Choosing the Right Filler Comes With Experience

BOSTON — Cosmetic dermatologists have the knowledge and training to choose the right fillers that will garner the best results, according to Dr. Mary Lupo.

"Every FDA-approved filler, in my opinion, has an appropriate indication. You just need to know the relative strengths and weaknesses," said Dr. Lupo, at the American Academy of Dermatology's Academy 2009 meeting.

Optimal results require an appropriate candidate, the choice of an appropriate product based on the patient's presentation, injection of a sufficient amount of product, the right complementing procedures, and maintenance of the effect with touch-ups, said Dr. Lupo, professor of dermatology at Tulane University in New Orleans.

Treating Older Patients

In general, older patients need more volume restoration, because their immune response is decreased. "So when one has an active filler, such as poly-L-lactic acid, the older patient may have less of an immune response to give you a final result," she said. However, the corollary is that the older patient may require so much volume with other fillers that it becomes financially unfeasible.

"Older patients always need complementing procedures to get a good result," she said.

When examining the defect being considered for correction, decide whether it is a line or a fold. Lines require less viscous fillers to avoid lumpiness. "When a skin fold is more redundant, however, you need a thicker, more structural filler in order to lift the fold." When working with folds, Dr. Lupo recommends improving the area superior to the fold in addition to filling the fold.

When talking with the patient, "it's important to point out that it really doesn't do much good to fill a line if the overall photoaging is so severe and the 'canvas of the skin' is so mottled and deformed that it will not give an overall improvement," she said. Fillers can be used adjunctively with other methods to achieve better results.

Filler Contraindications

Many of the hyaluronic acid (HA) fillers are manufactured from a streptococcal fermentation process, so ask about hypersensitivity to strep, she said. Some patients have sensitivity to lidocaine. If this is the case, avoid using Prevelle Silk, CosmoDerm, and CosmoPlast. Poly-L-lactic acid is a component of Vicryl sutures, so if a patient has a history of allergic reaction to these sutures, avoid using Sculptra.

The use of anticoagulants by a patient is not necessarily a contraindication, "but it certainly behooves you to discuss the incidence of bruising that might be significant in these patients," Dr. Lupo said. For smokers wanting fillers, she uses a consent form to make these patients aware of the increased risk of necrosis.

Managing Expectations

The issue of cost also should be part of the discussion. Older patients will need more filler, meaning that temporary fillers may not be as cost effective over time. Semipermanent fillers may offer more benefit and it might be worth considering permanent.

To get the most out of a filler, complementing procedures should be considered. Such procedures can include onabotulinumtoxinA (Botox), intense pulsed light, chemical peel, nonablative laser, and ablative laser. "At the end of the day, the more procedures that a patient can afford, the better they will look," Dr. Lupo noted.

The Fillers

▸ CosmoDerm and CosmoPlast (human collagen). These products are the best choice for immediate results. They are great for lining the lips and for fine perioral lines, and both are fairly painless. They have a short duration, however, and both will be discontinued in 2010, according to Dr. Lupo.

▸ Restylane (HA gel). The filler is versatile and can be reversed by using hyaluronidase. It also can be injected with a finer-gauge needle, which reduces pain and allows treatment of finer lines. One injection lasts about 6 months, but it can last longer with touch-ups. Swelling and bruising should be considered, she said.

▸ Perlane (HA gel). This filler is a larger-particle gel suspension of HA. It is typically used for nasolabial folds and cheeks, and it can be used for lips with good technique to avoid lumping. "I have not found that the duration is any better than with Restylane," said Dr. Lupo.

▸ Juvéderm Ultra and Juvéderm Ultra Plus (cross-linked HA). This product is malleable and soft. It is also great for lips; however, because it is so malleable, it is not the best choice for defining the lip border. This filler is also reversible. "It is a little bit harder to get through a 1-inch needle," she said. Duration is 7-9 months without touch-ups.

Juvéderm Ultra Plus is the same as Juvéderm Ultra, although increased crosslinking of HA results in improved longevity—up to 1 year without touch-ups. "It's never to be used in fine lines, in my opinion," Dr. Lupo said. It is best injected with a 30-gauge needle. This filler is extremely good in skin of color.

▸ Prevelle Silk (cross-linked HA and lidocaine). The added lidocaine decreases patient discomfort. There is very little swelling because of the low HA concentration, but as a result it does not last as long—3 months or less. "It's inexpensive, and it's a good introductory filler for the hesitant patient," she said.

