Fillers

 

INTRODUCTION

In the early 1970s, bovine collagen became the first injectable filler used to augment the face. A multitude of products have since been developed for soft tissue augmentation.  Hyaluronic acid (HA) is the most frequently used agent (87% of all soft tissue filler procedures), In fact, HA has become the most commonly used filler worldwide. Not all injectables are created equal, however, and no filler is ideal, nor can a single filler meet every patient’s wishes and expectations.

TYPE OF FILLERS

Broadly, facial fillers can be divided into 4 categories: autologous fat, collagens, hyaluronic acid, and synthetic fillers

INDICATIONS

Injectable soft tissue fillers are indicated for wrinkles, folds, and lines associated with aging. Areas commonly addressed in the face include the forehead, glabella, nasolabial folds, and lips. Certain fillers are also used for contour deformities associated with acne scarring or HIV-associated lipoatrophy. Some commonly used fillers and their properties are listed below.

Restylane/Restylane-L (Galderma)

  • Material: Hyaluronic acid derived fromStreptococcus equi, 1% cross-linked. Restylane-L contains 0.3% lidocaine
  • How supplied: Disposable glass syringe with Luer-Lok fitting, 30-ga needle
  • Skin testing required: No
  • Duration: 6 months
  • Depth of injection: Mid to deep dermis
  • FDA indications: Moderate to severe facial wrinkles and folds, such as nasolabial folds
  • Off-label uses: Correction of age-, surgery-, and disease-related facial depressions and rhytides and volume augmentation at other body sites
  • Contraindications: Severe allergies manifested by history of anaphylaxis, allergies to gram-positive bacteria proteins, bleeding disorders

Perlane/Perlane-L (Galderma)

  • Material: Hyaluronic acid derived fromS equi, chemically cross-linked, Perlane-L contains 0.3% lidocaine
  • How supplied: Disposable glass syringe with Luer-Lok fitting, 27-ga needle
  • Skin testing required: No
  • Duration: 6-12 months
  • Depth of injection: Deep dermis to superficial subcutis
  • FDA indications: Moderate to severe facial wrinkles and folds, such as nasolabial folds
  • Off-label uses: Correction of age-, surgery-, and disease-related facial depressions and rhytids and volume augmentation at other body sites
  • Contraindications: Severe allergies manifested by history of anaphylaxis, allergies to gram-positive bacteria proteins, bleeding disorders

Juvéderm XC (Allergan)

  • Material: Hyaluronic acid derived fromS equi cross-linked with BDDE in homogenized gel; concentration 24 mg/mL
  • How supplied: Suspended in physiological buffer; syringe contains 0.8 mL with Luer-Lok adaptor, 30-ga needle
  • Skin testing required: No
  • Duration: 3-6 months
  • Depth of injection: Mid to deep dermis
  • FDA indications: Moderate to severe facial wrinkles and folds, such as nasolabial folds
  • Off-label uses: Correction of age-, surgery-, and disease-related facial depressions and rhytids and volume augmentation at other body sites
  • Contraindications: Severe allergies manifested by history of anaphylaxis, allergies to gram-positive bacteria proteins

Juvéderm Voluma XC (Allergan)

  • Material: Hyaluronic acid derived fromS equi cross-linked with BDDE in homogenized gel; concentration 24 mg/mL; higher proportion of cross-linked HA; contains lidocaine
  • How supplied: Suspended in physiological buffer; syringe contains 0.8 mL with Luer-Lok adaptor, 27-ga needle
  • Skin testing required: No
  • Duration: Up to 24 months
  • Depth of injection: Subcutaneous, deep injection
  • FDA indications: Deep injection in the cheek area to correct age-related volume loss in adults older than 21 years
  • Off-label uses: Correction of age-, surgery-, and disease-related facial depressions and rhytids and volume augmentation at other body sites
  • Contraindications: Severe allergies manifested by history of anaphylaxis, allergies to gram-positive bacteria proteins or to lidocaine

Radiesse (Merz)

  • Material: Calcium hydroxyapatite microspheres (25-45 µm) suspended in a gel carrier of sterile water, glycerin, and sodium carboxymethylcellulose
  • How supplied: 1-mL syringe
  • Skin testing required: No
  • Duration: 1-2 years
  • Depth of injection: Subdermal
  • FDA indications: HIV-associated lipoatrophy, moderate to severe facial wrinkles and folds (eg, nasolabial folds)
  • Off-label uses: Marionette lines, glabella folds, prejowl sulcus, cheek volume loss, dorsal nasal deformities, lip augmentation
  • Contraindications: Severe allergies manifested by history of anaphylaxis or history or presence of multiple severe allergies; hypersensitivity to any of the components

Sculptra (Galderma)

