Joely Kaufman, MDVoluntary Assistant Professor Dermatology

University of MiamiMiller School of Medicine

Update on Dermal Fillers

Relevant Disclosures

Contracted Research: Merz Pharmaceuticals; RevanceAdvisory Board: Allergan; Merz Pharmaceuticals

Pathophysiology of aging

Dermal loss of:CollagenElastinGlycosaminoglycans

Subcutaneous loss of:

FatBone resorption

Temporary fillers of the worldHylaformHylan DexHylan SeSHyruan InjectionIsologenJuvederm 18, 24, 30Koken AutocollagenMacDermol SMacdermol RMatrigelMartidexMatridurMatrexNewfill Polylactic acidPerlanePermicollPermacollPlasma GelPurogen

AcHyalAtleanBeloteroCosmetalifeCosmodermCosmoplastDermiColEvolence & evolence breezeEmervel EsthelisFibrel Procine CollagenFibroquelHyal 2000 InjectionHyacellHydrafillHydrafill Coftline

PrevelleRadiesseResoplastResylaneRestylane fine lineRestylane vitaleRestylane lipReviderm IntraRhegecollRofilan Hylan GelSculptraTeosyalUma JeunesseVariodermVolumaZyderm IZyderm IIZyplast Bovine Collagen

FDA approved fillersZyplastZyderm 1 & 2CosmoplastCosmoderm 1 & 2Evolence

Autologous fat

Artefill

RestylaneCaptiqueHylaformHylaform PlusJuvederm Ultra, PlusPerlanePrevelleBeloteroVoluma

SculptraRadiesse

Filler Choices

DurationTemporary (2-9months)Semi-permanent (>9 months)Permanent

PropertiesDensity/Viscosity

PurposeFilling

Fine linesDeep lines

Sculpting

PlacementSuperficialMidDeep

Update on Fillers: Lecture outline

Update on products, usesHyaluronic acidsPolylactic acidCalcium hydroxylapetite

Injection techniques:CanulasSpecific areas, specific techniques

Hyaluronic acids

Most versatile fillers on the marketExcellent safety profileHA is chemically identical across species

Less chance of antigenicity

Hyaluronic Acid

Polymer of disaccharides linked via glycosidic bonds

Carbohydrate (polysaccharide) portion of the extracellular matrix

Hyaluronic acidIdentical in all species

Able to bind 100x its weight in water

Used as a cushion and lubricant in tissues- in joints/synovial fluid, cartilage, dermis of skin

Hyaluronic acid fillers

Currently the most popular filler category in US

Can be placed in mid or deep dermis/ subdermal plane, or supraperiostial

Very soft

Hyaluronic Acid Fillers

Binding with water yields a plumping effect

Reversible with hyaluronidase

Hyaluronic Acids

Non-animal source (NASHA)

CaptiqueRestyleneJuvedermPerlaneBeloteroVoluma

Hyaluronic acids

Physical Differences between HAs

Cross linkingMethod (ether, ester)Type (BDDE)Amount Double cross-link

Concentration of HA

5-30mg/ml

Particle size10,000-200,000 gel particles/ml (biphasic)Uniform gel, non-particle (monophasic)

Size of HA chain

Product Concentration Particle size

Restylane fine line

20mg/ml 200,000 gel particles/ml

Restylane 20mg/ml 100,000 gel particles/ml

Perlane 20mg/ml 10,000 gel particles/ml

Restylane subQ 20mg/ml 1,000 gel particles/ml

Product Concentration Particle or homogenousgel

Juvederm ultra Homogenous gel

Juvederm ultra plus Homogenous gel

Belotero 22.5mg/mL Homogenous gelBDDE cross linking

Voluma

VolumaFDA approval 2013

Indicated for deep (subcutaneous and/or supraperiosteal) injection for cheek augmentation to correct age-related volume deficit in the mid-face in adults over the age of 21

Belotero

Tan Delta (tan ) of HA Fillers

Measured at 0.7 Hz*Homogenous gel, 22.5 mg/mL HA manufactured by Anteis S.A.

*

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

Restylane Restylane-L Perlane Perlane-L Juvederm Ultra

Juvederm Ultra XC

Belotero Balance

Particulate Gel

Cohesive Polydensified Gel

Cohesive Gel

tan =Measures presence and extent of elasticity

Data on File, Merz Aesthetics, Inc. 2012.

Cohesivity Evaluation

*Homogenous gel, 22.5 mg/mL HA manufactured by Anteis S.A.

Restylane-LBELOTEROBALANCE

R t l LBELOTERORestylaneBELOTEROBALANCE

Perlane-LBELOTEROBALANCE

PerlaneBELOTEROBALANCE

8 mm plate separation

Data on File, Merz Aesthetics, Inc. 2012.

HA Distribution in the Dermis

Blue = HA

Day 7

Day 114

RestylaneJuvédermBELOTERO BASIC*

*Homogenous gel, 22.5 mg/mL HA manufactured by Anteis S.A.

Courtesy of Dr. Patrick Micheels and HCU Geneva, Dr. Salomon, University of Geneva / Anteis

0

100

200

300

400

500

600

700

Restylane Restylane-L Perlane Perlane-L Juvederm Ultra

Juvederm Ultra XC

Belotero Balance

Particulate Gel

Cohesive Polydensified Gel

Cohesive Gel

Elastic Modulus = G Measures ability to resist outside forces

Data on File, Merz Aesthetics, Inc. 2012.

