TYPES OF INJECTABLE FILLERS
BOTOX® COSMETICS
Botox® Cosmetics is a purified protein, botulinum A toxin, made from botulism bacteria. The solution causes temporary paralysis of the muscles injected, so that they cannot contract.
It is this ability to block the muscle from contracting, that has propelled Botox as one of the most popular forms of cosmetic and esthetic treatments in the world.
It is a very effective method for reducing wrinkles, primarily those wrinkles known as dymamic, because they are caused by repetitive contraction of the underlying muscle. By blocking the neuromuscular connection to that muscle, it becomes unable to contract for a period of time, allowing the skin above it time to relax, and thus helps to decrease those wrinkles.
This is why Botox can be used to smooth out many of the wrinkles of the face and neck, and particularly those more dynamic wrinkles on the forehead, mouth and eyes, in a more targeted manner, dramatically changing the patient's look.
Besides the cosmetic uses of Botox, many others have been found. It is being used for the treatment of excessive sweating of the palms of the hands and underarms. It is also being used in the treatment of some forms of migraine headaches, neck muscle problems, different eye muscle disturbances, and it has also been FDA approved in the treatment of chronic arthritis (osteoarthritis) of the knee joints, when surgery is not recommended or not feasible.
Many other medical problems are being treated with Botox, with significant success, and many other problems may be found to be helped by the use of Botox.
ARTEFILL | COSMODERM | COSMOPLAST | ZYDERM | ZYPLAST
Collagen is a natural component of the skin. It can be obtained from cows (bovine collagen), from human cadavers, or your own body.
Injections can give your skin the necessary collagen to minimize fine lines and wrinkles and to redefine the size and shape of your lips. Depending upon its source, skin testing may be needed prior to its use. With all forms of collagen, occasional and temporary swelling can occur. Cutaneous necrosis and blindness have been described when injected in the glabellar region (between the eyebrow region), but these adverse reactions can occur with any filler or substance injected in that area.
Bovine collagen (Zyderm and Zyplast) was the most frequently used temporary filler until the introduction of newer, non-animal derived hyaluronic acid fillers such as Restylane and Juvederm. The non-animal hyaluronic acid fillers do not require skin testing, and do not have the potential for allergic reactions of its predecessors. In the case of bovine collagen-derived products, soft tissue swelling, bruising are not uncommon, like with most other fillers, but the potential for allergic reactions are there and skin testing has to be done prior to their use.
Recently, human-derived collagen (Cosmoderm and Cosmoplast) has been introduced. Cosmoderm is used mainly for superficial lines and wrinkles. Cosmoplast, because of its cross-linking, can be used for deeper wrinkles. They do not require skin testing, and results typically last 6 to 12 months and side effects are usually swelling and bruising, as with most other fillers, and usually lasting for short periods of time.
Artefill
Artefill was FDA approved for use in the United States in 2007. Because this dermal filler contains lidocaine, the injection is less painful compared with other dermal fillers that do not contain lidocaine.
This dermal filler is indicated for the correction of the nasolabial folds, although it has been used for acne scars and forehead furrows. Using a 26-gauge needle, Artefill should be injected directly beneath the skin fold into the deep dermis and not into the subcutis. Most practitioners prefer a threading injection technique.
Unlike the other dermal fillers, this dermal filler should be considered a permanent dermal filler.
Because this product contains bovine collagen, skin testing must be performed prior to treatment, as would be indicated with Zyderm or Zyplast. Because results are permanent, it is often best not to try to achieve full correction in one session, but to accomplish the desired result over several treatment sessions. In addition to allergy, other adverse effects may include lumpiness, persistent swelling or redness, and increased sensitivity at the injection site.
CAPTIQUE | HYLAFORM | JUVEDERM | PERLANE | RESTYLANE
Restylane is an FDA-approved non-animal-stabilized hyaluronic acid derivative used for soft tissue augmentation. It is derived from bacteria that produce hyaluronic acid. It is used to treat wrinkles and scars and for lip augmentation. This dermal filler has been used for correction of the nasolabial folds, marionette lines, tear troughs, and glabellar frown lines, in addition to lip enhancement and cheek augmentation. Other clinical uses include correction of the jowls and nasal deformities. In general, most patients can expect 6 months of correction, if not longer.
Adds natural volume as it integrates into the dermal tissue; then, attracts and binds water molecules to help maintain volume.
Perlane is also a hyaluronic acid derivative, but it is a more resistant to breakdown and it is used in the deep dermis and at the dermal-fat junction.
Being hyaluronic acid derivatives similar to Hylaform Gel, Restylane and Perlane have less risk of clumping and go in more smoothly.
This dermal filler is identical to Restylane except that it consists of larger gel particles. This dermal filler is suitable for the correction of deeper folds, such as the nasolabial folds, and works well for cheek enhancement. Additionally, some experienced physicians prefer this dermal filler for lip augmentation over Restylane. Most patients can expect 6-12 months of correction with Perlane.
