Laser Therapy: Benign Pigmented Lesions

Benign Pigmented Lesions

Epidermal lesions include lentigo, café-au-lait macules, ephelides, junctional nevus, and seborrheic keratosis. Dermal lesions include blue nevi and Nevus of Ota or Ito. Some lesions have both dermal and epidermal fractions such as melasma. Pigmented lesions with atypical characteristics should never be treated with a laser. They follow the acronym ABCDE. A is for asymmetry, B is for irregular border, C is for multicolored, D is for enlarging diameter, and E is for evolving. These need to be evaluated by a dermatologist. Patients with a family history of melanoma or dysplastic nevi should not get laser treatment.

Lentigines are small irregular patches with sharp borders. Solar lentigo (sun spots) grow in number with aging, is related to the amount of sun exposure, and is not pre malignant. These lesions can be treated with KTP lasers or IPL. Lesions will darken with treatment.

Ephelides (freckles) are tan to dark brown patches or spots with sharp borders, occur on sunexposed areas, and darken with sun light. Appearance decreases with age. Treatment involves sun screen and sun avoidance. Hydroquinone, alpha hydroxyl acids and tretinoin can decrease freckles if used regularly. Q switched, KTP lasers, and IPL are effective treatments. Repeat sun exposure without protection causes recurrences.

Seborrheic keratosis are epidermal growths that progress from yellow smooth patches to irregular papules or plaques. For thicker lesions the longer pulsed Alexandrite laser is more efficacious and need fewer treatments.

Melasma
This is an area of light to dark brown facial discoloration that develops gradually. Its cause may be unknown, or it may be related to pregnancy or birth control pills. It occurs in 50-70% of pregnant women usually in the second and third trimesters. It occurs in 8-29% of women taking birth control pills. Laser therapy has been used when topical therapy fails. Recurrence can be decreased by sun block, abstinence, and regular use of hydroquinone. Treatment with Q switched lasers, IPL, erbium, and CO2 are not that successful with repigmentation being common, as well as post inflammatory hyperpigmentation. A test site is recommended before treating an entire area since some cases are worsened by treatment. Superficial resurfacing with erbium gives the best chance for benefit but is unpredictable and still may recur.

Epidermal nevus before and after treatment with a CO2 laser

Blue Nevi

Before and after treatment of nevi with a diode laser

These are usually single discreet plaques 1-8 mm in diameter that appear in children and young adults. They are mostly benign and are removed for cosmetic reasons. The principle method of removal is surgical excision. However, Q switched alexandrite and Nd:YAG lasers can be used if the lesion has not spread too deeply into the underlying fat. There are rare cases of conversion to malignant melanoma. So new, multinodular or plaque like lesions should be biopsied. Patients should be made aware that not all lesions can be removed completely and significant lightening may need several treatments 6 weeks apart. Side effects include transient hyper or hypopigmentation, scarring, permanent hyperpigmentation, incomplete clearance, or recurrences. To avoid hyperpigmentation after laser treatment, patients should avoid the sun and use sunblock with micronized zinc dioxide. If hyperpigmentation occurs, hydroquinone should be used two times a day until it resolves. If hypopigmentation occurs, it usually resolves with time. If not an excimer laser can be used. For scarring, early treatment with a PDL is used.

BBL vascular Protocol v4.3 110904 Page 1 of 12
PROFILE™ BBL™ PULSED LIGHT MODULE:
NON-ABLATIVE VASCULAR/SKIN TREATMENT
WITH 560 & 590 NM FILTERS
Introduction
Vascular lesions can be treated with the selective absorption of light by blood in the target vessel. This process was described as early as 1968 using ruby (694 nm) and Nd:YAG (1064 nm) lasers (Solomon et al., J Inv Derm, 1968, 50:141-146). The absorption converts light into heat energy, which raises the temperature of blood within vessels. With appropriate selection of fluence and pulse width, the temperature of the blood will be high enough to alter and damage the vessel wall resulting in the elimination of the vessel.
Pigmented lesions are treated by selective destruction of melanin or melanocytes with short high intensity light pulses.
The theory of Selective Photothermolysis explains how wavelength, energy, pulse width and thermal relaxation time all play a part in the destruction of a target and the preservation of surrounding tissue. Because of their large surface area-to-volume ratio, melanin and microvessels rapidly lose absorbed energy (heat) into the surrounding tissue. The thermal relaxation time of very small vessels is less than 1 millisecond, while that of larger vessels and hair can be 20 -100 milliseconds (ms) depending on size, and the thermal relaxation time
of the epidermis is 3 -10 ms.
The PROFILE BBL can deliver enough energy or fluence to effectively target melanin and surface vessels, and has variable pulse widths for treating a range of target sizes. When the BBL is used to treat blood vessels, there is heat build-up in tissue from the absorption of light energy in vessels. The heat dissipates from the vessel into surrounding tissue. Absorption of the BBL light in melanin can be substantial, and epidermal cooling is recommended for darker skin.

Surface Cooling
Although absorption of the BBL light in melanin may be desirable, some epidermal cooling is beneficial to protect the skin. The amount of cooling required will vary depending upon the patient’s skin type. Lighter skin types require less cooling, and darker skin types require more cooling. The BBL contact cooling plate insures that the epidermis is adequately protected from overheating regardless of skin type. When the BBL is used to treat blood vessels, there is heat build-up in tissue from the absorption of light energy in vessels and melanin. The heat dissipates towards the skin surface. Surface cooling before, during and immediately after BBL treatment, or after the light is converted to heat, can quench heat from the surface and protect the epidermis from undesirable heating. For the parameters used in treating microvascular conditions there is
minimal heat build up and less cooling is required.

Classification of Skin Types
The following table offers a broad guidance to identifying skin types based on hair, skin and eye color as well as sun reaction.

Fitzpatrick Scale
Type /Hair Color /Skin Color /Eye Color /Sun Reaction
I /Red /Light /Blue-green /Burn, never tan
II /Blonde /Light /Blue /Burn, may tan
III /Brown /Medium /Brown /Burn, then tan
IV /Brown-black /Moderate brown /Brown-black /Tan
V /Black /Dark brown /Dark /Tan
VI /Black /Black (African) /Dark /Tan

Consultation / Treatment
The consultation or initial visit allows an exchange of views between case provider and patient in an attempt to reach a decision regarding treatment. The patient must understand the procedure, pre and post care instructions, and expectations before the procedure is performed.

Patient Education (Expectations)
The BBL is used to reduce flushing, telangiectasia, redness, dyspigmentation, reduce unwanted hair, and improve skin tone. Patients must understand that results vary with each individual. Multiple treatments may be necessary over a time span (2-4 week intervals) to reduce redness in most areas. Results should be evaluated several weeks post treatment. The BBL light pulse is often described as a wave of heat with the sensation of a pinprick. A topical anesthetic may be necessary.

Patient Documentation Forms

• Consent: the process of accepting and confirming treatment must be reviewed,
understood and signed by the patient prior to treatment. This document must review the topics discussed during consultation. It acknowledges that the patient understands the procedure and that all questions have been answered.
• Review post care instructions and confirm that the patient will adhere to such
instructions throughout the course of their treatment.
• Upon patient's assessment, the case provider must determine the need of medications or creams. These can be given before the procedure and used throughout the treatment.
• Post-treatment appointments are scheduled for: treatment assessment, patient
evaluation and routine therapy.

