Physician's pushing the limit with fillers, tissue augmentation

"At this point, I do believe that we have a good variety of products, and it is about time that we optimize their use. Now, the key question is how to use these fillers and push the limits, and see how far we can go. Today we are doing things in cosmetic dermatology that we could never have imagined we could do not too long ago," says Mariano E. Busso, M.D., chief of dermatology, Mercy Hospital, and voluntary assistant clinical professor, department of dermatology, University of Miami, Miami, Fla.

Dr. Busso says fillers are used in cosmetic dermatology for facial contouring as a rejuvenation procedure. The three tissue augmentation zones where they are used are the orbital, periorbital and temple area; the nasolabial, cheek and preauricular area; and the chin, prejowl and jawline area.

Tailored treatments

"JuvE9derm Ultra and JuvE9derm Ultra Plus (Allergan) are uniform gels and are monophasic, meaning that all the hyaluronic acid molecules are cross-linked. They offer a smooth flow but less of a lifting effect. Restylane on the other hand has more of a robust quality and more of a lifting effect," Dr. Busso says.

Restylane (Medicis) consists of about 100,000 U/ml, 250 millimicron gel bead size, and Perlane (Medicis) consists of 10,000 U/ml, 1,000 millimicron gel bead size. Dr. Busso cited one Food and Drug Administration clinical trial in which these two fillers were compared in the correction of nasolabial folds.

Results showed that at 24 weeks, the correction was maintained in 63 percent of Perlane-treated patients and 74 percent of patients who received Restylane.

"It appears that particle size does not affect longevity, but allows better tissue persistence in the subcutaneous layer," Dr. Busso explains.

Location plays large role

Depending on what area of the face Dr. Busso performs a contouring procedure, he picks and chooses among the various fillers available, such as polylactic acid, hyaluronic acid, calcium hydroxylapatite fillers and silicon. Dr. Busso says Restylane and JuvE9derm have a short-term effect (months); Radiesse (BioForm) and Sculptra (Dermik) have an intermediate-term effect (years); and silicon 1000 has a permanent effect.

"The periorbital skin is thin and, therefore, has a higher incidence of nodule formation post-injection. To avoid this complication when performing a temple/periorbital augmentation with poly-L-lactic acid, I can either dilute the filler, inject less, or inject periosteal," Dr. Busso says.

To achieve a dermal thickening in the region, he sometimes injects polylactic acid and Botox (Allergan) for a combined effect with excellent cosmetic results. Other procedures he does with fillers in the region include a browlift, suborbital augmentation (dark circles) and tear trough deformity correction (only with hyaluronic acid derivative).

The complications that can occur from a suborbital augmentation procedure include bruising, swelling, lumpiness, blue discoloration (Tyndall effect) and amaurosis (rare – 1/1,000,000). Dr. Busso says that aside from massaging the area to lessen the lumpiness, one can also use hyaluronidase solutions such as Amphadase (Amphastar) and Vitrase (ISTA), both being extremely effective in correcting this unwanted complication.

If amaurosis occurs, Dr. Busso says, the patient must be kept in the supine position and external ocular massage should be applied. To reduce the intraocular pressure, Diamox (Cerner Multum) or mannitol can be given intravenously.