▸ Elevess (cross-linked HA and lidocaine). Elevess has the highest concentration of HA available on the market. "My personal opinion, based on my limited experience with it, is that it tends to be highly inflammatory as a result of this high concentration of HA," she said.

▸ Radiesse (calcium hydroxylapatite). This structural filler is great for men. It does cause a lot of same-day redness. "I do routinely mix it with lidocaine, and that is now FDA approved and has been found not to decrease its longevity," she said. It's a good choice for marionette lines and the pre-jowl sulcus, but avoid using it for the lips, she said.

▸ Sculptra (poly-L-lactic acid). The FDA cleared Sculptra this year for cosmetic purposes—correction of mild-to-severe nasolabial folds and wrinkles and contour irregularities. "The optimal patient for this is a younger lipoatrophy patient, because these patients still have enough of an immune response to actually get a good bang for the buck," she said. This filler is not reversible. The most common problem with Sculptra is the presence of nodules if it is injected too superficially, said Dr. Lupo.

▸ Evolence (porcine collagen). "In my opinion, it's a stiffer, more structural filler," she said. It works well in the nasolabial folds. Dr. Lupo always mixes it with lidocaine, though this makes it flow more quickly, so she uses a 30-gauge needle. It is a good choice for men with thick skin. Evolence has a low incidence of bruising and swelling.

Dr. Lupo reported significant financial relationships with a number of pharmaceutical and skin care companies.

A patient is shown before treatment with one syringe of Restylane.

The effect was prolonged for 3.5 years by performing periodic touch-ups.

Source Photos courtesy Dr. Mary Lupo

BOSTON — Cosmetic dermatologists have the knowledge and training to choose the right fillers that will garner the best results, according to Dr. Mary Lupo.

"Every FDA-approved filler, in my opinion, has an appropriate indication. You just need to know the relative strengths and weaknesses," said Dr. Lupo, at the American Academy of Dermatology's Academy 2009 meeting.

Optimal results require an appropriate candidate, the choice of an appropriate product based on the patient's presentation, injection of a sufficient amount of product, the right complementing procedures, and maintenance of the effect with touch-ups, said Dr. Lupo, professor of dermatology at Tulane University in New Orleans.

Treating Older Patients

In general, older patients need more volume restoration, because their immune response is decreased. "So when one has an active filler, such as poly-L-lactic acid, the older patient may have less of an immune response to give you a final result," she said. However, the corollary is that the older patient may require so much volume with other fillers that it becomes financially unfeasible.

"Older patients always need complementing procedures to get a good result," she said.

When examining the defect being considered for correction, decide whether it is a line or a fold. Lines require less viscous fillers to avoid lumpiness. "When a skin fold is more redundant, however, you need a thicker, more structural filler in order to lift the fold." When working with folds, Dr. Lupo recommends improving the area superior to the fold in addition to filling the fold.

When talking with the patient, "it's important to point out that it really doesn't do much good to fill a line if the overall photoaging is so severe and the 'canvas of the skin' is so mottled and deformed that it will not give an overall improvement," she said. Fillers can be used adjunctively with other methods to achieve better results.

Filler Contraindications

Many of the hyaluronic acid (HA) fillers are manufactured from a streptococcal fermentation process, so ask about hypersensitivity to strep, she said. Some patients have sensitivity to lidocaine. If this is the case, avoid using Prevelle Silk, CosmoDerm, and CosmoPlast. Poly-L-lactic acid is a component of Vicryl sutures, so if a patient has a history of allergic reaction to these sutures, avoid using Sculptra.

The use of anticoagulants by a patient is not necessarily a contraindication, "but it certainly behooves you to discuss the incidence of bruising that might be significant in these patients," Dr. Lupo said. For smokers wanting fillers, she uses a consent form to make these patients aware of the increased risk of necrosis.

Managing Expectations

The issue of cost also should be part of the discussion. Older patients will need more filler, meaning that temporary fillers may not be as cost effective over time. Semipermanent fillers may offer more benefit and it might be worth considering permanent.

To get the most out of a filler, complementing procedures should be considered. Such procedures can include onabotulinumtoxinA (Botox), intense pulsed light, chemical peel, nonablative laser, and ablative laser. "At the end of the day, the more procedures that a patient can afford, the better they will look," Dr. Lupo noted.

The Fillers

▸ CosmoDerm and CosmoPlast (human collagen). These products are the best choice for immediate results. They are great for lining the lips and for fine perioral lines, and both are fairly painless. They have a short duration, however, and both will be discontinued in 2010, according to Dr. Lupo.