Photographs
Before and after photographs should be taken throughout the course of the treatment to monitor patient response to therapy. Photographs should be taken prior to treatment, immediately after treatment and during follow-up visits. Camera settings should be the same to maintain photographs of similar quality. Photographs are useful in demonstrating efficacy of treatment to the patient.
Pre Treatment Procedure
• For better results, patients should avoid sun exposure, tanning beds and tanning creams for 2-3 weeks prior to treatment and throughout the course of their BBL treatment. Sunless tanning lotions must also be avoided for 2-3 weeks prior to treatment. However, if sun exposure is not avoidable treatment sessions need to be increased since treatments on sun-exposed skin will require lower fluence settings to protect the epidermis. • Instruct the patient that recent sun exposure may result in cancellation of the treatment.
Post Testing Evaluation
• Evaluation of any tested area(s) usually occurs 1-2 weeks post treatment.
• Verify that any hypo/hyperpigmentation has been transient (to date). If the patient is concerned about the pigmentary changes, further treatments may be delayed. Once the area returns to normal skin tone, treatments may be resumed.
• Further testing may be indicated depending on the results seen from the first tested area(s).
Determination of Clinical Endpoint
Caution: Treating with excess energy levels can result in adverse effects
such as abnormal pigmentation, blistering and scarring.
• Erythema should be noted in the skin. If the treatment area has even the slightest tan, the erythema response may be greater. If blistering occurs, treatment should be stopped immediately. Treatment can resume when the tan has faded.

Treatment Procedures
• The highest energy density determined through test spots should be utilized. An increase in fluence should be tolerated after 2-3 consecutive treatments.
• Double treatment of the same area is not recommended and can increase the chances of post treatment complications.
• Treatments are scheduled at 2 to 4 week intervals for most areas, 6 to 8 weeks for hair removal.
Sun Protection
• A broad spectrum (UVA/UVB) sun block with an SPF of 30 must be applied 15
minutes prior to casual sun exposure.
• Prolonged sun exposure requires repeated applications of sun block every 2 hours (e.g. yard work, beach activities, etc.).
• Sun block must be reapplied after swimming.
Adverse Effects
Complications, though rare, can occur and should be discussed and understood. The patient must understand the importance of the post-care instructions, and that failure to comply may increase the potential for complications.
• Scarring, though rare, can occur following any intense light procedure.
• Histamine/Hives: some patients develop raised urtecaria similar to hives. This irritation usually subsides in a few hours.
• Pigmentary changes: hyperpigmentation or hypopigmentation may occur. There is a higher risk in darker skin types. Sun exposure to the treatment area should be avoided at least 2-3 weeks prior to treatment. A broad spectrum (UVA/UVB) sunscreen SPF 30 or greater should be applied to the area(s)
to be treated whenever exposed to the sun.

Post Treatment Skin Care
Patients should receive post skin care instruction following each BBL treatment. Sample post care instruction sheets are included.
• Application of an ointment or aloe vera:
I. Ointment is applied to the area to prevent drying. Ointment applied following
the BBL treatment can have a soothing effect.
II. An antibiotic ointment should be utilized if there is any blistering or break
in the skin, and the patient should be instructed to contact the office.

PROFILE™ BBL™ PULSED LIGHT MODULE:
NON-ABLATIVE VASCULAR/SKIN TREATMENT
SAFE START PROTOCOL
The following protocol is a safe start guide based upon the clinical observations of
experienced physicians.
IMPORTANT: Treating with too high of a fluence or overlapping pulses may lead to undesirable outcomes, including blisters, depressions and transient
hyperpigmentation, all due to overheating of tissue.

1. PRE-TREATMENT CONSIDERATIONS
1.1. CLEAN SKIN
Use a mild cleanser to remove any dirt, makeup, or moisture from the treatment
area. Follow with an alcohol wipe. Allow alcohol to evaporate before treatment. Use special care around the eyes.
1.2. SITE PREP
Cleanse the area with mild soap and water followed by an alcohol swab to
thoroughly remove any residue from lotions, makeup or shaving. Remove the alcohol with a gauze and plain water leaving the surface of the skin slightly moist.
Use caution when treating over beards – fluence should be lowered, and there is a small possibility of alopecia. A small test area is recommended.
1.3. ANESTHESIA
Use a topical preparation, as needed, to alleviate discomfort for sensitive patients or sensitive areas prior to treatment. Remove before treatment with mild soap and water or an alcohol swab, then plain water. Dry the area thoroughly before treatment.
1.4. EYEBROWS AND BEARDED AREAS
Use caution when treating over beards – fluence should be lowered, and there is a small possibility of alopecia. A small test area is recommended.
Eyebrows should be protected as there is a small possibility of alopecia.
1.5. EYE PROTECTION
Always use eye protection for the patient, the operator, and anyone in the treatment room during the treatment.
1.6. PATIENT EXAMINATION
Shave the area to be treated. Veins and telangiectasias, wrinkles, and skin tone
should be classified prior to treatment according to size and depth. A pre-treatment photo should be taken to assist in evaluating the effectiveness of the treatment.
1.7. TREATMENT OF AREAS WITH ARTIFICAL MAKE-UP, TATTOOS AND
DARKENED MOLES.
Areas tattooed with designs or permanent make-up should be avoided. Not only do they create an additional and unwanted target for deposition of heat, but those targets with red or frosty white appearance commonly have iron or titanium in their composition. The red or white pigment will often oxidize and turn black from exposure to high intensity light. If you must treat those areas, a test spot with close monitoring for one to four days is recommended.
CAUTION: Tattooed areas should not be treated. Tattoo ink may absorb
energy resulting in a color change in tattoo ink or a risk of epidermal
damage. Darkened moles should not be treated. Moles may absorb energy
resulting in a color change creating a risk of epidermal damage and the
inability to monitor the lesion under ABCD guidelines.

2. SETTING TREATMENT PARAMETERS
2.1 FLUENCE
Starting fluence will be will depend on the condition and the skin type. The
parameters in Table 1 are safe start parameters. Patient response can vary, so the fluence setting should begin low and be increased gradually after assessing the individual patient response. The desired response is spontaneous erythema (redness).
Fluence and pulse widths may change for a patient during the series of treatments. Be sure to properly evaluate the treatment parameters before each treatment based on previous successes or complications, and the response of the patient to questions about the first 24 hours after the previous treatment. Those who respond with no irritation or without prolonged erythema for the first 24 hours after treatment are within a safe, and possibly low, fluence range.
2.2 COOLING
Cooling is recommended for patient comfort and protecting the surface of dark
skin. Treating with warmer temperatures will require treating with lower FLUENCE settings. The inverse also applies. Most treatments for lighter Fitzpatrick skin types can be performed at the 25°C setting. A thin coating of colorless gel, KY, surgilube or water should be used in conjunction with the system for better heat removal, improved optical coupling, and lubrication for sliding the plate over skin.
2.3 PULSE WIDTH
Select the starting pulse width from the table. It may be necessary to change the
pulse width and fluence to achieve the desired erythema response. Shorter pulse
width and higher fluence settings are more aggressive. Longer pulse width and
lower fluence settings are less aggressive.

