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List of Fillers

Bradley T. Kovach

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Fillers of List 115 Chapter

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116

Dermal Filler Pearls:

the Hyaluronic Acids

John R. Burroughs and Richard L. Anderson

Our preferred hyaluronic acid dermal fillers are Restylane, Perlane, and

Juvederm. Each of these has a very high safety profile and are easier to inject than Radiesse. They are outstanding for lip enhancement, including the vermillion border, perioral rhytids, and for less severe glabellar and nasolabial folds or as a superficial fine tuning to deeper filling with Radiesse. The newer, higher viscosity hyaluronic acids, however, are excellent for deep lip augmentation, nasolabial folds, and deep rhytid

lling.We have found excellent success treating nasojugal (“tear trough”) deformities with hyaluronic acids, which offers a nonsurgical option to cosmetic lower eyelid blepharoplasty (Figure 116.1). Patients require variable amounts depending on the desired outcome and severity of the folds. Injections deep (periosteally) or just below the orbicularis tend to cause less swelling and bruising below the eyes. The effects are potentiated by the concomitant application of Botox. We generally use the provided needle and find that direct injection with withdrawal of the needle as well as the described “feathering” technique both work well.

We routinely perform the infraorbital and mental nerve blocks as previously prescribed, as lip injections are quite painful. Premark the perioral rhytids prior to the nerve blocks to ensure optimal filling.

We have found that the hyaluronic acids last longer when Botox is also injected. We recommend that patients not aggressively massage any perceived irregularities, as this can worsen bruising and swelling and the patient may inadvertently overmassage the filler out of position. We advise patients to ice the areas a few hours following injections to reduce swelling. Injection to areas of high dynamicity (the perioral rhytids) will last less time that relatively adynamic areas, such as horizontal forehead rhytids or lower eyelid tear trough defects. Perlane and Juvederm Ultra Plus contain higher concentrations and reportedly last longer than the other hyaluronic formulations. Deep rhytids may further benefit by first performing subcision with a needle (e.g., 27-gauge) followed by placement of hyaluronic filler.

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117

Radiesse Pearls

John R. Burroughs and Richard L. Anderson

For deep glabellar and nasolabial folds, our preferred filler is Radiesse® Radiesse is calcium hydroxyapatite gel. Radiesse is an excellent dermal ller for severe folds, wrinkles that require large volumes and respond well to deep placement, which is critical with Radiesse. It is recommended to inject Radiesse below the dermis to avoid visibly noticeable lumps and irregularities. For the nasolabial folds, inject slightly medial to each nasolabial fold as the natural muscular action of the facial muscles will tend to lateralize the effect and can worsen the appearance of the

folds if not placed medially (Figure 117.1).

We inject with a 1.25-inch 27-gauge needle as the material is quite thick. A linear threading or fanning technique can be used to achieve linear filling or volumization. Mark the nasolabial folds prior to injection of a nerve block, which is preferred by most patients for nasolabial and lip augmentation. The nerve block is performed by injecting the upper and lower gingival sulcus with a 1.25-inch 27-gauge needle in line with the patient’s pupils, which will anesthetize the infraorbital and mental nerves. Use 1–2% lidocaine with epinephrine with 1–2 ml at each injection site. It is critical to premark the nasolabial folds prior to local anesthetic injection due to distortion of the tissues and to ensure slight medialization of the fi ller placement. A single syringe (1.3 cc) of Radiesse is adequate for most nasolabial folds. Some patients desire or require a second syringe at a later time to achieve an optimal result. In the glabellar areas a quarter to half a syringe is all that is required. Patients should be cautioned, and placement must be precise in the glabellar region as necrosis and or visual loss has been reported with intravascular injection of llers. In general, glabellar fold injections are not uncomfortable, and we do not inject local anesthetic, which distorts the target area. However, a small amoung (0.5 cc) of local may be injected for supratrochlear and suproorbital nerve blocks.Radiesse is not optimal for lip augmentation, as the patients often complain of lumps and irregularities. Caution must be exercised to avoid injecting Radiesse too superficially, which can cause skin necrosis. We have found Radiesse to give improvement for the reported 2 years in most of our patients.

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Juvederm Pearls: Fine and

Superficial Lines

John R. Burroughs and Richard L. Anderson

Juvederm is a newer nonanimal-based hyaluronic acid that has the advantage of lower viscosity allowing for easier injection. Juvederm is technically for filling minimal rhytids, particularly for perioral lines and for defining the vermillion border. It works very well to enhance the vermillion border as an adjunct to deeper lip augmentation with Restylane, Perlane, and Juvederm Ultra Plus. Superficial, fine lines may also be treated by fi rst performingsubcision with an injection needle (e. g., 27-gauge), followed by an injection of hyaluronic acid through a 32guage needle. The 32-gauge needle seems to thin the filler viscosity, enabling fine, super cial rhytid filling while avoiding lumps. Caution is needed with superficial filling to avoid skin color discoloration, and it is imperative to ensure that the needle is securely fastened to the luer-lock syringe to avoid accidental needle expulsion and potential ocular injury.1

Reference

1.Lin DJ, Sami MS, Burroughs JR, Soparkar CN, Patrinely JR. Ocular injury from local anesthetic injections: needle expulsion—the luer-lock allure. Arch Facial Plast Surg 2006;8:436.

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