Expect more bruising and pain compared with the collagen fillers. Erythema and edema are common after treatment and typically last a few days. As with collagen, patients should avoid all blood thinners for 10 days prior to treatment.
Juvederm (Juvederm Ultra/Juvederm Ultra Plus)
In 2006, the FDA approved Juvederm, which is also a nonanimal stabilized hyaluronic dermal filler. In the United States, only 2 types of Juvederm dermal fillers are FDA approved. Both Juvederm Ultra and Juvederm Ultra Plus contain 24 mg/mL of hyaluronic acid, but Juvederm Ultra Plus has a higher proportion of cross-linking than Juvederm Ultra. Juvederm is a homologous gel with the highest degree of cross-linking of any of the hyaluronic acid fillers and thus has a smooth consistency. Juvederm Ultra and Juvederm Ultra Plus have indications similar to those of Restylane and Perlane, respectively, and also do not require refrigeration or skin tests prior to use.
The adverse effects of Juvederm are similar to those seen with Restylane and Perlane. Like all of the hyaluronic acid filling agents that are FDA approved, Juvederm does not contain lidocaine. Therefore, in addition to discomfort with injection, one may see erythema, swelling, and bruising.
One can expect the treatments with Juvedern Ultra to last between 6-12 months and with the Ultra Plus product between 9-12 months.
Hylaform/Hylaform Plus
A sterile, nonpyrogenic, clear gel implant composed of cross-linked molecules of hyaluronic acid derived from an avian (bird) source. Hylaform Plus contains larger molecules of the same concentration of Hylaform. The indications for Hylaform and Hylaform Plus are similar to Juvederm Ultra and Juvederm Ultra Plus, respectively.
These dermal fillers have precautions similar to those of Restylane and Perlane. Additionally, because this dermal filler is derived from an avian (bird) source, persons with a known allergy to avian proteins should not be treated with these dermal fillers. The Hylaform dermal fillers are stored at room temperature and no skin test is required before use.
Treatment is expected to last between 3-6 months.
Captique
This dermal filler is identical to Hylaform except that it is derived from a bacterial source through fermentation.
This dermal filler is slightly stiffer than Hylaform.
Captique is stored at room temperature and no skin test is required before use. Treatments will last approximately 4 months.
Prevelle Silk
This dermal filler was FDA approved for use in the United States in 2008 and is the only hyaluronic acid dermal filler that contains lidocaine, which reduces pain upon injection.
Prevelle Silk is indicated for the treatment of moderate-to-severe facial wrinkles, although it may be better suited for fine lines. Injection into the mid-to-deep dermis is recommended by Mentor, the manufacturer.
Similar to other hyaluronic dermal fillers, the most common adverse effects include temporary injection site reactions such as swelling, pain, tenderness, redness, lumps, and bumps.
Treatments last about 6 months.
SCULPTRA | RADIESSE
Sculptra
The biochemical characteristics of this polymer are believed to stimulate fibroblasts to produce more collagen, thus increasing facial volume. In the United States, poly-L-lactic acid is only FDA approved for the treatment of HIV-induced lipoatrophy, although it is routinely used for the correction of skin folds, ie, nasolabial folds.
Because poly-L-lactic acid is not a true filler, but relies on new collagen formation to achieve clinical improvement, the clinical results from this agent are less predictable than the true dermal fillers. Patients should be properly educated that results take 4-6 weeks to be appreciated. Dermal nodules have been reported after treatment and often take 7 months or much longer to develop. When treating the face, these nodules can often be felt, but not seen. Reconstitution of the product with 6 or more milliliters of sterile water, in addition to vigorous post-treatment massage, is believed to reduce the incidence of nodule formation.
No skin test is required prior to treatment. The product is stored at room temperature, although it must be reconstituted prior to treatment. Treatments can last up to one year.
Radiesse
Was FDA approved in December 2006 for the correction of facial wrinkles and folds and for the correction of HIV-associated facial atrophy. The dermal filler is composed of 30% calcium hydroxylapatite and 70% carrier gel. The clinical results may last as long as 12 months. Radiesse is nearly always injected subdermally at the dermal-subcutaneous junction, thus this product is not a true dermal filler. Most commonly, Radiesse is used for the correction of nasolabial folds, atrophic cheeks, and temporal wasting. Because of the pain associated with injection, some practitioners add lidocaine to the syringe, without a clinical appreciable decrease in effect. Without the addition of lidocaine, discomfort upon injection can be mild to moderate.
Injection into the dermis may result in nodule formation and should be avoided. Extreme care must be taken to avoid injection while withdrawing the needle out of the skin, which will result in the deposition of material into the dermis. Treatment of the lips has resulted in cyst formation containing the carrier gel.3 For this reason, most cosmetic surgeons avoid treating the lips with Radiesse.
No skin test is required prior to treatment, and the product is stored at room temperature.