3. TECHNIQUE
3.1. PATIENT POSITION
Position is based on the area to be treated. Patient should be in a comfortable
position. The treatment area should be presented to the BBL user at a convenient height and position.
3.2. TEST AREA
Treating a test area before a patient’s first treatment can establish their response
threshold and help establish safe starting parameters. The test area should be
monitored for response for a period of five to ten minutes. Blistering or the
immediate grey or white presentation of the skin is the immediate concern.
TEST AREA should reach the desired response of erythema within a few minutes. Increase fluence in small increments until the desired response is achieved.
CAUTION: Use only enough fluence to achieve the desired endpoint of erythema.
IMPORTANT: Keep fluence conservative for the first treatment session, and monitor
the patient for any evidence of prolonged erythema, swelling, urticaria or blistering.
3.3. HANDPIECE POSITION
Position the patient so the BBL can be held perpendicular to the skin surface. Move the patient if necessary so that the treatment area is easy to reach.
Position the BBL so the cooling plate is in full contact with the skin. For highly
curved regions, use the edge of the cooling plate while pushing the skin upward
with your other hand to insure proper cooling. If you are unable to maintain
contact, then use a white ‘block’ or tongue depressor to protect the non-cooled
tissue.
The BBL must remain in contact with skin long enough before and after the the
light pulse to cool the surface of the skin and reduce the heat sensation. It may
take several seconds for the deeper heat to propagate to the surface after the light pulse. A coating of colorless gel, KY, surgilube or water should be used in
conjunction with the system for better heat removal, improved optical coupling, and lubrication for sliding the plate over skin.
3.4. TREATMENT METHOD
Match the “trailing edge” of the next treatment area to the “leading edge” of the
previous treatment. The BBL will give a uniform treatment with uniform fluence
within the treatment area.
Make certain to maintain complete skin contact with the treatment area before,
during and after the treatment. A coating of colorless gel, KY, surgilube or water
should be used in conjunction with the system for better heat removal, improved
optical coupling, and lubrication for sliding the plate over skin.
Do not overlap or immediately repeat BBL pulses.
For small lesions such as cherry angiomas a mask can be used to protect
surrounding skin. Use a white card and cut out an area corresponding to the size of the lesion. Place the card over the lesion such that only it is exposed to direct light from the BBL. Higher fluences can be used since the surrounding skin is shielded from intense light.

4. TREATMENT GOALS
The immediate goal is light, uniform erythema a few minutes after treatment.
Patients will typically report feeling tighter skin or the sensation of mild sunburn
following treatment.
CAUTION: Presentation of a blister or immediate graying or whitening of tissue indicates immediate complication. Treatment methods and parameters should immediately be reevaluated. The blisters or skin discoloration will commonly resolve without complication.

5. POST-TREATMENT CONSIDERATIONS
5.1. OBSERVATIONS
Erythema or a mild sunburn sensation should be noticed in the treatment area for up to two hours after treatment. Patients should not feel any significant discomfort after treatment.
5.2. INTERVENTION
While not often used, a cold compress can provide some comfort after treatment. If blistering occurs, aggressive wound treatment should be administered ( i.e. Vigilon, Second Skin, silastic sheeting or other intervention).
5.3. INTERVAL
Recommended time interval between treatments is 2-4 weeks. 4 to 6 treatments maybe necessary.

6. CONCURRENT PROCEDURES
COMBINATIONS –treatments may be given in combination with other minimally invasive therapies. If a patient is to receive another treatment (Botox, collagen injection) in conjunction with the PROFILE, it is advisable to perform the PROFILE treatment first. There may be increased sensitivity in the treated areas for an hour or two.

7. CONCLUSIONS
Do not be overly aggressive. Begin conservatively and be patient. Results are determined by the physiology of the patient’s skin. Patients will usually notice a change in their erythema after the second treatment for small matting or vessels. It will take longer for larger telangiectasias to resolve.

Laser Therapy: Skin Tightening

Skin Tightening

Nonablative therapies aim to deliver heat energy to the dermis (through the outer layer (epidermis) protected by cooling) to stimulate collagen remodeling to tighten skin. In this way skin tightening could be done without aggressive skin resurfacing.
The patient must have realistic expectations and preop photos taken. They should be made aware that changes are subtle. However, they are more natural and overcorrection are almost never seen. There are no scars or recovery period needed. For many this is a worthwhile option. There is a wide range of results possible including no results at all.

Patients wash their face thoroughly to remove all make up. Anchoring points are identified. Points are usually on the periphery of the face from where muscles pull up facial structures and skin. The operator stands in front of the patient and uses his thumbs to evaluate skin mobility. Skin next to the hair line is barely movable but moving toward the center of the face, the skin becomes more mobile. A treatment line is drawn at the border of movable and nonmovable skin. Movable skin up to that line is the target of treatment. Tightening of this skin can result in eyebrow lifting and softening the nasolabial fold. Lower eyelid sagging can be treated by treating near the anchor point just outside of the eye or by treating directly over eyelid skin. Treating skin just outside the lower eyelids over the cheeks is the safest. For lifting cheek skin to soften the nasolabialfold, treatment is done around the ears. The neck can be improved by treating under the chin.

The patients wash their face thoroughly. Treatment areas are marked. The skin needs no other prep. No topical anesthesia is needed for fluences less than 30J/cm2. Treatment areas are radiated in addition to other areas of loose sagging skin, including jowls and the neck. Immediate contraction can be seen in some cases. Total number of passes will vary. Each pass feels progressively hotter. The procedure is stopped if definite pain is noted. Complications include blistering or second degree burns. Fat atrophy has never been seen with this modality.

Treatment Summary: The BBL (Broad Band Light)

The proper combination of skin surface cooling and pulsed light treatment can create a beneficial rise in temperature at a desirable point below the skin surface. Cooling the surface of skin will alter its subsurface temperature gradient. The temperature of the BBL cooling plate and the fluence delivered from the BBL will determine the temperature profile beneath the surface of treated skin.

The epidermis is a robust and resilient structure at the surface. It functions as a physicial barrier to protect the deeper dermis, and retain the skin’s hydration. It is less hydrated than the dermis resulting in less absorption of energy at infrared wavelengths than in the dermis, since infrared energy is preferentially absorbed in water and collagen. The highest absorption, and thus the highest temperature, will occur below the epidermis in the more hydrated dermis. The result is a higher temperature near the region of the dermis. By clamping the outer skin surface at a fixed temperature with the BBL cooling plate, the peak temperature from laser treatment can be biased toward shallower or deeper regions of the skin.

An examination of the dermal anatomy will show that the papillary dermis is in contact and protrudes into the epidermis. It is therefore impossible to cool the epidermis without some cooling of the papillary dermis. Attempts to selectively pre-cool the epidermis by pulsed cooling followed by laser are equivalent to contact surface cooling with simultaneous laser treatment at the depths and times of interest for collagen remodeling.

The thermal profile in the skin will have a maximum temperature below the epidermis at a depth determined by the surface temperature and the absorption characteristics of the infrared pulsed light energy in tissue. It is thought that collagen strands are denatured and contract in response to high temperatures. The temperature for this effect is inversely proportional to the exposure time. Ideally, the peak temperature is just above the threshold for initiating collagen coagulation, but not enough to cause full thickness necrosis. By using long exposure times of several seconds and lower temperatures the risk of full thickness coagulation can be eliminated.

PRETREATMENT CONSIDERATIONS
Use a mild cleanser to remove any dirt, makeup, or moisture from the treatment area. Follow with an alcohol wipe. Allow alcohol to evaporate before treatment. Use special care around the eyes.

ANESTHESIA
Topical ansthetics are avoided in order to get the patient’s feedback on the heat associated with the treatment. A feeling of excessive heat will signal a need to change parameters or the end of the procedure. A coating of colorless gel will be placed on the patient’s skin to allow easy movement of the laser handpiece across the skin.

TREATMENT GOALS
The immediate goal is light, uniform erythema developing a few minutes after treatment. The longer term treatment goal, after 3 – 6 months, is collagen remodeling of partially denatured and contracted collagen resulting in subsequent rhytid (wrinkle) improvement and reduction of laxity, followed by continued or maintained improvement with a maintenance program. Patients will typically report felling tighter skin following treatment.

