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Injectable Soft Tissue Fillers: Practical Applications
Karol A Gutowski, MD, FACS
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Disclosures
Instructor for Suneva (Bellafill)
Will describe off-label uses
Will use brand names
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Injectable Tissue Filler Options
Hyaluronic Acids(Juvederm & Voluma, Restylane, Belotero)
Reversible
Animal Collagen(Zyderm, Zyplasty, Evolence)
Human Collagen(CosmoDerm, CosmoPlast,
Fascian, Autologen,Cymetra, LaViv)
StimulatorsPLLA (Sculptra)PMM (Bellafill)
CaHA (Radiesse)
Fat
Silicone
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Elastic Modulus* (G prime)
*Mathematical description of product’s tendency to be deformed elastically May not match clinical results
More “lift” Less “lift”
Less “spread” More “spread”
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Filler Rheology
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Restylane Product Particle Size
Silk Restylane Lyft
All 3 have 20 mg HA per mLParticle size is different
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Particle Size & Injection Depth
Silk
Restylane
Lyft
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Water Absorption
Prevelle Silk
Restylane and Perlane
Juvéderm Ultra Plus
Less Swelling
More Swelling
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Where & What to Inject
Neuromodulator (Botox, Dysport, Xeomin)
For wrinkles with movement
Filler (Juvederm, Restylane)
For wrinkles at rest
For small volume deficits
Stimulator (Sculptra, Bellafill)
For replacing regional volume loss
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1 Year Personal Experience
• Injectable patient encounters 1016
– Neuromodulator only 416
– Filler only 291
– Neuromodulator + filler 271
– Filler touch up 38
• Typical filler volume used 2-3 cc
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Fillers Used & Locations
Most Common Sites
• Malar & cheeks
• Lips & perioral
• Tear troughs & periorbital
• Nasolabial folds
• Temples, hands, nose
Most Common Filler
• Radiesse
• Restylane products
• Bellafill
• Juvederm products
• Belotero
• Sculptra
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Practice Overview
Karol Maggie Chris Rhonda Suzie
MD PA PA RN RN
Instructor Bellafill - Bellafill Restylane -
Patients per Month 50 120 40 60 20
Ave Volume (cc) 2 to 3 2 to 3 5 to 7 2 to 3 3
Restylane Products 25% 65% 20% 90% 70%
Juvederm Products 5% 20% - 10% 30%
Radiesse 50% 5% - - -
Bellafill 15% 5% 80% - -
Belotero 5% 5% - - -
Most Common Area Malar Lips, Malar Malar Lips, Malar Malar, Lips
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Target the Volume Loss
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Basic Set Up
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Block & Tackle the Face
Jesper SorensenZide 1998
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Injection Technique
Target the correct level
• Mid to deep dermis
– Low G’ HAs
• Subcutaneous
– PLLA, CaHA, PMMA
– Higher G’ HAs
• Deep/preperiosteal
– High G’ HAs, CaHA
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Serial Puncture
Example: Tear Trough
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Linear Threading
Example: Nasolabial Fold
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Fanning
Example: Deep Malar Elevation
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Cross Hatching
Example: Lateral Lip Frown
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Placement at dermal/subdermal junction
Tunneling or Linear Threading
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Correct PlacementToo DeepToo Superficial
Proper Dermal Injection
Needle lifted
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Blunt Injection Cannulas
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Blunt Injection Cannulas
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Patient Selection
Volume LossFillers
Volume DescentFacelift
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The Power of Volume
After fat grafting
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The Power of Volume
After fat grafting
Rebuild the deep volume with fatThen fill fine lines with a filler
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Hollow Temples
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Lower Lids & Tear TroughsProceed with Caution
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Tear Trough Asymmetry
Topical anestheticRestylane (Moderate G’)30G needle80% correction
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Tear Trough Asymmetry
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Mild Fat Pad Herniation
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Mild Fat Pad Herniation
Topical anestheticJuvederm (Low G’)30G needle80% correction
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Fat Pad Herniation Correction
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Fat Pad Herniation Correction
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Fat Pad Herniation Correction
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Fat Pad Herniation Correction
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Tear Trough & Malar Support
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Tear Trough & Malar Support
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Tear Trough & Malar Support
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Tear Trough & Malar Support
Restylane
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Tear Trough & Malar Support
Restylane
Radiesse
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Tear Trough & Malar Support
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Tear Trough & Prominent Orbicularis
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Tear Trough & Prominent Orbicularis
JuvedermLow G’
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Tear Trough & Prominent Orbicularis
Juvederm1:1 Saline
JuvedermLow G’
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Tear Trough & Prominent Orbicularis
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Lower Lid & Midface
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Lower Lid & Midface
Belotero 1cc per side
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Tear Trough & Lower Lids
• Inject on periosteum
• Expect edema & ecchymosis
• Under correct
– Touch up in 2 weeks
• Prolonged edema
– Treat early
– Hyaluronidase
• May persist for years
Not for novice injectors
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Malar & CheekBest Bang for the Buck
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Hollow Cheeks
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Hollow Cheeks
After 1 vial Sculptra to each cheek
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Malar & Cheeks
• Malar– High G’ (Radiesse or Lyft, Bellafill for long-term)
