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.