OBSERVATION
Erythema, a moderate sunburn sensation, and tightening should be noticed in the treatment area for up to two hours after treatment. Patients should not feel any significant discomfort after BBL/ST treatment.

INTERVENTION
While not often used, cold compress can provide some comfort after treatment. If blistering occurs, aggressive wound treatment should be administered like Vigilon, Second Skin, silastic sheeting or other intervention.

INTERVAL
Recommended time interval between treatments is 2-4 weeks. Dermal changes from fibroblast activity may begin to be observed between 3-6 months after treatment. Incremental improvement may progress for six months or longer. Tightness of the treated area may be noticed immediately after treatment. Usually, 2-3 treatment sessions are done. Remind patients that this is not a surgical process, collagen remodeling takes time, and that the results are long term.

CONCURRENT PROCEDURES
Rejuvenation treatments may be given in combination with other minimally invasive therapies. If a patient is to receive another treatment (light chemical peel, microdermabrasion, Botox, collagen injection) in conjunction with the BBL, it is advisable to perform the BBL treatment first. There may be increased sensitivity in the treated areas for an hour or two.

Injectable Fillers for Cosmetic Use

Injectable Fillers for Cosmetic Use

Introduction

Medical technology is developing a growing number of injectable implants that can fill in the grooves, folds, and hollow areas of the aging face. First there was fat. It was cut out from one area and implanted under the skin of another area. Later collagen was developed which could be injected through a needle into desired areas but it required skin testing to screen for allergies before use. Both products do not last that long. Recently new lines of products have become available that need no skin tests and last longer.

Beauty and youth are associated with symmetry, roundness, and fullness of facial structures as well as good skin tone and texture. Age and disease can dampen this image. Acne can leave scars and pits in the face. Wrinkles form in aging skin. As the skin loses its resiliency, it can sag, deepening lines and folds in the face. Gradual loss of underlying tissue causes hollowed areas and thinning lips. Fillers can be used to treat all these defects. They can fill in acne scars, and hollowed cheeks. The most common use is smoothing over the nasolabial fold (the groove extending from just outside the nostril and running to the corner of the mouth). Drool lines are grooves that run from the corner of the mouth down towards the chin. Fillers can smooth these over as well. Injections can be made into the lips to add definition to the lip border and restoring fullness to the thinning lip body. The wrinkles fanning out from the lips (lipstick lines) can be filled in as well.

Preprocedure Planning
Patients undergoing filler injections should have a medical, social, and physical examination. The patient s concerns and treatment options must be discussed as well as the risks and benefits including possible bruising, lumps, nodules, and swelling. The patient should avoid blood thinners for a week including aspirin, nonsteroidal antiinflammatories, vitamin E, or Ginko. If the patient is on Coumadin, the INR must be below 2.0. Patients allergic to any part of the filler cannot get it. Before and after photographs should be done from the front, side, and angled views.

Choosing the right filler
There are several different types of fillers available. They have been shown to be safe. Many last short periods of time and must be reinjected every 3 months. Newer fillers last much longer but have a higher incidence of nodular scar formation. And if the patient is not happy with the result, the effect is more permanent.

Bovine (cow) collagen was most popular until 2003, as Zyderm I, Zyderm II, and Zyplast. They were used for depressed acne scars, nasolabial folds and the lips. Because of possible allergic reactions, 2 negative skin tests are required before use. The improvement rarely lasts longer than 6 months. Human collagen does not need skin testing but lasts no longer. Fat is cheaper and larger amounts can be used but duration of effect is still short.

The hyaluronic acid fillers are now the most popular fillers. No allergy tests are needed. They last longer than collagen with 80% of the filler still there at 8 months. Another filler is the polymethylmethacrylate microspheres which cause scarring around the beads and are more permanent. Nodular scars have formed with Artecoll, but Artefill has replaced it. It is FDA approved and has a low complication rate, and continued improvement at 4-5 years.

Calcium hydroxylapatite (Radiesse) is a semipermanent filler that can keep its effect in nasolabial folds for 6-9 months and 10-12 months in less mobile areas. It can be used in hollowed out cheeks, bigger acne scars, and for smoothing out the jawline. It is not recommended for lips because of lumpiness.

Poly-l-lactic acid is FDA approved for filling sunken areas in HIV patients. It stimulates scar tissue build up for a more permanent result. A new silicone preparation is being used as a permanent implant. It seems to lack the impurities that were thought to cause nodular scars, inflammation and outward migration of the older formulation.

General Technique
The patient should be sitting up. Anesthesia can be a cream applied 30 minutes prior to injection or as an injectable nerve block. Injections of collagen or hyaluronic acid are delivered with a very small needle. Thicker fillers like Artecoll or Radiesse require a little larger needle and fat needs a larger cannula or tube. Multiple injections are required to place enough filler to cover the defect. Care must be given to injecting filler at the right depth. Too superficial and the implant will be lumpy. Too deep and the effect may not be seen. Post procedure ice is used to reduce swelling and soreness. Post procedure photographs should be done and patients should try not to move the face much for 48 hours.


Injection technique

Complications include allergic reactions, infection, bruising, blood collections under the skin, asymmetrical results, nodular scars, filler movement and the implant pushing out of the skin. Lumpiness may resolve over 1-2 weeks by itself, maybe faster with massage. Nodular scars can be treated with steroid injections.

Combination therapy can maximize improvement. Fillers can be combined with Botox, laser resurfacing, and surgical face lifts.

Filler aesthetics

The term esthetics comes from the Greek term aesthesis meaning a love of what is beautiful. The perfect female face is thought to have a larger smooth forehead and smaller nose, arched eyebrows, eyes set wider apart, prominent cheekbones, full lips, and a smaller lower face. The males have lower horizontal eyebrows, deeper closer set eyes, a larger nose, wider mouth, squared jaw, and rougher lower facial skin.

The aging face
A number of things cause the face to age more. Sun damage is the biggest factor. The rounded face in the young becomes flat or sunken in places because of the deterioration of underlying fat. The facial muscles are always folding the skin. When the folds remain at rest they appear as wrinkles and larger grooves in the face. With age the skin loses elasticity and begins to sag. The cartilage and bone of the face may deteriorate. Because of this, features like the nose may droop. These changes are more difficult to correct. Patients need to understand this and be realistic about what can be changed.

Advanced photoaging

Photoaging
There is a Glogau scale documenting the changes of the aging face. Glogau I patients are in their 20-30’s. They have no wrinkles. Glogau II patients are in their late 30-40’s. Wrinkles appear with facial movements but are not visible at rest. Glogau III patients are in their 50’s and older. Wrinkles occur with movement and remain at rest. They appear from the eyes and around the lips and mouth. Glogau IV patients are in their 60-70’s. Wrinkles cover the entire face.

When discussing cosmetic procedures, the face is divided into thirds. The upper third goes from the top of the forehead to the eyebrows. The middle third goes from the brow to just under the nose. The lower third goes from the nose to the chin.

The upper third
Changes here are from sun damaged skin that wrinkle from underlying muscle activity, leading to forehead lines. The tissue has lost elasticity and the brow begins to sag.

The middle third
Aging effects the areas around the eyes, cheeks and nose. As tissues lose resiliency, the eyelids can droop. Loss of fatty tissue around the eye leads to a sunken appearance leaving patients looking like a skeleton. The cheeks may lose fatty tissue as well and appear flat or sunken. The nose tip may droop as underlying support structures deteriorate.

