Top: Non-surgical facelift; a combination of Restylane and Radiesse“ .
Bottom: Restylane injections under the eyes to combat dark circles.
Today’s Dermal Fillers
The most prominent of the new dermal fillers is the non-animal-based Restylane, which is comprised of cross-linked hyaluronic acid. Restylane had been in use in Europe for several years before it was approved in the United States in December 2003. It has since become the dominant dermal filler in this country.
Restylane can be used safely and effectively in lips, nasolabial folds, marionette lines and, with caution, on glabellar lines and around the eyes. Unlike the collagen fillers, Restylane does not contain lidocaine, so the injections are more painful. Topical anesthetic and ice application usually are sufficient to control the pain, except during lip augmentation injections. I have found that a dental block along with ice application to prevent excessive bleeding and bruising are absolutely mandatory when injecting the lips with Restylane. The injection technique with Restylane is very precise. If the physician has not had specific training in Restylane injection during residency, he or she should undertake such training via courses and seminars.
I personally use Restylane to augment lips and to fill in vertical lip lines (in combination with Botox). I occasionally will use it to fill in small lines around the face. But, I have moved to a different product, Radiesse, for filling in nasolabial folds, marionette lines and facial sculpting.
Radiesse, produced by BioForm Medical, Inc., is a non-animal-based calcium hydroxylapatite filler that is becoming more popular. Yet, the company has not yet obtained Food and Drug Administration (FDA) approval for the use of Radiesse as a cosmetic filler, which has prevented the company from marketing it as such. However, Radiesse is approved for other indications and is thus being used “off label” for cosmetic procedures. In my experience, the material has delivered outstanding cosmetic results and longevity, so I use it as my principal filling agent for facial sculpting, nasolabial folds and marionette lines. The material lasts one and a half to two years, depending on the area injected and requires no allergy testing.
As is the case with other injections, Radiesse results are quite technique-sensitive, and a poor injection can mean many months of unhappiness for the patient. Physicians should start with Restylane and collagen, switching to Radiesse after they have mastered those shorter-duration fillers. Here again, delegating Radiesse injections to less-qualified personnel is not desirable, since a poor result is a major risk for the overseeing physician and the medical spa.
Two other hyaluronic acid fillers, both from Inamed Corp., have been FDA-approved. Use of Hyalform®, which is manufactured from rooster combs, requires allergy testing and lasts about three months. Captique™, the approval of which drew much publicity, is non-animal-based and is reported to cause less bruising and swelling than does Restylane. The duration of Captique’s effects is unclear—the company claims one year, but practitioners have reported only four to six months.
Another interesting filler material is Sculptra®, which is more accurately described as a collagen stimulator than as a dermal filler. It is composed of poly-L-lactic acid in a powder form that must be reconstituted with preserved saline or bacteriostatic water the night before a procedure.
Sculptra is FDA-approved for treatment of HIV facial lipoatrophy only, but it commonly is used “off label” for cosmetic procedures. The advantage of Sculptra is that it is a fairly economic way to fill large areas of the face (such as the cheeks or temples) with natural-looking results. The disadvantages are that most areas require two to three injection sessions about one month apart, and the cost to the physician is rather steep. Another drawback is that between the first and second injection session, the patient’s face goes back to its pre-injection appearance. It is not until after the second or third session that the collagen stimulation is evident and the final benefit is seen.
In The Pipeline
There are quite a few dermal fillers being widely used in Europe that have yet to gain FDA approval in the United States. One of the most talked about is Artecoll, a semi-permanent to permanent filler composed of polymethylmethacrylate beads suspended in collagen and lidocaine. After injection, the collagen is absorbed within three months, during which time a scar tissue capsule forms around each bead, preserving the filling effect for many years, if not forever.
When, and if, this material comes on the American market, practitioners will have to take great care with injection technique. There already have been several reports of patients developing post-injection lumps that have required surgical excision.
Other fillers awaiting FDA approval include Juvéderm®, Isolagen, Reviderm Intra and several more. Coming full circle, some physicians are again injecting silicone oil with a refined technique that shows some promise.
With the right training and skills, injectable fillers can be an extremely valuable tool for the aesthetic practitioner. In skilled hands, dermal fillers produce outstanding results and are even more effective when combined with Botox. The most popular applications for injectable fillers are:
Alexander Z. Rivkin, M.D., is a Yale-trained facial plastic specialist and owner of the Westside Medical Spa. He has focused his practice exclusively on providing his patients with the latest in non-invasive, non-ablative cosmetic treatments. Dr. Rivkin received his undergraduate degree from Columbia University, earned his doctorate at Yale Medical School, and underwent residency training in facial plastic surgery at the University of California, San Diego.
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