  • Material: Poly-L-lactic acid mixed with mannitol and sodium carboxymethylcellulose
  • How supplied: Reconstituted with 5 mL sterile water and lidocaine solution to form hydrocolloid suspension; supplied as freeze-dried preparation for injection in a clear glass vial
  • Skin testing required: No
  • Duration: 2 years
  • Depth of injection: Subdermal
  • FDA indications: HIV-associated lipoatrophy
  • Off-label uses: Cosmetic use
  • Contraindications: Hypersensitivity to any of the components

CONTRAINDICATIONS

  • General contraindications include a history of severe allergy oranaphylaxis, bleeding disorders, and hypersensitivity to one of the components in the product preparation. A skin test must be performed prior to injection of fillers derived from bovine sources
  • Other relative contraindications include recent use of aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or herbal supplements known to affect coagulation and hemostasis (see drug list in Indications section above for more details).

ANESTHESIA

  • Many options are available for providing anesthesia when injecting soft tissue fillers. Many practitioners use a combination of different agents, including ice, topical numbing cream, andlocal anesthetic for regional nerve blocks.
  • Perhaps the greatest anesthetic effect is achieved by putting the patient’s mind at ease. A softly lit room with soothing background music and a comfortable chair helps to provide a tranquil and relaxed experience. In fact, music has been shown to increase the level of sedation in patients undergoing surgical procedures.

Anesthesia for the procedure

  • Apply a topical numbing cream to the areas to be injected and occlude with Tegaderm. Wait at least 30 minutes for this to infiltrate the skin.
  • Next, lightly spray the gingivolabial sulcus of the upper lip with Cetacaine to dull the sensation of the lip in preparation for the infraorbital block. An infraorbital block is preferred to direct soft tissue infiltration, as the latter distorts the tissues to be augmented.
  • For the infraorbital block, a 1:1 mixture of lidocaine 1% with 1:100,000 epinephrine and bupivacaine 0.5% with 1:200,000 epinephrine provides long-term anesthesia with a rapid onset. Insert the needle through the upper gingivolabial sulcus and advance the tip up the face of the maxilla and into the infraorbital foramen. The infraorbital foramen is found within 1 cm inferior to the infraorbital rim in the midpupillary line.[12] Inject approximately 1 mL of the local mixture.

COMPLICATIONS

As with every procedure, complications do occur. Certain complications, such as pain, needle marks, bruising, and swelling, are expected in the immediate postprocedure period. Even some asymmetry associated with over or undercorrection is expected within the first 2 weeks but usually resolves without intervention.  Should overcorrection from hyaluronic acid persist, several authors have reported successfully using hyaluronidase to treat this problem. 

 Infections occur infrequently and are due to improper technique. They may have an immediate or delayed onset.

All fillers are expected to create some form of histological reaction that evolves over time. Nodules and granulomas can form as part of an inflammatory granulomatous process and may require excision if they do not respond to steroid injections.

Serious complications from injectable fillers have been reported and include anaphylaxis, skin necrosis, blindness, and death.  Fortunately, these complications are very rare. The glabella is believed to be at risk for skin necrosis because of small-caliber vessels that branch from the supratrochlear arteries to supply this area, though this is controversial.

Accidental intravascular injection of facial fillers can result in skin necrosis and blindness. Immediately following diagnosis of intravascular injection, hyaluronidase was used to treat the problem in 86% of cases. Most patients experienced uneventful healing. 

 INSTRUCTIONS AFTER THE PROCEDURE

  • Avoid strenuous physical activity for 24 hours and then return to normal activities. As always, the patient should avoid excessive sun exposure and should use a moisturizer with SPF 25.
  • Use acetaminophen as directed on the bottle for pain relief; prescription pain medication is not routine. All patient medications can be resumed the night of the procedure.
  • Encourage cold compresses to control pain and swelling.
  • Avoid massaging or manipulating the treated areas for at least 24 hours, as this can disturb the position of the filler.
  • If bruising should occur, treat with warm, moist compresses, such as a moist washcloth that has been placed in a microwave for 5-10 seconds. Other patients find that used black tea bags hasten the healing of bruises, perhaps because of an antioxidant effect.

Hyaluronic Acid 

Introduction

Though the word “acid” may sound scary in reference to something you put on your face, don’t worry, it doesn’t burn. Quite the opposite, in fact, hyaluronic acid for skin packs a ton of skin-boosting benefits including mega moisture.

It’s become an increasingly popular ingredient in serums and moisturizers for its superpower hydrating and anti-aging abilities.

What is Hyaluronic Acid?

  1. Hyaluronic acid (HA), or hyaluronan, is a carbohydrate molecule that is naturally occurring in our bodies. That’s right, it’s already in your skin!
  2. HA provides lubrication to the connective tissues of our joints and skin and is an important part of our skin’s overall health.
  3. HA is present in many areas of your body including your eyes, internal fluids, and connective tissue, but much of it is in your skin, which accounts for 50% of your body’s total HA level.
  4. Even though it occurs naturally in our bodies, HA is a super popular skincare ingredient replicated in a lab.

