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Procedure: Fillers (Juvederm, Restylane, Radiesse, Sculptra)

Author: Min Ahn

Author: David W. Kim, MD FACS

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HA Fillers (Juvederm, Restylane)

Hyaluronic Acid Fillers (Juvederm, Restylane)

Since the introduction of bovine collagen for treating wrinkles, significant advances have been made with soft tissue fillers. Currently the most popular fillers in the United States for skin creases and volume deficient areas are the hyaluronic acid fillers (HA). The two most popular of such fillers are Juvéderm® Ultra and Restylane®. Both fillers have the advantages of being well tolerated by the body, long lasting and natural appearing.

 

Hyaluronic Acid (HA)

Hyaluronic acid is a naturally occurring carbohydrate that is present in human skin, soft tissue and joints. It is often referred to as the “ground substance” and provides lubrication to joints and helps to maintain skin hydration and turgor. During the normal course of the day, much or our native HA turns over and is restored naturally. Whereas early versions of HA fillers were derived from animals, both Juvederm and Restylane® are non-animal derived HA fillers and therefore do not carry the same risk for allergic reactions.

 

Restylane® was the first (2005) HA filler to be approved by the FDA for cosmetic injection into sub dermal facial tissues. It is a clear gel consisting of stabilized HA (20 mg/mL) and is meant to be placed in the mid to deep dermis. The material is well tolerated by the body and is broken down through natural mechanisms. Perlane®, which contains larger particles of HA than Restylane®, is meant to be placed in the deep dermis. Both last 6-9 months and both come in versions that contain an anesthetic agent (lidocaine) to reduce discomfort during the procedure (Restylane® L).  

 

Juvéderm® Ultra and Juvéderm® Ultra Plus consist of cross linked hyaluronic acid (HA) produced by Streptococcus equi bacteria, formulated to a concentration of 24 mg/mL. Both are meant to be placed in the mid to deep dermis though the Ultra Plus is typically placed deeper. Juvéderm® Ultra Plus has higher degree of cross linking and therefore lasts longer. Juvéderm® typically lasts around 1 year and Ultra Plus lasts between 1 - 1½ years. The cross linking results in a visibly smoother gel that also lasts longer than Restylane®. Both also come in versions containing lidocaine (Juvéderm® XC) to minimize discomfort during treatment.

 

HA Filler

 

Concentration HA

 

Cross-linking

 

Placement

 

Lasting Effect

 

Restylane®

 

20 mg/mL

 

No

 

Mid-deep dermis

 

6-9 months

 

Perlane®

 

20 mg/mL

 

No

 

Deep dermis

 

6-9 months

 

Juvéderm®

 

24 mg/mL

 

Yes

 

Mid-deep dermis

 

Up to 1 year

 

Juvéderm ® Ultra Plus

 

24 mg/mL

 

Yes

 

Mid-deep dermis

 

Up to 1 year

 

 

HA fillers will cause a stretching of the skin while in place which incites certain cells (fibroblasts) to make new collagen. Therefore, while the material is in place the treated area is improving biologically. Even after the material has worn off, patients will often note that the crease or wrinkle is better than it was before the original treatment.

 

Indications

All of the HA fillers are FDA approved for correction of moderate to severe facial wrinkles and folds (such as nasolabial folds). Nasolabial folds are the creases that span from the nose to the corner of the mouth. Both Perlane® and Juvéderm ® Ultra Plus are typically placed at a slightly deeper level of the skin. HA fillers are used frequently in off label manners to add volume to areas such as:

 

  1. Eyebrows- to inflate flattened brows

  2. Upper eyelids- to correct overly hollowed eyelids from previous surgery

  3. Lower eyelids (tear trough groove)- to fill hollow areas and correct the tired look

  4. Nose- to add height to the bridge and smooth out a bump

  5. Cheeks- to add volume to the “apples” and cheek bones

  6. Lips- to shape lips and fill lip lines

  7. Corners of the mouth- to correct the downturned/sad mouth

  8. Chin creases- to fill the horizontal groove

  9. Jawline- to minimize the appearance of jowls

  10. Skin creases- to smooth the skin

 

HA fillers are contraindicated in people with a history of severe allergic reactions (anaphylaxis) allergies to Gram-positive bacterial proteins and in an area with an active infection.

