of the mouth. In addition, the collagen contained in these fillers has platelet-aggregating effects that may help decrease bruising.4 Both CosmoDerm and CosmoPlast contain lidocaine, which is believed to be responsible for reducing the incidence of swelling and bruising by inhibiting the activation of eosinophils.5 It is for these reasons that we often treat a particular patient first with CosmoPlast in the mid dermis and then, in the same treatment visit, with a hyaluronic acid filler at the same level in the mid dermis. Hyaluronic Acid Fillers Hyaluronic acid fillers can be used as alternatives to, or in combination with, collagen containing fillers. Several types of commercial HA fillers are now available in many countries. They include Hylaform, Hylaform Plus, Restylane, Perlane, Captique, Juvéderm and others. They have been approved for cosmetic use in several countries, but not all of them are currently approved in the United States. Hylaform, also known as Hylan B, is derived from rooster combs, known to contain a copious supply of HA. Sulfonyl-bis-ethyl cross-links are introduced between hydroxyl groups of the polysaccharide chains of hyaluronan to produce the filler material.6 The modified material forms a gel-like substance, which is then extruded through a sieve. The smallest resulting particles are packaged as the low-density dermal filler sold as Hylaform Fine Line; medium-sized particles as Hylaform; and the large particles form the high-density product as Hylaform Plus. At this time, Hylaform and Hylaform Plus are approved by the FDA. These product are the softest of the HA filler choices and leave a natural feeling when injected into the dermis or the body of the lips.7,8 Hylaform is often used alone in the body of the lips, or in combination with CosmoPlast in mild or moderately deep wrinkles. When used in combination with CosmoPlast, the CosmoPlast is injected first and then Hylaform is layered in the same plane. This layering technique has the perceived (but not yet proven) advantages of less bruising and increased longevity of the correction. Hylaform can also be used under the eyes in the tear trough area; however, this area frequently bruises and patients should be forewarned. Hylaform Plus is often used layered over CosmoPlast in deep wrinkles or alone over large areas needing volume such as the cheekbones, hollows of the cheeks and the pre-jowl hollow. The softness of Hylaform Plus gives it a soft, natural feel even when used in large quantities in these areas. In addition, many dermatologists choose to use Hylaform Plus in the body of the lips. Restylane (Q-med, Uppsala, Sweden) is produced through bacterial fermentation (streptococci) and stabilized by cross-link using a butanediol diglycidyl ether (BDDE). The resulting product is then broken down into smaller pieces, similar to Hylaform. The smallest particles are packaged as Restylane Fine Line, which is indicated for the upper or papillary dermis and, therefore, appropriate for treating small lines, for example, crow’s feet and vertical lip wrinkles. The medium-size particles are Restylane, which is intended for the mid-dermis. The largest particles are sold as Perlane, which is indicated for treatment of the deep dermis. The FDA approved Restylane for cosmetic use in December 2003. Restylane is the stiffest of the available HA products, which makes it a good choice for deep wrinkles, the vermilion border, shaping the nose and treatment of acne scars. Captique is the newest non-animal stabilized hyaluronic acid-based dermal filler to be FDA-approved in the United States on December 2004. Captique is manufactured in the same manner as Hylaform (hylan B gel) with the exception that hyaluronan is derived from a bacterial source rather than an avian source. The chains of HA derived from the bacteria have a shorter chain length than those of Hylaform, making this product slightly stiffer than Hylaform. Captique is very versatile and can be used as a wrinkle corrector or as a facial sculpting material. Its consistency and feel make it ideal for the “smoker’s lines” around the mouth, and as a filler for moderately deep wrinkles. It can also be injected along the lateral portion of the eyebrow to give an eye lift, and is ideal in the pre-jowl hollow. Juvéderm is obtained by bacterial fermentation process similar to the one used in the manufacture of Restylane. Heat destroys the streptococci and it is eliminated by filtration. BDDE, the cross-linking agent used in Restylane, is used to cross-link the strands of HA in Juvéderm. Juvéderm differs from Hylaform and Restylane because instead of being a gel broken into smaller particles, it is a homogenous gel. The Juvéderm line of products contains several variations that differ by the amount of HA per cc and the amount of cross-linking of the product, and the regularity of the cross-linking of the product. The “non HV” products (Juvéderm 18, 24 and 30) tend to stay where you inject them while the “HV” products (Juvéderm 24 HV and 30 HV) tend to diffuse. Juvéderm 18 is indicated for fine lines such as crow’s feet. Juvéderm 24 and Juvéderm 24 HV are used for moderately deep wrinkles such as nasolabial folds, glabellar lines and oral commisures. Juvéderm 30 is used for deeper lines and wrinkles. Juvéderm 24 or 30 can be used in the vermilion border, while Juvéderm 24 HV and 30 HV are ideal for the body of the lip. The Juvéderm line of products is available in many countries in Europe and South America, but are not yet approved by the FDA in the United States. Phase III trials are currently ongoing. Dermal Stimulators The above-mentioned products fill wrinkles and provide immediate gratification. However, a new product will stimulate the native fibroblast to make collagen, resulting in wrinkle correction over time. Sculptra, formerly New Fill (Dermik Laboratories, Sanofi-Aventis Group) as of August 2004 was approved by the FDA as a treatment of lipoatrophy. It is used off-label as a treatment of facial wrinkles and volume loss due to aging. This product is composed of Poly-L-lactic acid (PLLA), a synthetic polymer that is biocompatible, biode-gradable, immunologically inert, and free from toxicity. PLLA is injected into the deep dermis or into the subcutaneous tissue (superficial injections should be avoided). The injections are spaced at 2- to 4-week intervals. After two or three injection sessions, results are appreciable. Once the desired results are achieved, the results may last up to 2 years. The novel technique and mechanism of action of this product require physicians to adjust their practice of treating a specific wrinkle and instead focus on returning volume to the face. Sculptra has been used successfully for the correction of nasolabial folds, mid and lower facial volume loss, jawline laxity, and other signs of facial aging.10-12 Improper dilution of the product, improper preparation of the product or incorrect injection of the product can result in granuloma formation. Therefore, proper physician training is paramount prior to the use of this product. It is possible to combine this product with collagen and/or HA containing fillers in patients who prefer an immediate result. The “Best” Filler There is no one perfect filler. Each of the available fillers has unique characteristics that give them both advantages and disadvantages. When deciding which filler to use, base your decision on the following: • the site to be treated • your comfort level and experience with the filler • the patient’s desires, experience, and needs • the patient’s budget • how long the patient is willing to wait for the result and how long the patient wants the filler to last. Some fillers are better on fine lines, others on deeper ones; some are stiffer and some are softer; some have more bruising and swelling and some have less down time. For example, if a patient has a wedding in 5 days and wants to correct the nasolabial folds with minimal down time and an immediate result, CosmoPlast would be the filler of choice. If a patient is willing to wait 3 months for the result and undergo two to three injections, but does not want to worry about being re-injected again for several years, Sculptra would be the filler of choice. If a patient has a large budget, can afford the possibility of 2 to 10 days of bruising, and needs a natural result and superior facial sculpting, several of these fillers would be used in combination. The field of dermal fillers has become an art as well as a science. To be a leader in the field, one must combine meticulous patient evaluation and knowledge of the attributes of each product with artistic skill.