The lower third
Aging has effects on the lips, chin, lower cheeks, and neck. The loss of skin elasticity allows it to droop off the side of the jaw to form jowls and wattles from the neck. Tissue sagging from the cheeks and around the mouth contribute to the nasolabial fold (groove running from the nostril to the corner of the mouth) and Marionette lines (wrinkles running down from the mouth corners to the side of the chin). Vertical lines form around the lips (lipstick lines) from underlying muscle activity around the mouth. With age the lip margins blur and the lip itself looses fullness. Cupid’s bow, the arch in the center of the upper lip may flatten. Of all other defects on the face, fillers primarily address deep folds, depressed scars, hollowed areas where tissue loss has occurred, and the need for lip augmentation. It should be clearly explained to the patient that it will not remedy defects in bone structure.

Injectable Fillers; Collagen

Injectable collagens

These are temporary substances that can be injected to fill in areas of tissue loss or deeper folds in the face. Collagen is mostly used in the middle and lower third of the face like the nasolabial fold, marionette lines, and wrinkles around the lips, forehead, and eyes that fail Botox treatment.

Before and after injection of the nasolabial fold

History
Soft tissue filler have been around for over 100 years. Initially blocks of fat were taken from the arms and used for sunken facial defects. Later bovine collagen was invented and was the most popular filler until 2003 when hyaluronic acid fillers like Restylane became available.

FDA approved collagen products
The most popular collagen products include the Zyderm family from a bovine (cow) source and the Cosmoderm family from a human source. The Zyderm family includes Zyderm I, Zyderm II, and Zyplast. Zyderm I is the thinnest form and is used for superficial wrinkles or to layer over a thicker filler. Because much of Zyderm I is salt water which diffuses out of the area, more of this filler must be injected to overcorrect the area as it will flatten out later. Zyderm II is thicker and more concentrated and is used for deeper folds or wrinkles. It also should be injected to overcorrection. Zyplast has the longest effect, 3 months longer than the other products. It is placed deeper in the skin to treat deep folds. No overcorrection is necessary. Allergic reaction can be avoided by performing a skin test, looking for abnormal swelling, redness, itching, and tenderness at the site. If the first skin test is negative, then a second test is done 2 weeks later. If the second test is negative, then treatment can be done 2 weeks after that.

The human collagen formulations need no skin testing. Cosmoderm I, Cosmoderm II, and Cosmoplast are used in the same way as Zyderm I, Zyderm II, and Zyplast.

Patient Selection
The kind of defect, its size, depth, and location, and the health of the surrounding tissue must be taken into consideration. The patient should be aware of other treatment options such as plastic surgery, laser resurfacing, and Botox. The procedures benefits and risks of each option should be understood. Patients especially need to be aware that collagen filler injection is temporary and will need to be repeated to maintain the effect.

Treatment guidelines
Patients should avoid any blood thinning medication for 1-2 weeks before treatment, to avoid bruising. Treatment areas should be photographed. Then areas should be cleaned with an antiseptic. Anesthesia can be given as a cream that is left on for 20-30 minutes, then removed, or as an injected nerve block. Patients should be sitting up so that gravity will make their folds more prominent. The filler is then injected, the area massaged and ice applied to decrease swelling and bruising. Patients can then reapply make up and resume normal activities.

Indications
Crow’s feet, (the wrinkles radiating out from the outer corners of the eyes), and lipstick lines, (wrinkles spreading from the lips), can be treated with Zyderm I or Cosmoderm I. Lines on the brow and forehead can be treated with Zyderm I or II or Cosmoderm I or II. The mouth corners, lip borders, and nasolabial folds need the thicker products like Zyplast or Cosmoplast. Soft scars from injection or acne can get any type of collagen. However the thickest fillers Zyplast and Cosmoplast must not be used in the glabellar area (between the eyebrows). This can lead to blood vessel blockage and necrosis of the skin.

Skin necrosis

Scars
Fillers can be used for nonice pick shallow scars, 1-2 mm deep. For thin skin Zyderm or Cosmoderm can be used. For males with thick skin, Zyplast or Cosmoplast is needed.

Lip augmentation
Lip enhancement is one of the most frequent uses for fillers. Patients may complain of thinning lips, lipstick or smoker’s lines, and drooping mouth corners. Patients with recurrent herpes infections will require antiviral medications to prevent herpes reactivation that can occur with filler injection. The thickest collagen is used for adding definition to the lip border, and bolstering the angles of the mouth. For adding volume to the lips and treating lipstick lines, thinner fillers like Zyderm I and II or Cosmoderm I or II are used.

The Nasolabial fold
Smile lines, folds that run from the nose to the mouth corners, are often addressed by fillers. Thicker substances like Zyplast or Cosmoplast are used.

Before and after treatment of the nasolabial fold and the melomental folds

Periocular lines
Many of the wrinkles around the eyes are etched in lines from constant folding of the skin by underlying muscle. Therefore, Botox is usually the first treatment to stop or freeze these movements. But any of the wrinkles that persist can be addressed with the thinnest fillers like Zyderm I or Cosmoderm I. Often after Botox treatment wrinkles may persist in the area between the eyebrows. Zyderm I and Cosmoderm I may be used, but Zyplast and Cosmoplast can absolutely not be used here.

Complications
In general, improvements with fillers last about 3-6 months. Allergic reactions can occur. Bruising can occur. If the filler is placed too superficially, lumps or nodules can occur. Placing fillers too deep could result in blocking a blood vessel leading to skin tissue damage. When a filler is injected into a blood vessel, the skin may whiten and generate sharp pain. Heat and nitroglycerin paste can help open up the blood vessels and salvage some skin.

Even after negative skin tests, there is a 1% chance of developing an allergic type reactions after collagen injection. There may be a swollen nodule formation that would take a year to resolve. Nonsteroidal anti-inflammatories, steroids, and other immunologic medicines can help. Sterile abscesses can also form and are treated with drainage, steroid injections, and antibiotics. Scarring can occur.

Injectable Fillers: Restyland, Juvederm and the Hylans

The Hylans and Other Fillers

Hyaluronic acid fillers have now become the most popular fillers. They do not require skin tests and last longer than collagen. Folds and wrinkles that improve with stretching get the best results. Deep, ice pick scars that do not smooth with stretching will not improve much.

Restylane is the first FDA approved hyaluronic acid. The treatment lasts 6-12 months, longer than Zyplast. Side effects include redness, swelling, bruising and pain which usually resolve in 3 days. Allergic reactions are extremely rare (1 in 5000). They can get a rash that appears about 22 days and lasts about 15 days. Other reported side effects include abscesses, tender nodules, and blood vessel damage. Two incidents of skin necrosis in the mid brow have been reported. Combination with laser therapies does not affect Restylane.

Juvederm
Juvederm is the newest hyaluronic aced. It comes as 5 products; Juvederm, 18, 24, 24HV, and 30 HV (HV meaning high viscosity).

Overall Treatment Strategy
The first step involves a detailed discussion about what features the patient wants changed. Using a mirror is helpful. Botox is better for wrinkles caused by repeated muscle movements like lines on the forehead, brow and the corners of the eyes. Fillers work best for deeper folds in the lower face. Best results may use both modalities in combination. Lips and nasolabial folds do best with fillers especially with hylans. Stretching a wrinkle or fold can illustrate how well it will respond to treatment. It can be shown to a patient in the mirror. The patient should know the limitations of fillers to avoid unrealistic expectations. They should especially be aware of the temporary nature of the result. Important history includes history of bulky scar formation, herpes infection, especially in the lips that could be reactivated. Injection should be avoided until inflammation in the area to be treated has resolved. Bleeding can be avoided if blood thinners are stopped 7-10 days before the procedure including aspirin, nonsteroidal antiinflammatories, vitamin E, and St. John’s Wort.

