voluma Archives | The Aesthetic Clinique

How to Minimize Risks of Vascular Occlusion and Blindness During Filler Injections

Dermal fillers improve volume loss or enhance facial features. Their use is increasing at rate of 10% or more per year worldwide. Adverse events are usually minor and consist of bruising, swelling, asymmetries, and nodularity. More significant complications are fortunately rare and include infection, granuloma, skin necrosis, and blindness. This blog will concentrate on techniques to minimize the risks of having a vascular event.

There are 2 ways a blood vessel can become occluded. If an artery is entered and filler is injected within the lumen (Intraluminal), filler will travel down the vessel until it gets lodged. At this point, the filler stops the flow of blood to areas which are dependant on this blood supply. Smaller pieces of the filler can break off and flow into areas far from the initial injection and into the very small arterioles. There are theories that an inflammatory response/cascade exacerbates the injury to the skin and dependent structures. This is Dr. Weiner’s opinion for the etiology of the majority of vascular occlusion cases.

A second way a vessel can occlude is if there is external compression of the vessel by filler. This is plausible in areas of compartmentalization, such as in the nasal tip. If the pressure within the nasal tip exceeds the pressure within an artery, flow will stop. Unfortunately in this area, vascularity is so poor that peripheral flow doesn’t occur. External compression is not a major problem in most areas of the face in Dr. Weiner’s opinion. Most vessels can be ligated during surgery and there is no resultant skin necrosis – proving that peripheral flow can make up for an externally compressed vessel.

The worst cases of vascular occlusion result in blindness. This is the result of a filler embolus that travels through an anastomosis between the external and internal carotid systems. The filler backs up into the central retinal artery which feeds the retina. Blood flow is blocked to the retina and blindness ensues.

In most cases, early recognition of a vascular event can be reversed with hyaluronidase if a hyaluronic acid filler was used. Minimal or no sequelae are seen if action is taken within the first 4-6 hours. Unfortunately, even immediate action for blindness related to a filler complication, has little or no success.

There have been about 100 reported cases of blindness from fillers, with most of the cases coming out of Asia. This is certainly underreported though. The areas of most risk for blindness are injections in: glabella, nose, periocular, and NLF. Fat is the most common filler causing blindness, but all fillers have been implicated. Any area of face is at risk for vascular occlusion/necrosis.

The key to avoiding vascular complications from fillers is implementing safe techniques and knowledge of the vascular anatomy. While there is a paucity of data to support this, Dr. Weiner believes that cannula injections are less risky than needles for a vascular event. Larger cannulas, 25g or larger, are less likely to enter a vessel than a needle. While there have been cases of vascular occlusion with cannulas, to the author’s knowledge, none have been reported with 23g or larger. The smaller the cannula, the closer it becomes to looking like a needle, and therefore the advantages are less. (Please read Dr. Weiner’s blog about cannulas to understand their advantages.)

Techniques for optimizing safety during dermal filler administration:

Know the major vascular structures and their landmarks
Avoid areas you (the injector) are not comfortable with. Particularly the high risk areas: glabella, nose, periocular
Consider using only reversible fillers if there is any concern regarding vascular occlusion or experience
Use cannulas whenever feasible, preferably 25/23g or larger
Avoid boluses, small linear threads are safer
Constantly move tip of cannula/needle. If more filler is needed in a particular area, revisit the area with another pass.
A NEGATIVE ASPIRATION DOESN’T EQUATE TO BEING EXTRAVASCULAR AND CAN GIVE A FALSE SENSE OF SAFETY
Injection onto periosteum is safest but does not guarantee a vascular free injection
Pressure on the supratrochlear vessels during glabellar or nasal injections might limit reflux of filler into the orbital vessels
Retrograde injections are safer than anterograde injections
Dermal injections should be relatively safe
Avoid deep injections in the lips. Stay superficial to the muscles
An injection that is perpendicular to a vessel is purported to be safer than one which is parallel because the time within the vessel should be less if it is entered
Have on hand 6-8 vials of Hylenex
Any unusual bruising, pain or visual change needs immediate evaluation

The bottom line is that complications can occur with dermal fillers, even during a routine procedure. Many measures can be taken to minimize the risks. Choosing an experienced injector will result in safer and better outcomes.