 

Treatment

The treatment is performed in an examination room and takes about 15-30 minutes. A qualified doctor, nurse, nurse practitioner or physician’s assistant may perform the treatment depending on the state. Injecting a filler causes more discomfort that a Botox® treatment and typically requires more passes of the needle as well. Therefore some form of anesthetic is used. If the HA filler does not already contain lidocaine, ice, numbing cream, numbing injections or a combination of the three are used. The area is cleaned with alcohol and may be marked prior to the numbing injection. In all areas except for the tear troughs, a retrograde threading technique is used, meaning that the material is injected in multiple small linear threads while the needle is being withdrawn.  The material should not be injected in a lump sum and then massaged into place. This will not result in a natural appearance. With tear trough treatments, the HA is usually placed using a serial point technique wherein it is injected along the rim of the lower eye socket at separate points. Lip injections require careful sculpting with small amounts placed precisely in order to avoid that “fish mouth” or “duck” appearance.

 

Recovery and Side Effects

Immediately afterwards, there will likely be redness of the skin and possibly some bruising. Redness resolves within 24-48 hours whereas bruising can last for several days. One can usually cover the area with makeup. Rarely does the patient feel discomfort after the procedure. Lumps and irregularities can occur as well and usually can be massaged out by the injector.  The HA fillers, particularly Juvéderm®, have a property (hygroscopic) that cause them to absorb water and swell. This may be noticeable initially and typically resolves within 1-2 weeks. Most patients are advised not to have the treatment done within 24 hours of an important event so as to avoid others noticing. Most patients feel comfortable appearing in public within 48 hours.

If the material is placed too close to the surface of the skin, light may be refracted and cause a bluish color, known as the Tyndall effect.  Proper depth of placement, as well as not filling excessively, will avoid this occurrence. If this does happen, or if there is simply too much filler placed, the HA can be dissolved using an agent called hyaluronidase. This enzyme breaks down the HA within 24-48 hours and can be used to correct poorly placed HA filler.

The safety of JUVÉDERM® for use during pregnancy, in breastfeeding females, or in patients under 18 years has not been established. Therefore most practitioners will not perform the treatment in such patients.

 

References

 

  1. Arch Dermatol. 2007 Feb;143(2):155-63. In vivo stimulation of de novo collagen production caused by cross-linked hyaluronic acid dermal filler injections in photodamaged human skin. Wang FGarza LAKang SVarani JOrringer JSFisher GJVoorhees JJ

  2. Aesthet Surg J. 2008 Jan-Feb;28(1):17-23. Juvéderm injectable gel: a multicenter, double-blind, randomized study of safety and effectiveness. Pinsky MAThomas JAMurphy DKWalker PSJuvéderm vs. Zyplast Nasolabial Fold Study Group.

Radiesse

Radiesse

Radiesse is long lasting soft tissue filler that is a popular choice for facial volumizing treatments. It is FDA approved for the correction of moderate to severe facial wrinkles and folds, such as nasolabial folds (laugh lines). Radiesse is composed of Calcium hydroxylapatite microspheres suspended in a gel carrier and high purity water. When Radiesse is injected into tissue it provides an immediate 1:1 level of correction. Over the course of 3-6 months, the gel carrier is degraded and the remaining Radiesse particles act as a scaffold for new collagen formation. This process is thought to account for extended, “semi-permanent” correction. 

 

Indications and Treatment

The most common sites for use of Radiesse in facial rejuvenation include deeper creases such as the nasolabial folds (laugh lines), corners of the mouth, and areas in need of volume: cheeks, jaw line, back of the hands and bridge of the nose. It has the consistency of a thick paste and therefore must be placed just below the skin or deeper in order to avoid visibility and nodularity. A typical treatment session takes 15 minutes and is performed in the doctor’s office by a qualified injector. The material is injected using a fanning technique with a cross hatching pattern. This allows for the most natural and smooth looking result. To minimize discomfort during the treatment the area is made numb with a nerve block using local anesthesia, or the local anesthesia is directly mixed with the Radiesse before injection.

 

After Treatment

Immediately after treatment the patient may use an ice pack to reduce bruising and swelling. Typically the patient can expect mild redness and swelling and varying degrees of bruising for 1-3 days. Usually this can be covered with makeup. Visible white nodules are a rare if the material is properly placed. Radiesse treatment should not be performed in areas showing signs of inflammation or infection.