Conditions Treated With Fillers
Static facial rhytids
Forehead ('worry' lines)
Periorbital lines ('crow's feet')
Perioral (upper lip and smile) lines
Glabellar lines
Nasolabial folds
Hollows

Labiomental folds (marionettes)
Horizontal neck bands

Lip sculpture
Volume enhancement
Vermilion border definition
Philtral crest definition
Oral commissure effacement

Facial contouring
Cheek augmentation
Chin augmentation
Temporal augmentation
Infraorbital augmentation

Other
Distensible scars
Earlobe enhancement
Hand rejuvenation
Brow augmentation
Perimental
Nasal contouring

Conditions for which hylans are not indicated
Dynamic rhytids
'Ice pick' & other nondistensible scars
Striae & widened surgical scars
Actinic damage of lips
Extensive facial rhytids

Contraindications to Fillers
Absolute
Previous serious reaction to hyaluronic acid derivatives

Patients with severe allergies manifested by history of anaphylaxis
Patients with multiple severe allergies

Implantation for breast augmentation
Implantation into muscle, bone, tendon, blood vessels

Relative
History of hypertrophic or keloid scars
Active inflammation at site to be treated (acne, rashes, etc.)

Active disease which koebnerizes (pyoderma gangrenosum, etc.)
Patient has important social function in next 72 hours (erythema)
Unrealistic expectations of patient
Pregnant, breastfeeding, or under age 18
Autoimmune conditions or on immunosuppressive therapy Patients on substances that can prolong bleeding

History of pigmentation disorders

Side effects
Common

Erythema
Swelling/edema Pain
Tenderness at injection site

Bruising

Itching

Rare
Angioedema acute hypersensitivity reaction

Delayed local hypersensitivity

Granulomatous reaction

Abscess-Iike swelling

Arterial embolization
Venous occlusion resulting in lip varix

Acneiform eruption
Facial atrophy similar to HIV lipoatrophy

Superficial blue nodules (Tyndall effect)

Targets for filler injections

Choosing an Implant
Fine superficial wrinkles and stretchable scars do best with thin fillers. Deeper wrinkles and folds need a thicker filler and hollowed out areas need a very thick filler. Restylane products include Restylane, Restylane Fineline, Perlane, and Restylane Sub Q. These products differ in gell particle size. Restylane Fine line has the smallest particle size and is used for fine wrinkles. Restylane has larger particles and treats moderate nasolabial folds and lip thinning. Perlane has larger, particles and treats deep folds or adds bulk to hollow areas on the face. Restylane SQ has the largest particles and is used to fill in flattened or hollowed out areas of the face. These products can also be layered to build up the area more. Thicker fillers can be place deeper in the skin and thinner fillers injected over it in a superficial layer of the skin.

General Treatment Technique
Make up is removed and the area is prepped with alcohol or an antiseptic. Anesthetic skin creams can be applied 20-30 minutes before injection or a nerve block can be used. Nerve blocks take 10-20 minutes to take effect. They are usually needed for lip injections. Several injections are made along folds depositing small amounts of the filler at a time. Materials are placed into different depths of the skin. The epidermis is the outer most layer of the skin. The dermis is a thicker layer underneath, and subcutaneous fat and tissue is under that. Thinner fillers like Restylane Fine Lines are placed in the high dermis to treat fine shallow wrinkles. Thicker fillers for deeper wrinkles should be injected into the mid dermis. And thick fillers should go into the deep dermis for deep folds. If injections are too superficial bluish spots form on the skin. If too much filler is deposited about 20% overcorrection can be massaged out. Hyaluronidase is an enzyme that can breakdown hyaluronic acid filler, also removing excessive filler. It can also treat threatened skin necrosis from hyaluronic acid injection too.

Fillers working by fibroplasias

Collagen and hyaluronic acid simply fill a space and dissolve away with time. However, newer fillers contain injectable small beads that stimulate the formation of new collagen that fill in defects more permanently. Radiesse contains beads of calcium hydroxylapatite. Artefill uses polymethylmethacrylate (PMMA) microspheres. Other products include Sculptra, poly-L-Lactic acid and silicone oil.

Artefill
Artefill consists of polymethyl methacrylate (PMMA) microspheres. The spheres stimulate human collagen formation around them for a more permanent result. Artefill is injected into the deep dermis to correct deeper folds. Because it is a permanent filler, patients need to be comfortable with the risks of an undesirable result. 2-3 injection sessions are done several weeks to months apart. Skin testing is required.

Artefill has been used for forehead lines, brow lines, nasolabial folds, lipstick lines, acne scars, and for bulking up parts of the face. The FDA has recommended Artefill not be used for lip augmentation. 2.5% of Artefill patients develop granulomas, small nodular scars. These can be treated with steroids injected into the nodule. Artecoll is a second generation product with less impurities and a lower incidence of granulomas (<0.01%).

Radiesse
Calcium hydroxylapatite gel is injected and stimulates human tissue growth. So when the gel is resorbed, the patients own collagen stays to fill the defect. Skin testing is not necessary. It is used to fill folds, depressed scars, and hollowed out areas. In one study of patients injected into the lips, nasolabial folds, brow lines, marionette lines and tissue defects, 88% rated satisfaction good to excellent. Side effects include injection pain redness, swelling and bruising. Duration of improvement may be 12-24 months. Nodules occurred in 12.4% treated for lip augmentation and 3.7% for lipstick lines. There are no reports of allergic type reactions.

Silicone
Liquid injectable silicone is a permanent implant. It is used for lip augmentation and filling in tissue defects. The microdroplets stimulate collagen growth around them. It is a permanent filler so careful placement is needed. Silicone has been found to be safe but there are reports of nodules, cellulites, and implant movement. Safety requires only pure medical grade liquid injectable silicone is used. The microdroplet serial puncture technique is used and smaller volumes are injected at one time and gradual correction continued with follow up sessions 1-6 months apart. Silicone can be used in nasolaabial folds, labiomental folds, scars, surgical defects, and wrinkles. Side effects include swelling and bruising. A brown or bluish discoloration can show through if the injection is too superficial. Beading is the formation of 1-5 mm nodules from collagen growth around the sllicone implant. Beading can be treated with steroid injection, dermabrasion or it can be cut out or shaved off. Injection into blood vessels must be avoided. This could lead to tissue damage with the loss of its blood supply. Nodular inflammatory reactions may occur with overinjection, injection into sites best avoided, and injection of impure materials. This may be treated with imiquimod, steroids, and antibiotics. Sometimes these reactions occur after an infection in another site. Therefore no implants should be done if any infection is present anywhere. Movement of the implant can occur if large volumes are injected. This should not happen with the microdroplet technique.

Poly-L-lactic acid (PLLA)
PLLA when injected, initiates an inflammatory response with scar build up that fills in the defect. Areas best treated include hollows of the cheek, nasolabial folds, and areas under the eyes and temples. Patient satisfaction has been up to 95%. This is a long lasting filler, reported to also improve skin color and texture. Nonvisible subcutaneous nodules are reported in 3% of which 30% resolve by themselves in 3 months. Visible nodules are seen in 1% and rarely require treatment with excision or steroids.

Injectable Fillers: Treatment of the Lips and Around the Mouth

Management of Lips and Mouth Corners

With age, sun damage and smoking worsen lipstick lines (the vertical wrinkles around the lips) and the loss of fullness of the lips. The loss of skin resiliency leads to sagging skin accentuating the folds running from the mouth corners to the chin.