Dr. Steven F. Weiner is the #1 physician trainer for Galderma (Restylane, Silk, Lyft, Sculptra, Defyne, Refyne). He has been using cannulas since 2011 and is one of the most experience injectors in the US.

Deceptive Practices Used in Before and After Photos

“A picture is worth a thousand words”. It’s true, seeing a great before and after speaks volumes for a certain physician’s or practitioner’s abilities. Unfortunately, there are some deceptive practices that can trick the eyes into believing results are better than they are really are. Instagram is a showcase for the aesthetic industry, but there is no oversight as to the claims made on the photos displayed. The bullet points below will help one to develop a critical eye to discern the truth from the “fictional results”.

Lightening must be the same in both pictures. A common misleading practice is to have a dark before picture and a light after picture. In the lighter picture, wrinkles and shadows are going to be less, and fool the observing into thinking these were related to the procedure.
Angle of the neck/head must be the same in both pictures. Take a look at the nose and jaw to see if the head is in the exact same position. If the head is tilted more upward in the after picture, the neck will appear to have less fullness, less wrinkles, and be firmer. This is particularly popular in the Kybella before and after photos.
The expression must be the same in both pictures. If a patients is partially smiling in the before and not in the after, the wrinkles around the mouth and cheek will appear falsely improved.
Sculptra pictures should have at least a 3-6 month interval. Sculptra is always mixed with water or saline for reconstitution. The immediate results after injection reflect merely the effects of the water/saline and not that of Sculptra. The collagen stimulation from Sculptra will take at least 3 months to appreciate, with 6-9 months being even a better gauge of results.
Using company photos or other physician’s photos without noting this or giving the appropriate credit on their websites or posts is also a common practice.
If make-up is used, it must be similar in both photos. Too often the before has none and the after has make-up.

Perfect before and after photos are very challenging. Even when results are extraordinaire, there are often difficulties trying to capture these changes with the camera. However, purposely trying to “enhance” photos with the practices above must be pointed out to the practitioners.

Proper Sterile Technique is Critical for Optimal Dermal Filler Results

In surgery, sterile technique is “the law”. Any break in sterility places the patient at risk for a potentially life threatening infection. It is the duty for the surgeon(s), scrub tech, and circulating nurse to self report or call out any suspected or potential contamination risk. Immediate actions are taken to remedy the situation and to limit the risk to patient.

Why should dermal fillers be treated as anything differently? They shouldn’t! Fillers are semipermanent or permanent implants, and they must be administered in aseptic technique. The majority of injectors are not trained as surgeons and therefore don’t fully comprehend what sterile technique entails. Granulomas, one of the more serious complications from fillers, have now been traced to biofilms. Biofilms are latent bacteria that somehow get activated and present as infection or granulomas, months to years after the initial injection. Most often biofilms are deposited in the tissues during the initial injection procedure. Clearing infections or granulomas takes weeks or months to clear and often entails antibiotics, steroids, 5 FU, and hyaluronidase (if a hyaluronic acid was used).

The following guidelines should serve as a reference for physicians and nurses to minimize infectious complications during dermal filler injections.