– 0.1 cc needle bolus at 2-4 points on periosteum at malar prominence
– Massage & shape to desired form
• Cheeks– Moderate to high G’ blunt cannula injection
– Subcutaneous fanning or cross-hatching
• Treat before nasolabial folds
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Nasolabial FoldsAfter Malar Correction
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Mild Nasolabial Folds
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Mild Nasolabial Folds
Low to moderate G’Blunt cannulaSubdermal injection
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Mild Nasolabial Folds
Before and after Bellafill to nasolabial folds2 syringes (Right 1.2 cc, Left 0.5cc)
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Before and after Juvederm Ultra Plus to nasolabial folds1 syringe (Right 0.45 cc, Left 0.55cc)
Moderate Nasolabial Folds
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Moderate Nasolabial Folds
Before and after 1.5 cc Radiesse to nasolabial folds
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Moderate Nasolabial Folds
Before and after 1.5 cc Radiesse to nasolabial folds
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Lips & Perioral
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Lips & Corners
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Lip Vermilion
Moderate G’30G needle (or cannula)Serial puncture
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Lip Corners
Moderate to high G’29G or 30G needle Cross hatch
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Lips & Corners
2 cc Restylane
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Thin Lips & Lip Lines
1 cc Restylane
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Marionette Lines
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Marionette Lines
Moderate to high G’27G or 29G needle Fanning
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Marionette Lines
0.25 cc Radiesse/side
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Marionette Lines
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Marionette Lines
Moderate to high G’27G or 29G needle Fanning
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Marionette Lines
Moderate to high G’27G or 29G needle Cross hatch as needed
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Marionette Lines
1 cc Restylane
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Gummy Smile
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Gummy Smile - Neuromodulator
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Consider Central & Corner Lip Lift
1 cc Radiesse
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Neuromodulator for Lip Lines
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Neuromodulator for Lip Lines
2u BTA per side
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Neuromodulator for Lip Lines
1 cc Radiesse
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Filler for Lower Lip Support
2 cc Juvederm Plus
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Chin Fine Lines & Creases
1 cc Hydrell Intradermal
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Neuromodulator for DAO
BTA 5 u DAO + 1 cc Restylane
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Lips, Perioral, Cheeks
4.6 cc Bellafill
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Lips, Perioral, Cheeks
4.6 cc Bellafill
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Jaw Line & Pre Jowl SulcusSmall Volume, Big Result
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Mild Jowls
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Mild Jowls
Moderate to high G’27G needle 0.1 cc boluses pre-periostealMassage as needed
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Mild Jowls
0.3 cc Radiesse/side
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Mild Jowl & Pointing Chin
0.4 cc Radiesse/side
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Mandible Angle Enhancement
1.2 cc Bellafill/side
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NoseProceed with Caution
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Bellafill Rhinoplasty
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Restylane Rhinoplasty
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Restylane Rhinoplasty
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Restylane Rhinoplasty
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HandsWhy Stop at the Face?
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Aging Hand
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Aging Hand
High G’Blunt cannulaLinear threading Massage to position
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Restore Dorsal Hand Fullness
Before and after 1.5 cc Radiesse to dorsum (FDA Approved)
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Restore Dorsal Hand Fullness
Before and after 1.5 cc Radiesse to dorsum (FDA Approved)
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Fat Graft Dorsal Volumization
Before and 6 months after Fat Grafting to dorsum
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Fat Graft Dorsal Volumization
Before and 6 months after Fat Grafting to dorsum
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Acne Scars
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Atrophic Acne Scars
Bellafill FDA Approved for Acne Scars
Rolling scars improved with skin traction
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Scars Improved with Traction
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Patient Selection
Study: Grade 3 & 4 rolling acne scars
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Acne Scars Treatment
Before 6 Months 12 months
Before 6 Months 12 months
0.8 to 1.6 cc BellafillRolling acne scars that improve with stretch
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Putting it Together
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Facial Volumization
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Start Superior & Lateral
0.8 cc syringe40 to 50 passes27G blunt cannula
SupraperiostealMicrodroplets
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Volumize Inferior Orbit & Malar Area
0.8 cc syringe40 to 50 passes27G blunt cannula
Supraperiosteal
SubdermalFanning
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Treat Hollow Cheek
0.8 cc syringe40 to 50 passes27G blunt cannula
Supraperiosteal
Subdermal
SubdermalCross Hatching
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Move to Lower Face
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0.8 cc syringe40 to 50 passes27G blunt cannula
SubdermalFanning &Cross Hatching
Lower Face
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Facial Volumization: Bellafill 4.6 cc
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Realistic Expectations!
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Injectable Soft Tissue Fillers: Practical Applications
Karol A Gutowski, MD, FACS