Patient selection
Fillers using a bovine collagen (Zyderm, Zyplast, Artecoll, Artefill) need skin testing. A new porcine (pig) product Evolence does not need skin testing. Patients with connective tissue diseases like systemic lupus erythematosis should not get fillers. Patients with a history of herpes should get antiviral therapy like valacyclovir before implant to avoid herpes reactivation and subsequent scarring.

Superficial wrinkles around the mouth do best with Botox, laser resurfacing treatments, and superficial fillers. Improvement usually lasts 3-4 months. Deeper lines may require layering fillers in different depths of the skin to completely fill them in. The combination of laser resurfacing techniques and layered fillers can give the best results. For the lips fillers can be injected into the border roll for better definition and into the lip body for improving fullness. Injected nerve blocks and anesthetic creams are needed for most filler injections around the mouth.


Nerve blocks for the upper and lower lip

Overall Treatment Strategy
A long preprocedure discussion is necessary so that the patient’s expectations are the same as the physicians. The patient must be made aware of what realistically can be done and what cannot. Therapies have their limits. The point in time when improvement is first seen, its maximum, and how long it lasts should be discussed. It should be emphasized that these procedures need to be repeated to maintain benefit. They should know about other laser or surgical applications as well. Patients should be aware of the costs.

Patients can be classified according to the Glogau scale and treatments planned. Glogau I patients may have fine wrinkles and this can be taken care of with laser resurfacing and Botox injections. Glogau II patients may have more prominent lipstick lines. Thinning lips and drooping mouth corners. Fillers injected into the outer and mid layers of the skin can be used to fill these lines along with laser and Botox treatments for further smoothing effects. Glogau III patients have deeper lipstick lines, drool lines running down from the mouth corners, and thinning lips. Again combination of fillers, Botox and laser resurfacing is used. Glogau IV patients have severe wrinkles and folds in the skin, severe volume loss in the lips with drooping skin. They may need all the above therapies with cosmetic surgery as well.

Golgau I patients commonly request lip augmentation. There are two parts to this treatment. One is to improve the definition of the lip border by injecting filler into the lip margin. This may also help people whose lipstick bleeds into the vertical wrinkles coming off the lip. The second part is to make the lips bigger by injecting into the body of the lip. One can also inject the arch in the middle of the upper lip to create the pouting look or Paris lip.


Examples of injection sites for lip augmentation

Before and after lip injections

The patient should take Arnica Montana 2-3 days before to decrease bruising and valacyclovir 2 gms two times daily if they have a history of herpes infections. The lips are very sensitive areas and a nerve block is needed to numb the area enough for most injections. To improve the lip line definition the needle is inserted into the mouth corner and pushed along the upper border of the upper lip. Once the needle is all the way in , it is slowly pulled back and the filler injected leaving a line of it along the lip margin. Similar injections are done to outline the entire edge of the upper and lower lips. Filler can also be injected into the two vertical ridges in the skin running from the upper lip to the nose (the philtral crests). To plump the lips, filler can be injected into the lip body along the border where the wet inside of the lip meets the dry outside. Another technique involves injecting a medium depth filler like Restylane just below the white roll along the lip border, then injecting superficial filler like Restylane Fine Line into the white roll at the lip border.

Significant swelling and bruising commonly occur. Kissing the ice and keeping the head up will help. Swelling may decrease in 1-2 days, but bruising may not go away for 7-10 days. A short course of nonsteroidal anti-inflammatory drugs can be used for a lot of swelling. Rarely, a herpes injection can occur and is treated with a round of antiviral medications. One of the worst complications is injecting filler into an artery. This cuts off blood supply to the skin and can cause skin ulceration. It is more common with thicker fillers. If pain or extreme whitening of the lip skin is seen, the injection should be stopped. Warm packs or injection of Wydase (to break up hyaluronic acid fillers) is used. Other rare complications include allergic reactions that can be treated with steroid injections or laser treatments.

Glogau II patients may have more prominent lip stick lines. Fine lines can be treated with Botox, but deeper lines may require fillers. The skin above the lip is less sensitive than the lip itself and is usually alright with anesthetic cream alone without nerve block injection. A small needle is run under the wrinkle and a small amount of filler is injected to fill in the line. Thinner fillers like Restylane, Restylane Fine Line or Juvederm Ultra is used. If the implant is placed too superficially, beading can occur with bluish color showing through. It may be possible to massage this away. Use of hyaluronidase (Wydase) to dissolve the filler or a QS1064nm laser can help. Herpes infection in a patient with previous cold sores is possible. Again skin ulceration with injecting a blood vessel can happen. Combinations of Botox and fillers for the lips and lipstick lines gives the best overall look.

The fold running down from the corners of the mouth are treated with Restylane or Juvederm Ultra if they are superficial. Thicker fillers like Peralane or Juvederm Ultra Plus are for deeper folds, followed by the thinner fillers injected into a layer on top. Chin drooping can be treated with Botox. Complications for treatment in this area include movement of the filler, and injection into a blood vessel with skin ulceration and breakdown. Some treatments can be done on the same day as filler injection.


Examples of injection sites for treating the melomental folds

Before and after injections for the melomental folds

Glogau III patients will need combination therapy. They have deeper lipstick lines, lip thinning, and mouth corner droop with drool lines. Fractional laser resurfacing can be done first for the spider blood vessel lesions and fine wrinkles. Botox can be used for lip lines and the chin. Then, the melolabial folds (drool lines) can be injected with a deeper filler like Perlane with a superficial or medium depth filler on top. Filler can then be injected just under the corner of the mouth to raise it for a happier look. This may not all be done on the same day. The most obvious problems can be treated first and the rest on a follow up visit.



Glogau IV patients often require plastic surgery and aggressive laser resurfacing procedures first. Then the lip lines, thinning lips, and drool lines can be addressed with Botox and fillers.

Injectable Fillers: The Nasolabial Fold

The Nasolabial Fold

The nasolabial fold is the groove going from the nose to the corner of the mouth. The underlying muscles of the face with contraction carve in this fold overtime. As skin loses elasticity it sags over the fold making it deeper. Fillers can be injected to fill in the fold. Surgical face lift, skin resurfacing and tightening with a laser, and muscle relaxation with Botox also help.


Before and after treatment of the nasolabial fold

Patient selection
Patients need to have realistic expectations. Several treatments will be required. Wrinkles will require Botox, fillers for deeper folds, and facelift for drooping skin. Single procedures with much quicker recovery are usually done first followed by more invasive treatments. The best filler patient has a moderate NLF with realistic expectations. If they want more improvement than possible with a filler, because of over hanging skin, they will need a face lift. Patients with aging skin and fine wrinkles may also need laser resurfacing. Treatment of the NLF addresses the four major causes. Botox will treat wrinkles from muscular contraction. It can be injected into the muscle that lowers the lip to raise the corner of the mouth in addition to filler injection into the lower NLF and drool lines. The sagging cheek will often require a face lift. There is a technique of Sulamanidze-Aptos where hooks and threads are used to hold up the cheek and combined with fillers for severe NLF’s. Lasers can be used with fillers to treat sun damaged skin as well as deeper folds.

Different fillers can be used in combination to address all the problems of the NLF. Thinner fillers treat the fine wrinkles around the NLF and thicker fillers for the deeper fold. If filler is injected too superficially, nodules will develop. Injecting too deep into the fat under the skin instead of into the skin itself will result in the appearance of no improvement.