The patient should clean their face thoroughly with soap and water in the office. All make-up must be removed.
Never inject someone with a current/ongoing infection. Even if the infection is not in the area of the dermal filler, bacteria can seed the filler from distant areas through the bloodstream (bactermia).
If a patient is in the process of getting dental work or even dental cleanings, hold off on injections until after the work has been completed. Bactermia is well documented during dental cleanings. It is recommended to wait at least 2 weeks after fillers to get dental cleanings. The areas of filler placement will initially have increased blood flow (hyperemia) so it is best to wait until this settles down.
Skin should be prepped for injection with chlorhexidine, with Hibiclens being the preferred form by the author. Although isopropyl alcohol (70%) is effective in killing bacteria and fungus, it is only effective for seconds and becomes ineffective as soon as it evaporates. Hibiclens kills germs on contact and will give persistent bactericidal effects for at least 6 hours, and up to 24 hours. It will bond with the skin even after washing to give continued killing effects. Isopropyl alcohol doesn’t give this lasting bactericidal effect, so anytime after the initial cleaning that an unsterile glove touches the skin, that area is now contaminated. (Hibiclens must be kept out of the eyes because it can burn the cornea). Technicare is also a great antiseptic but the author doesn’t have experience with it. Too many patients are allergic to Betadine for it to be used routinely.
Do not use tap water when applying Hibiclens or to clean the face after completion of the injections. There are several bacteria, fungi, as well as mycobacterium in water which can seep through the injection ports and cause infection.
If the filler is prepared by mixing lidocaine or saline, this must be done in a sterile fashion. The female/female connector used to connect the 2 syringes together must not be reused. It can only be used for the current patient and cannot be sterilized for use on other patients. The tops of all the solutions used must be wiped with an alcohol wipe. Routine use of blending fillers opens up more avenues for filler contamination and must be done with the strictest of sterile technique. If any of the solution vials becomes unsterile, all future filler patients using that vial will become infected.
Blunt tip cannulas can be used for multiple injection sites ON THE SAME PATIENT and are not intended to be used for multiple patients. When changing the cannulas between syringes, they should be recapped first. It is not sterile technique to lay the cannula on an unsterile tray or even a sterile drape when uncapped. After a syringe of filler is removed from its sterile packaging, the areas touched with the exam gloves become “contaminated”. Therefore, the sterile drape is not a sterile field anymore, once the syringes is placed on it. Best practice is to cap the syringe every time it is laid down.
Blunt cannulas are much longer than needles and must be kept sterile throughout their entire length. The cannula is contaminated if anywhere along its length it touches non sterilized skin, gloves, or hair.
It is never appropriate to touch a needle or cannula with unsterile gloves. The needle/cannula are now contaminated and must be exchanged.
The introducing needle for the pilot hole with cannula use must be recapped as well to maintain sterility.
Unless the gauze used during the procedure is specifically labeled as sterile, it is not, and introduces another route of contamination. Gauze that comes in sealed pull away packs and labeled as sterile is best to use. The author will take unsterile gauze, place in autoclave packs, and place in the autoclave to obtain sterility.
Frequent “re-sterilization” of the areas being treated with Hibiclens soaked gauze is done by the author.
If ice or devices for vibration are used to control discomfort, these should be cleansed with Hibiclens prior to applying to the skin. In addition, the areas where these were applied should be “re-sterilized” prior to injections.
When the procedure is complete, sterile water or saline on sterile gauze should be used to clean the patient. Again, if tap water is used, this can seep through the injection ports and lead to infection. Also, when soaking the gauze, best practice is to pour the water/saline over the sink onto the sterile gauze so as to keep the remaining fluid in the container sterile. By tipping the water/saline onto gauze that is covering the top, there is risk of contamination going back into the container.
Make-up should not be applied to the skin until the morning. At this point, the injection ports have all healed and there is no risk of contamination.
Dental procedures, even cleanings, should be postponed for at least 2 weeks.

Although the details above are fairly lengthy, any break from any step will lead to a possible source of granuloma or infection in the future. Strict sterile technique will lead to better outcomes and happier patients,

Dermal Filler Providers Must Also Be Proficient With Hyaluronidase

The adoption of dermal fillers for age related volume replacement has contributed to the surge in aesthetic patients. As patients become more savvy, it becomes obvious that filler outcomes are dependent primarily on the provider and not the brand of the filler injected. Somewhere between 80-90% of the fillers used are based on Hyaluronic Acid, a naturally occurring substance found throughout the skin, and joints. (It is an interesting side note that the structure of HA is similar throughout all species.) One of the attractive qualities of HA is that there is an “antidote”, an enzyme called hyaluronidase, which can dissolve HA based dermal fillers.