 

What Can Hyaluronic Acid Do for Your Skin?

It’s Science

  1. 5. After observing women who used hyaluronic acid for just 8 weeks, researchers found dramatic improvements in the participants’ skin. Did Hyaluronic acid benefits all skin types.

 

Provides Incredible Moisture

  1. Hyaluronic acid’s main power move, and the reason it’s gained so much attention in skincare, is its amazing ability to deliver lasting moisture to the skin.
  2. HA is a humectant, which means it grabs moisture and holds it so skin can absorb it.
  3. 8. The hyaluronic acid molecule can hold up to 1000 times its weight in water!

 

  1. The HA molecule is too large to penetrate the top layer of skin. So, it sets up shop on your skin’s surface and gets to work grabbing and holding moisture so your skin can absorb it and stay healthy and hydrated.

 Anti-Aging Benefits

  1. As we age, our skin doesn’t maintain moisture as well as it used to. Babies are born with lots of hyaluronic acid in their skin, which is why it’s so soft.

When our skin loses its suppleness, it starts to sag and fine lines and wrinkles become more apparent.

  1. Diminishes Wrinkles– Applying hyaluronic acid on your face plumps up the skin to smooth out fine lines and wrinkles.
  2. Firms and Tones– When your skin is supple and hydrated, it plumps up to appear firmer, less saggy, and more toned.

HA restores skin’s moisture to temporarily turn back the clock and give your skin some oomph and youthful rejuvenation! 

Boosts Skin’s Health and Protection

  1. Improves Protective Barrier – When your skin is dry, its surface is more vulnerable to damage and even infection getting through.

By providing your skin’s outer layers with rich moisture, HA actually strengthens your skin’s protective barrier to give you stronger, healthier skin.

  1. Supports Healing– Likewise, HA supports your skin’s healing and repairing ability by giving skin soothing moisture and anti-inflammatory properties.
  2. 15. Antioxidant Defense– HA even gives your skin antioxidant defense to fight UV damage. This is important since free radicals can break down collagen and elastin to age our skin and make wrinkles and sagging more apparent.

 

How Do I Use Hyaluronic Acid in My Skincare?

  1. Hyaluronic acid is included as an ingredient in everything from makeup to serums to moisturizers. There are so many great ways to use it!
  2. Pro tip: To get the most bang for your buck, look for a formula that contains at least 1% hyaluronic acid. If it only includes something like 0.5%, you may not get the best efficacy.

 

HA Serum

  1. 18. If you want to get the most out of your HA usage, I would recommend a hyaluronic acid serum, especially if you have dry skin.

Serums typically have a thinner consistency and a more potent concentration of ingredients to deliver great results.

  1. 19. When using a serum, wait at least 15 minutes after applying for serum to completely absorb into skin before moving to the next step in your routine

HA Moisturizer

  1. 20. Another great way to get the benefits of hyaluronic acid is to use a moisturizer that includes HA to pack a hydration punch.

You can even double up by using both a serum and lotion that feature HA!

 

Are There Any Risks or Side Effects to Using Hyaluronic Acid?

  1. Because HA is naturally occurring in our bodies, it poses a pretty low risk for allergic reaction or irritation.
  2. Ironically, some users have reported that it dries out their skin, but this is rare. If you experience this, check to make sure you’re following the use instructions of your hyaluronic acid formula, or consult a dermatologist.
  3. As with any new skincare product, It is always recommended doing a patch testto see how your skin will react.

Apply a small amount of the product to the inside of your wrist or behind your ear. Wait 24-48 hours to make sure there’s no reaction before slathering that business over larger areas.

 

Is hyaluronic acid really worth using?

  1. Because it offers such lightweight hydration, HA is great for all skin types, including those with oilyor sensitive skin.
  2. Plus, we’re all aging. Even if you’re not concerned about wrinkles, you can still benefit from HA’s ability to hydrate and protect skin.
  3. And, hyaluronic acid is wonderful for restoring skin’s hydration year round. As we head into fall and winter months, cold, dry air, and heaters zap our skin’s moisture. In summer, heat and sun exposure totally dry us out.

Make sure you’re always replenishing skin’s hydration by using moisturizing skincare and drinking plenty of water.

 

Final Thoughts

Hyaluronic acid is a great skincare ingredient with so many wonderful benefits!

Whether you’re looking for ultra-hydration, diminishing those pesky fine lines, or boosting your skin’s health, HA has got your back.

But, even if you choose not to add it to your routine, make sure you’re always practicing the skincare that is best for your unique skin!