▸ Restylane (HA gel). The filler is versatile and can be reversed by using hyaluronidase. It also can be injected with a finer-gauge needle, which reduces pain and allows treatment of finer lines. One injection lasts about 6 months, but it can last longer with touch-ups. Swelling and bruising should be considered, she said.

▸ Perlane (HA gel). This filler is a larger-particle gel suspension of HA. It is typically used for nasolabial folds and cheeks, and it can be used for lips with good technique to avoid lumping. "I have not found that the duration is any better than with Restylane," said Dr. Lupo.

▸ Juvéderm Ultra and Juvéderm Ultra Plus (cross-linked HA). This product is malleable and soft. It is also great for lips; however, because it is so malleable, it is not the best choice for defining the lip border. This filler is also reversible. "It is a little bit harder to get through a 1-inch needle," she said. Duration is 7-9 months without touch-ups.

Juvéderm Ultra Plus is the same as Juvéderm Ultra, although increased crosslinking of HA results in improved longevity—up to 1 year without touch-ups. "It's never to be used in fine lines, in my opinion," Dr. Lupo said. It is best injected with a 30-gauge needle. This filler is extremely good in skin of color.

▸ Prevelle Silk (cross-linked HA and lidocaine). The added lidocaine decreases patient discomfort. There is very little swelling because of the low HA concentration, but as a result it does not last as long—3 months or less. "It's inexpensive, and it's a good introductory filler for the hesitant patient," she said.

▸ Elevess (cross-linked HA and lidocaine). Elevess has the highest concentration of HA available on the market. "My personal opinion, based on my limited experience with it, is that it tends to be highly inflammatory as a result of this high concentration of HA," she said.

▸ Radiesse (calcium hydroxylapatite). This structural filler is great for men. It does cause a lot of same-day redness. "I do routinely mix it with lidocaine, and that is now FDA approved and has been found not to decrease its longevity," she said. It's a good choice for marionette lines and the pre-jowl sulcus, but avoid using it for the lips, she said.

▸ Sculptra (poly-L-lactic acid). The FDA cleared Sculptra this year for cosmetic purposes—correction of mild-to-severe nasolabial folds and wrinkles and contour irregularities. "The optimal patient for this is a younger lipoatrophy patient, because these patients still have enough of an immune response to actually get a good bang for the buck," she said. This filler is not reversible. The most common problem with Sculptra is the presence of nodules if it is injected too superficially, said Dr. Lupo.

▸ Evolence (porcine collagen). "In my opinion, it's a stiffer, more structural filler," she said. It works well in the nasolabial folds. Dr. Lupo always mixes it with lidocaine, though this makes it flow more quickly, so she uses a 30-gauge needle. It is a good choice for men with thick skin. Evolence has a low incidence of bruising and swelling.

Dr. Lupo reported significant financial relationships with a number of pharmaceutical and skin care companies.

A patient is shown before treatment with one syringe of Restylane.

The effect was prolonged for 3.5 years by performing periodic touch-ups.

Source Photos courtesy Dr. Mary Lupo

BOSTON — Cosmetic dermatologists have the knowledge and training to choose the right fillers that will garner the best results, according to Dr. Mary Lupo.

"Every FDA-approved filler, in my opinion, has an appropriate indication. You just need to know the relative strengths and weaknesses," said Dr. Lupo, at the American Academy of Dermatology's Academy 2009 meeting.

Optimal results require an appropriate candidate, the choice of an appropriate product based on the patient's presentation, injection of a sufficient amount of product, the right complementing procedures, and maintenance of the effect with touch-ups, said Dr. Lupo, professor of dermatology at Tulane University in New Orleans.

Treating Older Patients

In general, older patients need more volume restoration, because their immune response is decreased. "So when one has an active filler, such as poly-L-lactic acid, the older patient may have less of an immune response to give you a final result," she said. However, the corollary is that the older patient may require so much volume with other fillers that it becomes financially unfeasible.

"Older patients always need complementing procedures to get a good result," she said.

When examining the defect being considered for correction, decide whether it is a line or a fold. Lines require less viscous fillers to avoid lumpiness. "When a skin fold is more redundant, however, you need a thicker, more structural filler in order to lift the fold." When working with folds, Dr. Lupo recommends improving the area superior to the fold in addition to filling the fold.

When talking with the patient, "it's important to point out that it really doesn't do much good to fill a line if the overall photoaging is so severe and the 'canvas of the skin' is so mottled and deformed that it will not give an overall improvement," she said. Fillers can be used adjunctively with other methods to achieve better results.