Patient Interview
A complete medical history and physical exam should be done including history of collagen vascular diseases and allergies. Skin tests should be done if necessary. Bleeding problems and blood thinning drugs should be noted. The patient should go through a series of facial expressions like looking up, smiling, and grimacing, and all of the patient’s facial defects should be noted and photos taken. The patient should make a list of the five things they want improved in their face. The list is reviewed and a mirror used to make sure everyone understands what is desired. Treatment options are discussed. More temporary treatments are used first so the patient has a chance to decide if a more permanent fix is actually desired. Also as the patient ages one implant may look unnatural later as the face changes. The costs are reviewed and patients given literature.

Treatment
Patients need to sign informed consent. Make up is removed and areas cleaned with alcohol. Photos are taken from the front, sides, and 45 degree angles.

Collagen
Bovine (cow) collagen has a long safety record and is used commonly in the NLF. It comes in 3 forms, Zyderm I, Zyderm II, and Zyplast. They all need skin tests. Zyderm I is for shallow defects and Zyderm II and Zyplast are for deeper defects. Zyplast may be used to fill the nasolabial groove and Zyderm I to fill the left over wrinkles. Two or more sessions may be required to complete the work, 2 or more weeks apart. To maintain the result, injections are repeated every 4-12 months. Best results are from using Zyplast deeper and layering Zyderm I on top to fill the fold. More filler is used at the top of the fold where it is more depressed. Massaging after injection helps avoid nodule formation and makes the implant look smoother. The disadvantages of Zyderm is the need for skin tests, its short duration of effect, and the possibility of blood vessel occlusion with tissue ulceration.

Before and after treatment of the nasolabial fold

Cosmoderm and Cosmoplast are human collagen fillers. They are used like Zyderm and Zyplast. No skin tests are deeded and they may last longer. It causes less swelling and bruising than any other filler. The most recent collagen released is Evolence or Dermical P-30. This porcine (pig) product can last up to a year. It is injected with a little bigger needle and therefore needs a nerve block for better anesthesia.

Hyaluronic acid
These are the most recently approved fillers. Restylane comes from bacteria and Hyalaform is from chicken combs. Juvederm is another hyaluronic acid that may last up to 6 months. Hyaluronic acids cause few side effects with rare allergic or inflammatory reactions. Granulomas rarely occur.

Calcium hydroxylapatite (Radiesse in the US) are microspheres carried in a gel. As the gel dissolves away, collagen forms around the spheres adding to the filling effect. Effects can last up to 2-5 years. It is injected through slightly larger needles and needs a nerve block for anesthesia. The defects are usually under treated and supplemental treatment done 2-4 weeks later. After injection it can be molded by massage to prevent lumpiness.

Sculptra can be injected deep into the skin. Because it stimulates collagen growth, there will be a gradual increase in filling over a few months. Nodules can occur as well as bruising, swelling, abscess formation, and allergic reactions. Treatments are spread over 2-3 sessions. The effects may last 2-4 years.

Permanent fillers include silicone and Artefill. Silicone has tiny droplets that stimulate collagen formation around them to grow the filler. Repeat injections are done every 6 months until the desired effect is achieved. Complications include implant movement and beading. Adatosil and Silikon are products being used.

Artefill is a permanent filler placed deep in the skin. Facial movement must be limited to prevent pushing the product deeper. The injection site can be taped to remind patients not to move. Complications include allergy and rarely granuloma formation.

Injectable Fillers: Anesthesia

Anesthesia

Anesthesia is important because a better job can be done on a patient who is comfortable, relaxed, and still. The environment should be pleasant. Before the visit oral medications can be given for pain including ibuprofen 800 mg or acetaminophen 2 grams. Propranol 40-8- mg, or Valium 10 mg can be given for anxiety.

Topical anesthesia
Eutectic mixture of local anesthetics (EMLA) is a mixture of lidocaine and prilocaine. It is spread on the skin and covered with plastic film for 30-60 minutes. After its removal, anesthesia lasts for 15-30 minutes. LMX-5 is a 5% lidocaine cream that lasts longer, about 30 minutes. Betacaine is a combination of lidocaine and prilocaine in a gel so it does not need coverage with a film dressing. Tetracaine gel is applied for 30-45 minutes under the dressing and lasts up to 4-6 hours. S-Caine Peel can give anesthesia within 20 minutes of application.

Cryoanesthesia
Applying ice before and after injection affords some anesthesia. Ice is placed for 30 seconds to get about 10-15 seconds of anesthesia. Rubbing the ice for about 5 seconds after injection also helps. When treating lips, ice should be placed for 60 seconds before injection.

Local anesthesia has the disadvantage of distorting the skin around the injection making it harder to see the effects of the filler.

Nerve blocks
The advantage of a nerve block is that one injection into a nerve can numb a large area of the face. Nerve blocks can be injected into the brow (supraorbital block) to numb almost half of the forehead. An injection into the upper cheek (infraorbital block) can numb the nose, cheek, lower eyelid, and upper lip. For this block anesthetic ointment is placed over the upper gum inside the mouth, then the needle is inserted above the gum directed at the cheek, and anesthetic injected. The nerve root above the cheek can also be stuck through the outside skin without going through the mouth. Other injection around the temple can anesthetize the outside eye, temple, and outside cheek. Blocking the nerve on the side of the chin either going through the lower gum or the skin will numb the lower lip mouth corner, chin and cheek. Another technique involves injecting anesthetic in 4-5 spots across the upper gum line and another 4 injections along the lower gum line to numb an entire area around the mouth.

The infraorbital nerve block to numb the upper lip and cheek

The mental nerve block to numb the lower lip

Injecting along the gum line to numb the upper and lower lip

Injectable Fillers: Complications

Complications of Injecting Fillers

Right after injections expected side effects include needle marks, swelling, and bruising. Using ice and avoiding blood thinning medications before hand will reduce this problem. Giving Arnica before the procedure can lessen bruising as well.

Hematoma (bleeding) under the eye


Hyaluronic acid fillers may cause hypersensitivity reactions appearing as several red tender nodules. There can be redness, itching, and painful swelling seen. Allergy to bovine collagen is seen in 3%. Therefore 2 skin tests are recommended before treatment. Necrosis is very rare, less than 0.001%. It can occur on the brow, cheeks, and lips. It occurs when filler is injected into a blood vessel and a patch of skin loses its blood supply and ulcerates or breaks down. Injection into an artery causes immediate pain and blanching. First, the injection is stopped. Massage may diffuse the product. Nitroglycerin paste and warm compresses can be applied to open up the vessel and hopefully reestablish circulation to the tissue. If skin breakdown occurs the wound needs antibiotic ointment, Vaseline and acetic acid soaks.

Another complication is blindness from filler injection into the retinal artery of the eye. Vision loss can be temporary or permanent.

Herpetic ulceration

Skin infection can occur so the area must be well prepped with alcohol. Antibiotics can be started 2 days before and kept on 3 days postop. Valacyclovir 500 mg 2 times a day can help prevent herpes activation. Bacteria like streptococcus and staphylococcus aureas can cause red single or multiple nodules. If nodules contain pus, it should be cultured and antibiotics tested on the bacteria isolated. Antobiotics used include Keflex, amoxicillin, Levaquin, Biaxin, and minocycline. If the nodules do not respond this may be an atypical mycobacterium. Biaxin 500 mg 2 times a day may treat this.



Misposition of the implant can occur. If placed too superficially collagen will give a whitish lesion. Hyaluronic acid fillers placed too shallow cause a bluish discolorization (Tyndall effect).





Tyndall effect

Injection of 15 units of hyaluronidase can dissolve the nodules away. A nodule may be nicked and filler expressed out. Some nodules will improve with steroid injection. Poly l lactic acid (Sculptra) can cause nodules as well.

Examples of skin nodules

Skin erosions following intravascular injections of fillers