There are several versions of hyaluronidase available in the US. There are animal based products such as Vitrase (ovine based), Hydase (bovine), and Amphadase (bovine). The one product, Hylenex, is actually a recombinant form of the human hyaluronidase. There is some risk of allergic reaction to the animal based products but not Hylenex (author’s preferred choice). The intended use of hyaluronidase is to allow for increased tissue permeability, thereby allowing for greater dispersion and delivery of products injected. It is also used when hyperosmolar fluids extravasate into the skin and in improving uptake of radiopaque solutions in the bladder. The primary reason it is used in aesthetics is to dissolve HA filler.

The reasons to dissolve HA filler are:

Poorly placed filler giving an aesthetically poor result
Where too much filler was placed
Filler that is infected
Filler is forming a granuloma
Filler is causing ischemia/vascular occlusion
Filler is causing visual changes or blindness

The are more and more fillers being introduced to the market each year. Each one has it’s own characteristics and nuances when injecting. There are also, many new injectors entering the industry daily. It is fair to say that the number of poor outcomes and complications is inevitably going to rise. Unfortunately, trainings are not being done for the indications and administration of hyaluronidase. It is beyond comprehension that there are many offices, I dare say, a majority, who either don’t normally have any or adequate doses of hyaluronidase.

It is absolutely imperative that a facility that injects HA fillers stock at least 1000 units of hyaluronidase. Doses of 400 units or more need to be injected in areas of vascular occlusion immediately to achieve optimal outcomes. If no response, additional doses need to be injected. If an ophthalmologic complication occurs, at least 1000 units needs to be injected immediately to have any chance for recovery of vision. Even with doses in the thousands of units, there should be no concern regarding loss of naturally occurring hyaluronic acid as it will replaced by the body’s normal regenerative process over 24-48 hours.

Unfortunately, the majority of providers have little or no experience with hyaluronidase and/or have none available in their facilities. It is beyond comprehension the lack of preparedness for not only reversing poor outcomes, but in resolving medical emergencies. The industry must rise up to educate about complication identification and treatment protocols. Poor outcomes and complications affect the entire aesthetics field and not just the individuals involved.

Dr. Steven F. Weiner’s 6 year Experience with Blunt Cannulas for Dermal Fillers

The value of volume replacement in the aging face is now universally recognized as one of the most beneficial procedures to restore youthfulness. The combination of sun exposure, aging, and genetics leads to collagen, fat, muscle, and bone loss. Reinflating the cheeks, lips, and tear troughs are routinely done by physicians across the world on a daily basis. Most of these patients will have a week or more of downtime – swelling, bruising, discomfort – but that doesn’t have to be. Blunt cannulas can minimize most of these side effects associated with filler injections and has become standard practice for Dr. Weiner for the past 6 years.

The benefits of blunt cannlas are:

There is only one insertion point to treat multiple areas. This equates to less intrusions through the skin and therefore a more comfortable procedure.
The tip is rounded and blunted. This very fact accounts for less bruising/swelling. When a blood vessel is encountered with the end of the cannula, the vessel is more likely to be gently displaced rather than punctured.
There is increased safety. A phenomenon termed “vascular occlusion” occurs when a filler is injected into a blood vessel. The filler then blocks the blood flow and can lead to necrosis (death of skin) or even blindness. It is much less likely to occur with blunt cannulas, particularly larger cannulas (23 or 25 guage), because they don’t enter blood vessels as easy as needles do.
Allows treatment in areas otherwise not easily accessible. Due to the safety of the cannulas, there are now areas of the face which are more easily treated. The superficial temporal area, supraorbital, forehead, piriform, periocular and lower eyelid are now routinely treated with cannulas whereas with needles, these areas were very precarious to inject.
Downtime is minimize. As a result of all the benefits listed above, most patients have significantly less healing time and are much happier after receiving their filler treatments with blunt “safety” cannulas.