Filler Contraindications

Many of the hyaluronic acid (HA) fillers are manufactured from a streptococcal fermentation process, so ask about hypersensitivity to strep, she said. Some patients have sensitivity to lidocaine. If this is the case, avoid using Prevelle Silk, CosmoDerm, and CosmoPlast. Poly-L-lactic acid is a component of Vicryl sutures, so if a patient has a history of allergic reaction to these sutures, avoid using Sculptra.

The use of anticoagulants by a patient is not necessarily a contraindication, "but it certainly behooves you to discuss the incidence of bruising that might be significant in these patients," Dr. Lupo said. For smokers wanting fillers, she uses a consent form to make these patients aware of the increased risk of necrosis.

Managing Expectations

The issue of cost also should be part of the discussion. Older patients will need more filler, meaning that temporary fillers may not be as cost effective over time. Semipermanent fillers may offer more benefit and it might be worth considering permanent.

To get the most out of a filler, complementing procedures should be considered. Such procedures can include onabotulinumtoxinA (Botox), intense pulsed light, chemical peel, nonablative laser, and ablative laser. "At the end of the day, the more procedures that a patient can afford, the better they will look," Dr. Lupo noted.

The Fillers

▸ CosmoDerm and CosmoPlast (human collagen). These products are the best choice for immediate results. They are great for lining the lips and for fine perioral lines, and both are fairly painless. They have a short duration, however, and both will be discontinued in 2010, according to Dr. Lupo.

▸ Restylane (HA gel). The filler is versatile and can be reversed by using hyaluronidase. It also can be injected with a finer-gauge needle, which reduces pain and allows treatment of finer lines. One injection lasts about 6 months, but it can last longer with touch-ups. Swelling and bruising should be considered, she said.

▸ Perlane (HA gel). This filler is a larger-particle gel suspension of HA. It is typically used for nasolabial folds and cheeks, and it can be used for lips with good technique to avoid lumping. "I have not found that the duration is any better than with Restylane," said Dr. Lupo.

▸ Juvéderm Ultra and Juvéderm Ultra Plus (cross-linked HA). This product is malleable and soft. It is also great for lips; however, because it is so malleable, it is not the best choice for defining the lip border. This filler is also reversible. "It is a little bit harder to get through a 1-inch needle," she said. Duration is 7-9 months without touch-ups.

Juvéderm Ultra Plus is the same as Juvéderm Ultra, although increased crosslinking of HA results in improved longevity—up to 1 year without touch-ups. "It's never to be used in fine lines, in my opinion," Dr. Lupo said. It is best injected with a 30-gauge needle. This filler is extremely good in skin of color.

▸ Prevelle Silk (cross-linked HA and lidocaine). The added lidocaine decreases patient discomfort. There is very little swelling because of the low HA concentration, but as a result it does not last as long—3 months or less. "It's inexpensive, and it's a good introductory filler for the hesitant patient," she said.

▸ Elevess (cross-linked HA and lidocaine). Elevess has the highest concentration of HA available on the market. "My personal opinion, based on my limited experience with it, is that it tends to be highly inflammatory as a result of this high concentration of HA," she said.

▸ Radiesse (calcium hydroxylapatite). This structural filler is great for men. It does cause a lot of same-day redness. "I do routinely mix it with lidocaine, and that is now FDA approved and has been found not to decrease its longevity," she said. It's a good choice for marionette lines and the pre-jowl sulcus, but avoid using it for the lips, she said.

▸ Sculptra (poly-L-lactic acid). The FDA cleared Sculptra this year for cosmetic purposes—correction of mild-to-severe nasolabial folds and wrinkles and contour irregularities. "The optimal patient for this is a younger lipoatrophy patient, because these patients still have enough of an immune response to actually get a good bang for the buck," she said. This filler is not reversible. The most common problem with Sculptra is the presence of nodules if it is injected too superficially, said Dr. Lupo.

▸ Evolence (porcine collagen). "In my opinion, it's a stiffer, more structural filler," she said. It works well in the nasolabial folds. Dr. Lupo always mixes it with lidocaine, though this makes it flow more quickly, so she uses a 30-gauge needle. It is a good choice for men with thick skin. Evolence has a low incidence of bruising and swelling.

Dr. Lupo reported significant financial relationships with a number of pharmaceutical and skin care companies.

A patient is shown before treatment with one syringe of Restylane.

The effect was prolonged for 3.5 years by performing periodic touch-ups.

Source Photos courtesy Dr. Mary Lupo