industry insider | Injectables | The Liquid Facelift Comes of Age With an ever increasing number of dermal fillers and neurotoxins on the market, Wendy Lewis provides an insight into their evolving role in aesthetic medicine

ermal fillers and neurotoxins line fillers: bovine collagen and autologous fat. Those of us have evolved into the ideal gateway to pioneering injection techniques and pan­‑facial aesthetic medicine. Injectables are taking augmentation with fat back then were thought to be centre stage in aesthetic practices in new radical. I remember going to a lecture by a well-known and emerging ways, and the rate of cosmetic dermatologist in the early 90s who emphatically satisfaction among patients is consistently said ‘fillers fill and lifts lift so don’t confuse the two’. Now a high.D Once upon a time, fillers were just for filling in lines decade and a half later everyone is using fillers to lift, and , and plumping lips. The realities of modern blend, and smooth. It’s really amazing when you think practice have transformed this category from being thought about how this area has evolved,’ says New Haven, CT, of as simply adjuncts to surgical enhancements to highly Dermatologist Lisa M. Donofrio, MD. effective treatments using complex techniques that warrant Indeed, injectables are useful alternatives as well as skill and expertise. adjuncts to surgical procedures, wendy lewis is President of Wendy Lewis & Co Ltd, Global A global slowdown in and are widely considered a Aesthetics Consultancy, author innovation has created a void in Emphasis on pain-free mainstay in aesthetic practices. of 11 books, and Founder/ Editor-in-Chief of www. the filler market that has paved injections using soft or They can prevent wrinkles in beautyinthebag.com since the way for practitioners to step bendable needles, tubes, younger patients, reduce fine lines, 2008. She is a contributor to a up their game in terms of and smooth scars in patients in number of trade and consumer blunt-tip cannulas, injector publications in the USA and experimenting with advanced their 30s, and reverse deeper Europe. techniques, new instrumentation, pens, and novel systems that wrinkles in patients in their 40s and unique combinations and and older. Fillers are also valuable contact [email protected] are touted to cause less layering of products. Fillers tools for reshaping the face, adding containing lidocaine for pain trauma and bruising are fullness, enhancing contours, management have become the revolutionising the way fillers correcting asymmetries, gold standard. Emphasis on pain- are being injected. smoothing out bony irregularities, free injections using soft or and solving issues of facial ageing bendable needles, tubes, blunt-tip that surgery does not address cannulas, injector pens, and novel systems that are effectively. They are also used to correct minor defects touted to cause less trauma and bruising are post-surgery. Even for plastic surgeons who would rather revolutionising the way fillers are being injected. be operating, injectables have taken on new relevance in Practitioners are combining fillers in the same syringe, in today’s consumer-driven climate. addition to the same facial region. Another technique ‘Dermal fillers can enhance the results of a surgical often used is to dilute fillers to make them more facelift nicely, especially in terms of volumisation. But appropriate for injecting into fine lines. these treatments are also viewed as an alternative in many cases, such as younger patients who do not have Fillers are not one size fits all significant sagging, and those who are not good candidates ‘I have seen the filler market change dramatically over the for surgery. Injectables buy time until the patient is last 17 years. There was a time when all we had were the physically, mentally, and financially ready for a surgical

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introducing procedure,’ says New York City Plastic Surgeon Alan Matarasso, MD, FACS. Injectable landscape ‘Today’s injectable patient may be tomorrow’s surgical patient, if their Injectable products cleared by the FDA for aesthetic use as of September 20131 expectations are managed so they understand when surgery is indicated,’ he ■ Artefill® (Suneva Medical): bovine collagen with polymethylmethacrylate (PMMA) particles continues. ■ Belotero® Balance (Merz Aesthetics): hyaluronic acid The evolving menu of injectable agents ■ Botox® Cosmetic (Allergan): botulinum toxin type A offers practical solutions for patients ■ Dysport® (Valeant Aesthetics/Medicis): botulinum toxin type A seeking non-invasive, affordable aesthetic ■ Juvéderm® ULTRA XC, Juvéderm® ULTRA PLUS XC (Allergan): hyaluronic acid with lidocaine improvements. In many practices, the ■ Laviv™ (Fibrocell Science): autologous fibroblasts PRP most ‘bang for the buck’ among injectable ■ Perlane®, Perlane-L® (Valeant/Medicis): hyaluronic acid with lidocaine treatments are neurotoxins. Results are ■ Prevelle® Silk (Mentor): hyaluronic acid with lidocaine consistent, patients love the subtle ■ Radiesse® (Merz Aesthetics): calcium hydroxyiapatite improvements that can be achieved; and it ■ Restylane®, Restylane®-L (Valeant Aesthetics/Medicis): hyaluronic acid with lidocaine is an