Dr. Beer recommends that dermatologists master the use of Restylane before advancing to the use of Perlane, which is less forgiving.`
National report - Injectable fillers for soft tissue augmentation have multiplied to the point where physicians now can customize treatments to meet patients' needs and desires.
"Two or three years ago, we were using collagen, fat or nothing," says Kenneth Beer, M.D., director, Palm Beach Esthetic Institute, and clinical instructor of dermatology, University of Miami. "Now people come in and, based on their individual needs and budgets, I have a palette of about 20 products I can use."
Most noteworthy among these offerings are several novel products that recently have reached the marketplace.
"Sculptra (Dermik/Aventis) is the first of a new class of injectables called volume replacement therapy," Dr. Beer tells Dermatology Times. "Instead of injecting 1 ml of Restylane (QMed/Medicis) and achieving 1 ml of correction, for example, Sculptra actually stimulates the body to produce collagen. So it's a much more long-lasting fill. Sculptra is a totally novel concept that I believe holds great potential."
Called New-Fill in most countries, Sculptra consists of injectable poly-L-lactic acid. Currently, it's the only product approved by the Food and Drug Administration for treating lipoatrophy in patients with HIV.
Dr. Beer says that, off-label, "It's great for treating hollowed-out cheekbones in patients without HIV, and nasolabial creases. But it's really bad for lip augmentation" because it can create the delayed appearance of small bumps (usually palpable rather than visible) in the area treated.
In the next few months, Dr. Beer and his colleagues will begin conducting a trial of Sculptra for treating moderate to severe acne scars.
Growing hyaluronic market
The hyaluronic acid filler category also is expanding. Options in this area include animal-based and non-animal-sourced hyaluronic acid (NASHA) preparations.
In the former area, Dr. Beer says, "Hylaform and Captique (Inamed), because of their lower viscosity and lower concentrations of hyaluronic acid, are perfect for lip augmentation. They tend to be very smooth and easy to inject."
Captique, which won FDA approval late last year, represents the newest entry to the NASHA category. Also in this category are Restylane and Perlane (QMed/Medicis), which Dr. Beer considers ideal for treating nasolabial creases and for a procedure he calls the injectable facelift. Perlane is not presently approved for use in the United States, but approval is expected in the near future.
"We will add Restylane and Perlane to the zygomatic arches and try to pull the face up by 1 or 2 millimeters," he explains. "The results are phenomenal. And I will use Restylane for lip augmentation, although I caution my patients that it can cause lumps and bumps that are transient."
The main difference between Restylane and Perlane is particle size - 100,000 and 10,000 per milliliter, respectively. Both are biodegradable and require no overcorrection. Restylane, the injectable filler Dr. Beer uses most frequently, lasts six to nine months and must be injected deep into the dermis. He recommends mastering the use of Restylane before advancing to Perlane. That's because Perlane is a less forgiving filler than Restylane. Radiesse (formerly Radiance, BioForm Medical) also works well for nasolabial creases.
"It's great for treating marionette lines and for buttressing the corners of the mouth," Dr. Beer explains. "However, it is contraindicated for use in the lips in most instances because it tends to form granulomas there."
Radiesse consists of calcium hydroxylapatite particles measuring between 25 and 125 microns in an aqueous gel carrier made of carboxymethyl cellulose, glycerin and water. Once implanted, the gel is absorbed, allowing cells from surrounding tissue to grow into the scaffolding provided by the particles.
The silicone debate
Silicone, on the other hand, has sparked much controversy.