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.