ideal complement to other treatments ■ Sculptra® Aesthetic (Valeant Aesthetics): poly-L-lactic acid such as lasers and fillers. ■ Xeomin® (Merz Aesthetics): botulinum toxin type A Far from a ‘one size fits all’ type of treatment, dermal fillers command skill to create an optimal result. Advanced non- thereby increasing volume and correction the ‘wind tunnel’ facelift that was prevalent surgical techniques for over time, have had a dramatic impact on in the 80s. • Free centrifuge* involve looking at the face in a three facial contouring. Unlike hyaluronic acid dimensional way and using a robust gels, which offer immediate results, these A global perspective • On-Site support combination of facial-shaping agents. substances are designed to gradually When it comes to dermal fillers, Europe cause a foreign body reaction to achieve leads the way in terms of innovation, and • Easy to Use Knifeless facelifts long‑lasting effects. According to New York the US lags behind largely based on the Who gets injected with what and where City Plastic Surgeon Bryan G. Forley, stringent clinical data and safety criteria PR PR PRP depends largely on the patient’s desires, ‘Products that are biostimulatory like required to bring products to market. In the • High volume PRP yield: 6-7ml’s of PRP P budget, and understanding of their ageing Sculptra® Aesthetic enhance new collagen category of injectables, the EU ranks P per 12 mL tube process. High volume injectors do not treat production to produce longer-lasting second behind the US, followed by Asia every patient in the same way. They tend volumetric correction. When combined and Latin America2. Although the to graduate to using more volume to with skin tightening devices, we can injectable market is considered to be a • Highest Platelet Yield at 87.5%, +/- 9% address multiple areas of the face in one achieve dramatic effects that approximate more mature market with a lot of small session, which has elevated filler what a facelift can do in some instances. players and a handful of global giants, treatments to an unprecedented level. We now have a range of fillers that are some privately owned companies in Asia As recently as a decade ago, patients that useful to fill an isolated wrinkle, as well as are flooding the market with cheaper presented with sagging in the midface and fillers that can be injected into multiple products that are starting to show up in jowls would have been told that they tissue planes to create a change in facial clinics throughout Europe and the Middle needed a surgical face and necklift under shape and restore volume.’ East. This influx of less expensive products general anaesthesia, and 2 weeks out of Radiesse® is another popular choice for is driving the price down in many markets. work for recovery. They would most likely facial contouring and volumetric lifting In the US, there are 12 injectable products have been turned away from any owing to its ability to create structural that currently have the FDA nod and being non‑surgical or minimally-invasive collagen support. ‘Radiesse is a wonderful marketed: three neurotoxins and nine treatments. Today, by using advanced volume filler. It can correct the hollows that filling agents. As expected, temporary facial contouring techniques, practitioners develop in the cheeks, recreate flattened hyaluronic acid gels represent the largest are able to produce facelift-like results to cheekbones, and make the jowls look group. Several more products are currently meet consumers’ demands for safe, smoother. Its excellent longevity, versatility, in the FDA pipeline, although the process is effective and long‑lasting non-surgical and lifting capacity make it my go-to filler notoriously slow. In the US, dermal fillers options. for facial contouring,’ says New are often used in an off-label manner, Products that stimulate the production York City Dermatologist mainly because of the limited indications of new collagen, Judith Hellman, MD. each product is approved for. For example, When you consider although using hyaluronic acid based that a typical ‘Liquid fillers to enhance the lips is a very common Facelift’ takes about 30 treatment, Restylane® and Restylane®-L are to 60 minutes and the only fillers that are actually approved patients can wear for ‘lip enhancement in patients over Order Now: make-up almost 21 years’3. immediately and Each product has its niche. The most resume normal activities within 1 to recent addition in the US market was Eclipse Aesthetics, LLC. 800-759-6876 *Minimum purchase required 3 days, this represents a quantum leap over Belotero® Balance, manufactured by 13988 Diplomat Drive, Suite 160 Dallas, Texas 75234 16 September/October 2013 | prime-journal.com www.eclipseaesthetics.com ❚ industry insider | Injectables |

