Dermal Fillers

Hyaluronic Acid Fillers

Hyaluronic acid preparations revolutionized the injectable filler market for three main reasons: 

1. No need for skin test
2. Better durability compared to the other available biodegradable fillers and the availability of antidote (hyaluronidase). 
3. Immediate noticeable effect.

Hyaluronic acid, which belongs to the family of glycosaminoglycans, consists of repeated disaccharide units. The hydrophilic properties of hyaluronic acid attract water into the extracellular matrix and therefore increase the skin turgor. Hyaluronic acid is gradually degraded. In order to increase the durability of the various hyaluronic acid preparations, stabilization is usually obtained by cross-linking mostly with 1.4- butanediol diglycidyl ether (BDDE).

Below is the list of different HA products available in US

Restylane Group of Fillers

Restylane group of fillers are made by major pharmaceutical company Galderma. The fillers in this group are Restylane lyft, Restylane-L, Restylane Silk, Restylane Refyne and Restylane Defyne.

Restylane Silk is the first FDA-approved product specifically designed for lip augmentation and the smoothing of wrinkles around the mouth in patients 21 years of age and older.

Restylane Lyft Help complete your aesthetic look with natural-looking volume in your cheeks and hands for a smoother, fuller appearance. Restylane Lyft is a safe, effective and dissolvable HA filler. Treatment can be administered in your hands and face at the same appointment — and can result in a more youthful-looking appearance.

Restylane-L can be used to add volume and fullness to the skin to correct moderate to severe facial wrinkles and folds, such as the lines from your nose to the corners of your mouth (nasolabial folds). Restylane may also be used for lip enhancement. We also use this for tear trough injections.

Restylane Refyne is designed with XpresHAn Technology to help soften laugh lines (nasolabial folds and marionette lines). This can help you restore a more natural look to your face while maintaining your facial expressions.1-4 So, you always look like you. Talk to your specialist and see for yourself why it’s worth it.

Restylane Defyne Crafted with XpresHAn Technology, Restylane Defyne helps smooth out deep laugh lines (nasolabial folds and marionette lines). Using innovative cross-linking technology, Restylane Defyne is a hyaluronic acid dermal filler that is able to help restore a more youthful, natural-looking appearance, while helping you maintain your natural expressions.

Juvederm Group of Fillers

Juvederm has Ultra and Ultra + filler, the former gives softer plumper results and later is more robust. Both Ultra and Ultra+ are made by Hylacross technology, where large chain HA molecules are combined with BDDE Bonds. Juvederm group of fillers are made by a pharmaceutical company Allergan.

Juvederm Ultra is used mainly for soft, plumper lips, filling lip lines, fine line.

Juvederm Ultra plus is used for deeper nasolabial folds, and sometimes for lips for volume and firmness. 

Voluma, Volloure and Vobella are made with Vycorss technology where small and large molecular weight HA are combined which can increase the life of the fillers but also some what more difficult to dissolve with hyaluronidase an enzyme that breaks down BDDE Bonds.

Juvederm Voluma has high g prime and longevity up till 2 years when used in adequate amounts it is used for enhancing cheeks, temples, jaw line, chin.

Juvederm Vollore is firm but less g prime then Voluma, more flexible and is used for deep folds e.g. deep nasolabial folds, longevity up till 18 months.

Juvederm Vobella is the thinnest and softest HA gel with highest spread ability, used for subtle lip enhancement, lip lines, and could also be used for fine lines and tear trough injections.  

Belotero Balance

Belotero Balance is a sterile, bioresorbable, non-pyrogenic, viscoelastic, clear, colorless, homogeneous gel device. It is a bacterially fermented, injectable, hyaluronic-acid-based dermal filler. After extraction and purification, hyaluronic acid manufactured from streptococcal cultures is cross-linked with a binding agent 1,4-butanediol diglycidyl ether (BDDE) in two consecutively executed reactions and reconstituted in a physiologic buffer at pH 7 and concentration of 22.5 mg/mL. It could be used for fine lines, lip enhancement, NLF, and tear trough injections. It is made by Merz Aesthetics.