If blunt cannulas have so much benefits, why are only 5% of the providers using them for dermal fillers? The art of using cannulas is not an easy one. Patience is required because directing the tip to the exact spot it is needed is not always easy. Remember, when the tip encounters an obstruction (vessel, ligament, collagen), it will need to traverse around it and not pierce it (as needles would do). This can be frustrating and lead to longer and less satisfactory results for the inexperienced cannula injector.

Dr. Weiner is one of the leading authorities on cannula injections of dermal fillers and has used them for over 6 years for nearly all of his injections. The cannulas provide a safe, comfortable, minimal downtime technique for volumizing the aging face, even with multiple syringes being used simultaneously.

The Temples Shouldn’t be Ignored When Filling the Face

The ideal facial shaped has been described as “heart shaped”, “V shaped”, or “Upside Down Egg”. A youthful face draws attention to the upper face and eyes. With aging, the lower face becomes “heavier” and more dominant, as laxity and volume loss set it. Instead of round or oval, the shape of the face becomes closer to square. The underlying cause for these changes is primarily loss of fat, muscle, and bone.

The upper face’s width is determined primary by the temples. Fat pads in this area are particularly susceptible to atrophy associated with aging and exercise. To reestablish the youthful facial shape, it is essential to reflate the temples. There is a contiguous fat pad in the preauricular area which follows similar volume loss as the temples and should be volumized simultaneously. When the lateral cheeks are given filler, the temporal deficits become exaggerated and more obvious. Patients must be counseled on their temples whenever cheeks injected.

Besides the overall facial shape change, the benefits of filling the temples are the lift given to the surrounding tissues. The brow, and upper eyelid will be elevated with temporal filler. Placement of filler along the orbital rim and lower forehead further enhances this effect. The ideal temple should be convex in a women and slightly concave in the male.

The filling of the temples is reserved for the experienced injector. Dr. Weiner’s choice for this area is Sculptra because of its safety and natural appearance. The only downside to Sculptra is that when placed along the bone in the deepest aspect of the temporal fossa, a large volume of product is needed for complete correction. To finish corrections after the deep Sculptra placement, a superficial layer of HA filler (Restylane, Juvederm) can be safely placed using large bore cannulas. The filler is placed immediately below the dermis in the subcutaneous layer or just below the superficial layer of the temporalis fascia.

To reverse the signs of aging and restore the upper face dominance, temple volumization is required. It must be considered for patients that have brow and eyelid heaviness as well. This is an area that is difficult to treat with higher than average safety risks, and should be reserved for the most experienced injectors.

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The Cheek Challenge Results – Voluma Vs Restylane Lyft

There are currently 2 dermal fillers FDA approved for enhancing the cheeks – Voluma and Restylane Lyft. These are both HA (Hyaluronic acid) fillers which are injected into the deeper tissues of the cheek to volumize and lift the cheeks. By lifting the cheeks, the entire lower face is lifted as well, including the jowl area, nasolabial folds, and jawline. It is well known that for an aging face with volume loss, the mainstay of treatment starts with the cheek area.

There are 2 main distinctions between Voluma and Lyft. The first is G prime, which is a measure of resistance of a fluid to flow. What this translates into when injected into the body is it’s “lifting ability”. There is huge difference between the 2 with Lyft at 531 and Voluma at almost 1/2 of Lyft at 274. Although this is not important according to Allergan, the makers of Voluma, this was found to be significant in our challenge. The other factor is cohesivity. This has only been popularized since Voluma was introduced and it the pressure needed to “flatten” the filler. What this translate in the body is the amount of spreading of the filler in the body. Voluma is higher in this category (less spreading) when compared to Lyft, but it’s importance is not known.

When Voluma was introduced to the market, there was significant marketing on it’s “2 year duration”. What wasn’t discussed was how this FDA designation was obtained. Most people in the study were injected at 2 different times. Also, the average amount of filler injected was over 6 syringes. Lastly, only a minority of subjects had evidence of some correction at the end of 2 years. These important details are left out of most discussions with physicians, and certainly not what the public understands about Voluma. In addition, Voluma’s pricing is much higher than all the other fillers on the market, but justifies these prices due to it’s longer duration.