 

Length of Effect

Most patients can expect the improvement to last up to one year after treatment. Some patients elect to have “touch up” treatments at 6-month intervals to maintain full correction after the gel matrix has dissolved. After the gel matrix has dissolved, the correction is due to the presence of the microspheres and the building of collagen on that “scaffolding”.

 

Summary

            Radiesse is a popular choice among aesthetic providers for facial volumization. Other choices include hyaluronic acid fillers  (Juvederm, Restylane) and poly L lactic acid (Sculptra). The choice of material is largely based on the clinician’s comfort level and the particular area/problem that needs treatment.

 

References:

  1. Sklar JA, White SM Radiance FN: a new soft tissue filler. Dermatol Surg. 2004 May;30(5):764-8; discussion 768

  2. Injectable calcium hydroxylapatite microspheres (Radiesse). Ridenour B, Kontis TC. Facial Plast Surg. 2009 May;25(2):100-5.

 

Sculptra

Sculptra

Commercially available fillers have seen recent increased popularity.  These office based treatments improve the appearance of unwanted wrinkles, folds, and areas of hollowing or deflation in the face.  The most commonly used fillers come in a paste or gel form and are introduced to the desired location under the skin surface through needle injection.   Collagen, hyaluronic acid, or hydroxyapatite are types of fillers available on the market.  These substances, which also naturally exist in the body, create a beneficial effect by direct addition of volume into specific areas.  A disadvantage of these products is the fact that they are reabsorbed by the body within 6-18 months after placement.  Although there are some non-absorbable, permanent products used, these have not gained the popularity of the absorbable fillers, likely due to concerns about the potential for long term or permanent complications.

 

Product Description

Sculptra®, or poly-l-lactic acid, is a unique filler as it creates volume enhancement through stimulation of collagen growth, rather than through direct volume addition.  In other words, Sculptra® creates filling by causing the body to thicken the skin and soft tissue into which it is injected.  The material is packaged in powder form in a small vial.  Prior to use, sterile water must be added so that the Sculptra® dissolves.  During injection, the areas treated will fill with the volume of the water and swelling caused by the treatment.  But within a few days as the water absorbs into the body, the skin and soft tissue will return to their pre-injection appearance.  Then, over the course of the next few weeks as the Sculptra® stimulates collagen growth, the treated area gradually fills.  Therefore the results are seen slowly over time.

 

Treatment

Typically 2-3 treatments, each separated by at least 4- 6 weeks, are necessary to treat most patients. The treatments are performed with our without topical anesthetic. Often local anesthesia is directly mixed into the product as an off label way of reducing discomfort. There is usually minimal swelling and bruising after the treatments and often the patient can return to normal social activity the next day.  Results last longer than the traditional absorbable fillers, evident for up to two years following treatment.  Touch-up injections may be administered as the effects of the Sculptra® start to go away.  Touch-ups may require less product than the initial treatment.  Physicians will commonly advise 5 minutes, 5 times a day for 5 days of massage (the “5” rule).

According to the manufacturer, the depth of injection of Sculptra® should be in the deep dermal tissue of the skin.  However deeper placement has been used effectively by most aesthetic providers.  Clinical safety and efficacy studies for aesthetic treatment have only been conducted on treatment of the folds and lines around the mouth and nose (nasolabial folds).  However, many practitioners use Sculptra® to provide volume enhancement over broader regions of the face.  In fact, the initial FDA-approved use of Sculptra® was to provide volume replacement for individuals with facial wasting syndromes such as HIV-lipo-atrophy.  Currently, “off-label” aesthetic augmentation of the cheeks, temples, and midface are all common performed with Sculptra®. 

 

Advantages

The main advantage of Sculptra® is the longer duration of effect.  Advocates tout the fact that a natural-appearing improvement occurs since Sculptra® causes the body to create its own thickening of soft tissue.  Disadvantages include the need for multiple sessions, the delay in seeing results, and higher cost for full treatment. 

 

Side Effects

The main complication described is the formation of lumps under the skin.  These irregularities are more likely to occur if the material is placed superficially close to the skin surface or if the Sculptra is not diluted and dissolved adequately in the water solution.  These lumps may resolve on their own or may need to be broken down with a needle or excised. More imflamed nodules can form as well but are rare. Both can be minimized with adequate massage of the treated area after treatment.

 

References

  1. Using poly-L-lactic acid (PLLA) to mimic volume in multiple tissue layers. Fitzgerald R, Vleggaar D J Drugs Dermatol. 2009 Oct;8(10 Suppl):s5-14. Review.