Merz Aesthetics, and is widely used in you are trying to correct, treating superficial lines such as vertical lip how deep is the fold or lines, as well as the tear trough area, since it wrinkle to be filled, what is thought to reduce the possibility of a the ideal options are for Tyndall effect based on how it integrates each situation, considering into the skin. the patient’s expectations, As new products continue to gain FDA budget and history,’ says approval, the question is how many fillers Steven Fagien, MD, an do you really need? All injectors tend to Oculoplastic Surgeon in have their favourite ‘go to’ products on the Boca Raton, FL. shelf, but not all fillers can address every area and patient, so having a wide range of Natural born fillers tools in the toolbox is necessary. This will There is no question that autologous fat become even more important as big transfer and platelet‑rich plasma (PRP) take players continue to invest in large scale centre stage at aesthetic conferences direct-to-consumer marketing worldwide, and regenerative medicine is new filler to be launched in the US market. programmes to generate awareness of an important segment of the market. This ‘With the expanding menu of fillers now brand name fillers. has stimulated a growth industry around available and more products currently Injecting new areas requires a different fat harvesting tools, innovative centrifuges, under clinical investigation, we are technique, and in some cases, a lighter fat transfer systems, and syringes. A learning to treat the whole face with touch. Some of the new injectable sites growing sector of consumers embrace the unprecedented results,’ Fagien says. include traumatic scars, eyebrows, idea of a more natural approach to anti- ‘Allergan’s VOLUMA is the latest advance in temples, jawline, nasal dorsum, earlobes, ageing treatments using their own tissues. larger volume hyaluronic acid gel fillers, labia augmentation, the soles of the feet, Many plastic surgeons consider fat grafting and is poised to be the next game changer and dorsal hands. Ageing hands that are to be an integral part of their facelift protocol in facial rejuvenation. The main wrinkled, bony, or for most patients, except advantages of VOLUMA include its use in prominently veined are a Far from a ‘one perhaps those with very larger quantity facial volume restoration, promising arena for size fits all’ type of full faces. while enjoying the ability to mold and rejuvenation treatments. Another subset of sculpt with greater precision.’ ‘It takes a lot more treatment, dermal patients also want Donofrio agrees with Fagien: ‘The experience and expertise fillers command longer‑lasting fillers. Men demands of patients and doctors to to treat the hands because skill to create an especially like the idea of develop better, longer lasting fillers with you have to inject deeply treatments that do not superior lifting capabilities (high G Prime) and be careful to avoid optimal result. require much has led to products such as Juvéderm the veins,’ says Forley. maintenance. VOLUMA coming to market. Those of us ‘Cosmetic fillers have a proven safety ‘Longer‑lasting products have found their that have been volumising with fat for record when injected by a properly place in facial rejuvenation. There is a years feel that this will be the closest qualified and trained in an group of people who are seeking treatments approximation of the dramatic results we appropriate medical setting,’ says Edwin F. that last well so they do not have to keep can achieve with fat transfer. I have patients Williams, MD, Group Vice President for coming back for touch-ups every few on a waiting list to be called first. It’s an Public and Regulatory Affairs of the months,’ says Steven Cohen, Plastic exciting time to be a cosmetic sculptor.’ American Academy of Facial Plastic and Surgeon, MD, FACS in La Jolla, CA. Yet many (AAFPRS). ‘While practitioners are wary about using a injecting dermal fillers is not surgery, it is permanent product owing to concerns still a medical procedure that requires the over granuloma formation, and the fear experience of a physician trained in that the patient may not like the long-term cosmetic procedures of the face. Patient results. There is a decreasing tolerance of safety must be paramount. Although risks and side‑effects, especially as more complications can occur with any filler products have entered the market that are substance, using only FDA-approved biocompatible, non-immunogenic, and References products and good clinical instruction non-migratory. However, permanent fillers helps to minimise potential side-effects.’ are more accepted and widely used in Asia. 1. Wrinkle fillers approved by the center for devices There are nuances for each dermal filler, and radiological health. FDA. Silver Spring, MD: FDA, 2013. tinyurl.com/ndu9qd6 [accessed 11 September including ease of use, location of injection Next kid on the block 2013] into the skin, versatility, and duration of On 2 May, 2013 the members of the FDA’s 2. IMCAS conference. IMCAS industry tribune. Paris, results, as well as potential risks and the General and Devices Panel 2013. management of adverse events. ‘Patient gave their nod to Allergan’s Juvéderm® 3. The first and only FDA-approved products for lip enhancement. Restylane. Scottsdale, AZ: Medicis, a assessment is critical to achieving optimal VOLUMA® XC for the correction of division of Valeant Pharmaceuticals, Inc., 2013. outcomes with soft tissue fillers. You have age‑related volume loss in the midface. tinyurl.com/p6g6b4k [accessed 11 September 2013] to determine what is exactly the problem VOLUMA is well positioned to be the next

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