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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

I have no financial disclosures.

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

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?

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.

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

Ideal Filler Characteristics ! Safe, bio-compatible ! Easy to inject ! Readily prepared ! Easy to store ! Affordable ! Long-lasting effect ! Minimal complications

“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

Dermal Fillers Overview ! Hyaluronic acid fillers have become the prominent product ! Accounted for >85% of fillers used in 2008

! Originally derived from rooster combs

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

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

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

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 dermal- subcutaneous 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 alpha-

hydroxy-acid family ! Originally FDA approved for correction of lipoatrophy in HIV

patients

Poly-L-lactic Acid Filler ! Lasts 18-24 months ! Slow degradation of large, irregularly shaped PLLA particles ! 40-63 microns

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

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

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

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

Nasolabial Folds ! Malar descent with aging exaggerates folds

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

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

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

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

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

Vascular Compromise ! Signs and symptoms ! Skin blanching ! Unexpected level of pain ! Violaceous discoloration of treatment area

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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