Stay Abreast of Specific Benefits, Limitations as Filler Choice Grows

PARK CITY, UTAH — The growing number of fillers approved and pending approval in the United States presents cosmetic dermatologists not just with an array of choices, but also of benefits and risks specific to those choices, according to Dr. George J. Hruza.

Extra caution is required when injecting fillers into the mid-dermis of the thin skin over the glabella, Dr. Hruza, who is medical director of the Laser and Dermatologic Surgery Center in St. Louis, warned at a clinical dermatology seminar sponsored by Medicis.

Dr. Hruza says he mostly uses CosmoDerm in the glabella but added that Restylane is sometimes necessary in patients who have had Botox treatments. He recommends injection levels of the upper dermis for CosmoDerm, and the mid-dermis for CosmoPlast and the hyaluronic acid fillers. He said Sculptra should be reserved for large areas, and injected into the deep dermis or subcutaneously.

"Do not inject [Sculptra] superficially," Dr. Hruza said, warning that papules can result.

Also among the clinical pearls in his presentation were:

▸ When using Restylane, completely fill in an area before moving on. "It is difficult to come back to because you don't know what is swelling and what is Restylane," he said.

▸ Take steps to prevent last-minute cancellations when using Sculptra. Sold as a sterile, freeze-dried product, it is stable for only 72 hours after being reconstituted. Having to throw out two vials—enough to do two cheeks—is "pretty expensive" at $460 a vial, he said.

▸ One European study of Sculptra for facial lipoatrophy scheduled injections every 2 weeks. That's too close together. "You don't know what you are treating," he said. "It [Sculptra] takes time to build up."

▸ Manage patient expectations, so that they are realistic. "Sculptra provides gradual skin thickening. The number of treatment sessions depends on the depth of the effect," he said, adding that touch-up treatment may be needed. "Posttreatment massage by the patient is essential."

▸ Avoid the lips if using silicone off-label. Granulomas have occurred as late as 10 years after placement, he said. According to Dr. Hruza, European clinicians have seen a problem with ArteFill, a permanent filler under U.S. review. "I think there will be a problem down the road, so I won't be the first one to use these," he said.

▸ Be wary when patients want only the upper lip filled. "[The lips] don't look natural," he said, describing a ducklike effect. "Always do a little of both."

Sculptra should be reserved for large areas, and injected into the deep dermis or subcutaneously. DR. HRUZA

PARK CITY, UTAH — The growing number of fillers approved and pending approval in the United States presents cosmetic dermatologists not just with an array of choices, but also of benefits and risks specific to those choices, according to Dr. George J. Hruza.

Extra caution is required when injecting fillers into the mid-dermis of the thin skin over the glabella, Dr. Hruza, who is medical director of the Laser and Dermatologic Surgery Center in St. Louis, warned at a clinical dermatology seminar sponsored by Medicis.

Dr. Hruza says he mostly uses CosmoDerm in the glabella but added that Restylane is sometimes necessary in patients who have had Botox treatments. He recommends injection levels of the upper dermis for CosmoDerm, and the mid-dermis for CosmoPlast and the hyaluronic acid fillers. He said Sculptra should be reserved for large areas, and injected into the deep dermis or subcutaneously.

"Do not inject [Sculptra] superficially," Dr. Hruza said, warning that papules can result.

Also among the clinical pearls in his presentation were:

▸ When using Restylane, completely fill in an area before moving on. "It is difficult to come back to because you don't know what is swelling and what is Restylane," he said.

▸ Take steps to prevent last-minute cancellations when using Sculptra. Sold as a sterile, freeze-dried product, it is stable for only 72 hours after being reconstituted. Having to throw out two vials—enough to do two cheeks—is "pretty expensive" at $460 a vial, he said.

▸ One European study of Sculptra for facial lipoatrophy scheduled injections every 2 weeks. That's too close together. "You don't know what you are treating," he said. "It [Sculptra] takes time to build up."

▸ Manage patient expectations, so that they are realistic. "Sculptra provides gradual skin thickening. The number of treatment sessions depends on the depth of the effect," he said, adding that touch-up treatment may be needed. "Posttreatment massage by the patient is essential."

▸ Avoid the lips if using silicone off-label. Granulomas have occurred as late as 10 years after placement, he said. According to Dr. Hruza, European clinicians have seen a problem with ArteFill, a permanent filler under U.S. review. "I think there will be a problem down the road, so I won't be the first one to use these," he said.

▸ Be wary when patients want only the upper lip filled. "[The lips] don't look natural," he said, describing a ducklike effect. "Always do a little of both."

Sculptra should be reserved for large areas, and injected into the deep dermis or subcutaneously. DR. HRUZA

PARK CITY, UTAH — The growing number of fillers approved and pending approval in the United States presents cosmetic dermatologists not just with an array of choices, but also of benefits and risks specific to those choices, according to Dr. George J. Hruza.

Extra caution is required when injecting fillers into the mid-dermis of the thin skin over the glabella, Dr. Hruza, who is medical director of the Laser and Dermatologic Surgery Center in St. Louis, warned at a clinical dermatology seminar sponsored by Medicis.

Dr. Hruza says he mostly uses CosmoDerm in the glabella but added that Restylane is sometimes necessary in patients who have had Botox treatments. He recommends injection levels of the upper dermis for CosmoDerm, and the mid-dermis for CosmoPlast and the hyaluronic acid fillers. He said Sculptra should be reserved for large areas, and injected into the deep dermis or subcutaneously.

"Do not inject [Sculptra] superficially," Dr. Hruza said, warning that papules can result.

Also among the clinical pearls in his presentation were:

▸ When using Restylane, completely fill in an area before moving on. "It is difficult to come back to because you don't know what is swelling and what is Restylane," he said.

▸ Take steps to prevent last-minute cancellations when using Sculptra. Sold as a sterile, freeze-dried product, it is stable for only 72 hours after being reconstituted. Having to throw out two vials—enough to do two cheeks—is "pretty expensive" at $460 a vial, he said.

▸ One European study of Sculptra for facial lipoatrophy scheduled injections every 2 weeks. That's too close together. "You don't know what you are treating," he said. "It [Sculptra] takes time to build up."

▸ Manage patient expectations, so that they are realistic. "Sculptra provides gradual skin thickening. The number of treatment sessions depends on the depth of the effect," he said, adding that touch-up treatment may be needed. "Posttreatment massage by the patient is essential."

▸ Avoid the lips if using silicone off-label. Granulomas have occurred as late as 10 years after placement, he said. According to Dr. Hruza, European clinicians have seen a problem with ArteFill, a permanent filler under U.S. review. "I think there will be a problem down the road, so I won't be the first one to use these," he said.

▸ Be wary when patients want only the upper lip filled. "[The lips] don't look natural," he said, describing a ducklike effect. "Always do a little of both."

Sculptra should be reserved for large areas, and injected into the deep dermis or subcutaneously. DR. HRUZA