The “Cheek Challenge” was performed by Dr. Weiner to try to vet out whether there are significant differences between Restylane Lyft and Voluma. To try to keep the study similar to the FDA study, a total of 6cc was injected, 3 of Lyft on the right cheek, and 3 of Voluma on the left cheek. Follow ups and photos were taken at 1-2 month intervals for 1 year. There was no secondary injections because this is what most closely represents a real patient’s experience. Keep in mind this is only one patient but Dr. Weiner did challenge other physicians to do the same, similar to the “Ice Bucket Challenge”. There were about 4-5 other physicians which have also done the “Cheek Challenge”. Their findings have been similar per private discussions with them.

The Results:

Duration of improvement was the same. AT 12 MONTHS, THERE WAS NO DIFFERENCE BETWEEN THE RESTYLANE LYFT AND VOLUMA TREATED SIDES AND THE BASELINE PRE PROCEDURE PICTURES.
During the year, the patient noted that the Restylane Lyft cheek felt higher than the Voluma side.
During the year, the patient felt that the Voluma cheek dropped slighted.
During the first 1-2 weeks, more swelling was noted on the Lyft side.
There was no difference in pain between the 2 sides.
Noted improvements were seen in jowls, jawline, NLF, cheeks, and periocular area on both sides of face.

Although this is only a single patient, these results support multiple clinicians findings that Voluma’s duration is very similar to other HA products. Even with the use of 6 syringes, which is rarely used in a single patient, the duration did not exceed 12 months. Patients need to be counseled that 12 months is what can be expected for Voluma’s longevity. Less expensive and higher G prime filler, Restylane Lyft, seems to be a better choice for volumizing the cheek complex.

Video of patient at end of 1 year with discussion and pictures.

The Top 5 Procedures for a Youthful Appearance

There is so much information available on the internet that is becomes extremely confusing to the average person as to what is the right thing for them to do. While genetics, race, and lifestyle play a role in how one ages, there are many universal features of the aging face which are inescapable. While it is common to be asked “should I do this or that”, the best results are always a combination of several different procedures.

Wrinkles: Botox/Dysport relax hyperdynamic muscles which cause wrinkles with movement. There’s a reason this is the most popular cosmetic procedure in the world. It is quick, extremely effective, very little downtime, minimally painful, and with a high satisfaction rate. Common areas treated are the “11’s” or frown lines, crows feet, and forehead lines. Duration of effect is about 3-4 months. Early preventative treatment is effective in delaying lines which appear at rest (etched in lines).
Loss of Volume: Volume loss is inevitable. The aging process in combination with sun exposure causes the face to lose fat, bone, muscle, and collagen. Starting at the age of about 32, a cc or 2 of volume is lost per year. It begins to become visible at about age 38-40. This is called the “tipping point” in women, about the time when fertility starts to drops off. Sun protection and darker skin types will delay this lost volume up to 10 or 15 years. Replacing lost volume is done with fillers. The most common fillers are made with Hyaluronic Acid (HA) which is a natural component of skin. Examples of HA fillers include Juvederm, Restylane, and Voluma. Longer lasting fillers are Sculptra and Bellafill.
Pigmentation/Redness: Inevitably, skin gets exposed to the sun and “sun damage” occurs. The sun is responsible for destroying collagen in the skin, causing it to thin, and lose elasticity and hydration. Another effect is causing vascular fragility leading to visible vessels and redness. Melanin is produced as the body makes an effort to protect the skin resulting in “sun spots” or hyperpigmentation. Lasers are effective in treating these conditions near painlessly. For reds, VBeam or Excel V Lasers are the gold standards. Up to 3 treatments might be needed. For a few small patches of pigment, a Q Switched Laser or Excel V is used. For more diffuse patches of pigmentation, laser resurfacing (Fraxel) or IPL are good options.
Skin Laxity/Sagging: The combination of gravity and loss of skin elasticity can result in the need for skin tightening. Surgery will give the most aggressive result for this. Alternative treatments with less downtime, less risks are Infini, Thermitight, or Ablative Lasers.
Fat Accumlation: Aging leads to changes in metabolism and fat storage. Patients develop fatty collections which become difficult to diminish despite aggressive workout routines and diets. There are now multiple noninvasive approaches to removing fat permanently with no downtime. Larger more diffuse areas require a technology called Vanquish ME. Smaller areas can be spot treated with either Coolsculpting, Sculpsure, Ultrashape, or Liposonix. In the submental area, fat can be reduced with an injection called Kybella, a new handpiece from Coolsculpting (CoolMini) or with Thermitight. Of course surgery including liposuction or tummy tuck has been the gold standard for decades and is the best option for those desiring the most aggressive approach.