Measured at 0.7 Hz

Physical Differences between HAs

Already fully saturated with water in syringeCaptiqueHylaform

Result: less expansion after injection (less swelling)

Not fully saturated with water in syringeJuvedermRestylaneUnmodified HA is added to increase fluidity

Result: Some expansion after injection. Ease on injection. Not all HA is crosslinked.

Physical Differences between HAs

Higher concentration HA requires larger gauge needed and more injection pressure

Larger particles firmer filler, longer duration?

Higher G prime more stiffness

Sculptra (Newfill)Poly L-lactic acidLong lasting, non-permanent fillerApproved by FDA for facial lipoatrophy inimmunocompromised patients in 2004

SculptraComes in vial as powdered substanceReconstitute with saline and lidocaineWait at least 3 hours after reconstitutionInjections/substance stimulates collagen formationInjections should be placed in deep dermis or subcutaneous tissue

Industry-provided image for educational purposes only.

Sculptra +’s and –’s

Reconstitution26 gauge needle that sometimes clogsResults are not immediateMultiple treatmentsSQ papules

DurationNatural looking resultsForgiving if placed in SQNot ‘plumping’

Sculptra 1.5 vials

Photo courtesy of Steve Mandy, MD

Sculptra photo cheek

Sculptra update

Dilutions started around 6cc of dilutentGradually have increased

8cc of saline and 2cc of lidocaineOff face dilutions of 15cc

RadiesseSynthetic Calcium Hydroxylapatite microspheres [30%] suspended in a carboxy-methylcellulose resorbable aqueous gel carrier [70%]

Decalcified 25μm to 45 μm particles

Radiesse When placed into soft tissue, Radiesse provides immediate correction

Gel + CaHA ParticlesOver time the gel is resorbed and the CaHA particles stimulate the body to produce collagen

Radiesse

Radiesse stimulates collagen productionThe CaHA microspheres are synthetically derived and break down naturally over time by the body’s own metabolic processes into Ca2+ and PO3

2+

ions.No ossification or calcification of CaHA has been reported in over 6 years of clinical use and >400,000 syringes injected

27g needlePost injection edemaFirm for a couple of weeks after injectionProduct clumps in lipsMixed in office with lidocaine

Long duration (>12 mo) More filler per cc of productImmediate resultsSafety profile

Radiesse + and -s

Patient SatisfactionRadiesse vs. Restylane

More patients were Satisfied with Radiesse than were with RestylaneEven at 6 Months

% of Patients That are Satisfied & Extremely Satisfied*

89%

61% 58%

96%

6 Months 9 MonthsTime post 2nd Injection

RadiesseRestylane

Restylane

Volume 1.20cc Volume 0.80cc

Radiesse vs. Restylane6 months post second

treatment

Radiesse

Nasolabial fold correctionBefore Radiesse 12 weeks after Radiesse

Anatomic considerationsmust not be injected into blood vessels and should not be used in vascular-rich areas. Use in these areas, such as glabella and nose, has resulted in cases of vascular embolization, occlusion of the vessels, ischemia or infarction, or blindness. Symptoms of vessel occlusion and embolization include pain that is disproportionate to the procedure or remote to the injection site, immediate blanching extending beyond the injected area, and color changes that reflect ischemic tissue such as a dusky or reticular appearance

Depth of injection is dependenton area being augmented

Deep dermis/subdermal plane for treating linesNasolabial folds, marionette lines, mental crease, etc.Retrograde linear threading of material

Subcutaneous/supraperiosteal for restoring volume resulting from skeletal loss or if placing material against bone

Mid-face: infraorbital and malar, submalar, chin, nose, pre-jowl sulcus, etc.Retrograde linear threading or bolus injections

Structural AgingThe facial recurve concept:

Young facial musculature has a convex configuration with facial fat pads deep to the muscle

The facial musculature of older patients has shorter and flatter appearance by MRI

LeLouarn et al. Aesthet Plastic Surg, 2007.Fitzgerald et al. Aesthetic Surg Journal, July/August 2010.

Structural AgingFacial bony structures remodel throughout adulthood

Facial frontal bone moves anteriorly and inferiorlyMaxillary bone moves posteriorly and superiorly

Maxillary regression- NLFChanges in mandible and teeth

Pessa et al. Plastic Reconstr Surg, 1998.

Perioral Aging

Marionette linesDown turn angle of mouthFine radial linesDeflation of vermillion borderFlattening of cupids bow, philtrumChin dimpling

Perioral Aging

Marionette linesDeep placement

Correct structural defect

Superficial placement Correct dermal defect

Cannula

Perioral Rejuvenation27g, 37mm cannula30g, 27mm cannula

Insertion opening with 26g

Deposition point to turn up angle of mouth

Perioral Rejuvenation

Perioral rejuvenation

Perioral: Fine lines

Juvederm .4 cc syringe diluted with .3cc saline

Perioral: Fine lines

Belotero Balance

Perioral: Fine lines

Fine radial lines:Serial puncture technique32 gauge needleIntradermalIf using diluted product, slight overcorrection

Vermillion threading30 gauge

Perioral: fine lines

Perioral

Jeremy Green, MD

Perioral Rejuvenation

Etiology is multifactorialDo not disregard the structural abnormalities

Thank You! JKAUFMAN@MED.MIAMI.EDU