Versa

Revanesse versa is a relatively newer HA gel, is made with special wet milling technology producing more even gel particles in size. The gel is softer and manufacturer claims less swelling, could be used for lips, lip lines, nasolabial folds, tear troughs. It comes with and without lidocaine and in 1ml and 1.2 ml size syringes. 

Sculptra Aesthetics

Poly-l-lactid acid (PLLA) is a synthetic biodegradable material. It has a unique collagen stimulating quality. When injected into the dermis or subdermis, it gradually stimulates collagen formation and by this restructures the facial tissue, making it a facial volumizer. This is a gradual process, and the it is recommended three initial treatment sessions, each approximately 6–8 weeks apart. After the three initial treatments, the results are supposed to last for up to 2 years but much longer for most of the patients. This product comes as a powder and needs to be diluted with sterile water several hours before injection and add an additional 2 ml of a local anesthetic to decrease injection pain. 

Since the mechanism of volumization is by production of natural collagen which is a slow process some results are noticed during 6-8 week follow up meeting, but most effect is noticed starting 3 months. Additional Hyaluronic acid filler may be needed in the interim if immediate effect is desired. 

An average person in age of mid 40’s may need about 2 vials/treatment session and about 4-7 vials in  total. During the treatment multiple area of concern starting top down hollow temples, cheek bones, nasolabial folds, under the cheek hollows, jaw line can be approached each session. Most of the treatment is done using blunt tip cannula and could be done form 1-2 points of entry for the full face.

Other than any immediate complication of the filler injection, sculptra particles concentrated in one area can cause nodularity, the nodules resolve spontaneously but it can take from 1-2 years. The incidence of nodules has very significantly reduced with recent higher volume solutions, avoiding injections in the hyperdynamic areas like lips, and massage post treatment. 

 Sculptra massage post treatment is an important homework that clients must follow post treatment, this massage is done for each side of the face for five minutes, five time a day for five days i.e. 5-5-5 rule as pneumonic, this significantly reduces concentration of the sculptra particles at a single point and also redistribute to areas lifting is more desired. 

Radiesse

Radiesse is made from synthetically formed calcium phosphate pearls, a procedure that is classified as bioceramics and involves the ionic bonding of calcium and phosphate ions. When injected, they form a foundation within a matrix that allows the local cellular infiltration of fibroblasts. The complex is available as a gel to allow easier application. The complex has very high G- prime and hence very high lifting capability of the tissues, the CaHa spheres do stimulate collagen generation which increases overall duration of the effect. This product could be used for lifting sagging cheeks, fill in to lift nasolabial folds, fill in hollow temples. For its collagen generating effect the product in hyper diluted form could be used to improve skin quality, fine lines and wrinkles. The product is not recommended to use for tear trough area that is under the eye hollows, in the lips or very superficially. 

Bellafill

Bellafill is an implant composed of non-resorbablepolymethylmethacrylate (PMMA) microspheres, 30to50 microns in diameter, suspended in a water-based carrier gel composed of 3.5% bovine collagen, 92.6% buffered, isotonic water for injection, 0.3% lidocaine. While the collagen resorbs over a period of 2–3 months, the PMMA spheres become encapsulated by fibrotic material. Bellafill® is indicated for the correction of nasolabial folds and moderate to severe, atrophic, distensible facial acne scars on the cheek in patients over the age of 21 years. 

Due to presence of the Bovine Collagen a skin test is needed prior to the treatment. The skin is tested by injecting a tiny amount of test material bovine collagen just under the skin with normalizes totally in about a day with no reaction. An actual treatment can only be performed 1 month after this initial test unless this test has been done in a different clinic with the evidence of same or Bellafill injection done in the past.

1. When Bellafill is injected, the PMMA and collagen gel provides immediate correction.
2. Over time the collagen gel dissipates, and fibroblasts migrate in and around the PMMA microspheres.
3. The PMMA microspheres act as a scaffold around which fibroblasts deposit the patient’s own collagen.