Drum roll please….The top picks from the 5 categories (Dr. Weiner’s Choices):

Dysport, Sculptra, Excel V, Infini, Coolsculpting (CoolMini)

Sculptra is Different Than All Other Fillers: Natural, Structural Support, Cost Effective

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The concept of volume loss in the aging face is a relatively new realization by the aesthetic industry. Up until about 12-15 years ago, the dogma was correcting loose skin using primarily surgical approaches. Post surgical patients were very pleased parading around their newly tightened faces, free from wrinkles and sags, but prominently showing off their skeletonized features. There was no hiding the fact that something had been done, it wasn’t subtle, and it was obvious. Something didn’t jive with what the brain recognized as youthful or aesthetically pleasing. This dichotomy between what Plastic Surgeons and the brain thought was beautiful was due to the lack of understanding of the impact of volume loss on the aging face.

It is now widely documented that there is significant loss of volume in the face as one ages. Fat pads throughout the face become less prominent, and there is also bony resorption throughout the entire facial skeleton and jaw. Even if the skin didn’t stretch from gravity, there would be sagging related to loss of the structural support. A great analogy is in a youthful face, the dress (skin) and your body (facial structures) are the same size. An aging face wears the same dress, but the body is now a size or 2 smaller, so the dress doesn’t fit correctly.

How much volume loss occurs? Beginning at the age of 30, about 1-2 cc of loss occurs per year. However, it is so slow and subtle, and it isn’t until the late thirties or early forties that there is any noticeable changes. It seems to match the so called “tipping point” in women, just as they end their most “fertile” years. Doing the math, a person in their 50’s can have 20-30 cc’s of volume that needs replacing. Its up to the aesthetic physicians to combat this long standing evolutionary process, and keep women (and men) beautiful, well beyond their child bearing ages.

Fortunately dermal fillers can reverse the loss of volume that inevitably comes with aging foregoing the costs, downtime, and risks associated with surgery. The most recognized fillers, Restylane, Perlane, Juvederm, Voluma, are hyaluronic acid fillers. These all last about a year, with most of their longevity based on their ability to absorb water, hydrophillic characteristics. These are great fillers for small corrections around the eyes, lips, marionettes, and nasolabial folds. The cost/benefit ratio turns negative, once the number of syringes exceeds about 6. At this point, correction is still far from optimal, but the costs are significant. Also, in the author’s opinion, multiple syringes of HA filler give a “boggy” appearance to the correction, directly related to their hydrophillic nature.

The only filler that can correct large volume deficits in a cost effective manner is Sculptra.

Sculptra works by stimulating one’s own collagen to volumize the face “naturally”. Studies have shown Sculptra’s effect to last at least 2 years. The problem is, aging is always going to happen, so even after full correction with Sculptra, touch ups with one to two vials every 12 to 18 months are required. Not only does Sculptra produce a long lasting and natural result, it is a cost effective solution. When comparing Sculptra to an HA filler, one vial of Sculptra will volumize what approximately 4 (4 cc) syringes of an HA will do. The cost of Sculptra is usually about 1.5x the cost of a syringe of HA filler. It turns out that full volumization is usually about “1 vial per decade” with Sculptra. Sculptra should be considered the “workhorse” for replacing the structural loss of the face. Fine tuning, once the volume is replaced, is the job of the HA fillers.

Darker skin ethnicities are naturally better protected from the sun so the aging process is delayed (Skin aging is mostly related to sun exposure). These patients require less volume when compared to lighter skinned individuals. Also, severely sun damaged and unhealthy skin won’t respond quite as effectively in collagen production from Sculptra as the healthy, well protected skin, and will require more volume than the norm.

Although there is still a component of excess skin in the aging face, the primary cause of wrinkles and skin laxity is due to volume loss. Correcting volume deficits should be the primary focus of reversing the signs of aging. Of the fillers, Sculptra stands out from all the others in it’s ability to produce a long lasting, cost effective, and natural solution for large volume replacements.

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How Long Do Dermal Fillers Last…..It Depends!

It happens everyday. Patients ask how long they can count on their dermal filler lasting. The problem is, is that there is no quick and easy answer. There are a number of variables that factor into filler longevity, with the ultimate unknown being that there is no way that a physician can determine how one’s body is going to degrade a particular filler.

In the US, the majority of patients are injected with Hyaluronic Acid (HA) fillers. The commonly known HA fillers are: Juvederm Ultra, Juvederm Ultra Plus, Restylane, Perlane, Voluma, and Belotero. The differences between the HA fillers are their manufacturing process, and the concentration of the HA in the filler. The harder the HA is for the body to break down, the longer it will last. A larger particle of HA has less surface area then multiple smaller particles taking up the same space. Less surface area means there is less area for the cells to “chew up” the HA. In general, larger particles will last a little longer than smaller particles. Another factor in HA fillers is how tightly the particles are bound together. Cross-linking, adding bonds between molecules of HA, has been shown to significantly add longevity. All HA fillers are a combination of cross-linked and non cross-linked HA. Too much cross-linking leads to a filler that is very hard to inject, and has led to more complications (in a filler that is no longer on the market). Non cross-linked fillers last only 3-4 months and are hardly used anymore. One last variable in HA fillers is their ability to attract water, their hydrophylic properties. The more they attract water, the longer the HA filler gives a correction.

The fillers that are collagen stimulators, tend to lead to longer longevity. Fillers in this group are: Radiesse, Sculptra, and Bellafill. While studies have shown a very mild collagen response to the HA fillers, the visible volume correction with the HA fillers is the gel, not the collagen. With the collagen stimulators, the body responds to what is injected by creating an inflammatory response and lays down collagen. Until the particle is degraded by the body, collagen will continue to be produced. Radiesse is made of calcium hydroxylapatite, and is the shortest duration in this group. Artefill should be considered a permanent filler, because its component, Poly Methyl Methacrylate (PMMA), does not get broken down by the body. Sculptra has consistently given about 2-3 years duration in studies and in the authors experience.

The location in the face a filler is injected is one of the most important factors to determine longevity. Areas where there is more movement, there is faster breakdown. In order of increasing duration in the face, the order is (in the author’s experience):

Lips
Marionette
Nasolabial Folds
Tear Troughs
Cheeks
Temples

(Forehead, nose, earlobes are variable)

A couple more very important variables that should be mentioned. The more filler that is injected, the longer it will last. This applies to all the fillers. Also, filler doesn’t stop working all of a sudden. It takes months of gradual loss to notice a difference in volume. In fact, even when the patient believes there is no longer results, biopsies have proven that there is still filler present.

After all the above explanation, the author’s experience with the commonly used fillers is:

Lips: HA fillers give about 4 months, longer with recurrently injected lips.
Tear troughs: HA’s – about 9-12 months, Sculptra and Bellafill – years. Juvederm could last years and should never be injected in tear troughs.
Nasolabial: similar to tear troughs
Temples: HA’s – 12-18 months, Sculptra and Bellafill – years
Cheeks: HA’s – 18 months, perhaps 2 years with Voluma; Sculptra and Bellafill – years

Remember that individual results are unpredictable. These are generalizations and offer no guarantee as to how long a patient’s results will last. There are many variables that factor into longevity that are listed above, not to mention how each individual responds, degrades, a certain filler.