Who is a candidate for fillers?

The best candidates for injectable fillers are men and women who are:

1. Looking to reduce the appearance of lines, wrinkles, grooves, scars, and sunken facial areas in order to provide a smoother, more youthful appearance.
2. Those who are looking to add fullness to the lips, cheeks, or other areas.

Areas that can be injected with filler:

1. Lip cheek groove
2. Lip size
3. Lip wrinkling
4. Frown lines
5. Eyebrows
6. Cheeks/mid face
7. Ear lobes
8. Angle of jaw
9. Tear trough
10. Nose
11. Chin
12. Downturned mouth
13. Crow's feet
14. Temples
15. Pre-jowl groove
16. Facial scarring

Injectable fillers involve no anesthetic, but some topical or local anesthetic can be used.

After an injectable procedure, patients may experience some bruising, swelling and redness which typically fades or disappears within a day or two. Injectable fillers are associated with very little downtime and, depending upon the particular filler, many patients are immediately able to return to their normal activities.

There are 3 categories of injectable fillers:

1. temporary fillers (lasting 3-6 months),
2. long term fillers (lasting over 1 year upto 18 months)
3. permanent fillers (lasting forever, but as the aging process continues, more volume may need to be added)

Injectable fillers over the years have changed significantly and are constantly changing as new ones come to the market. All injectable fillers can cause a skin reaction and this occurs in less than .07%. In Canada, we have numerous choices of excellent injectable fillers that are not available in the United States. They can be divided into 2 types: large volume and small volume injectable fillers.

Small volume injectable fillers are the most common. Their use is for correction of certain facial wrinkles, lines or depressions in the face and neck. They are used as 3-dimensional volume fillers. The injectables may be temporary, lasting approximately 3 -6 months, or permanent and are made of various materials. Now there are some fillers that can last over a year that are not permanent. In most cases a temporary injectable is used so that the patient can assess the cosmetic improvement and if the patient is happy with the result then the permanent option is available. The decision on which one to use, is made by Dr. Ellis along with the patient after lengthy discussion. The choice is based on many factors including patient history, desired length of effect and clinical indication. However, most move to the permanent fillers.

Temporary fillers are good for the following patients:

1. Those who only want a temporary, not permanent correction e.g. to enlarge lips
2. Those who are uncertain that they would want the correction and wish to try it out e.g. to enlarge lips
3. Those who want a "quick fix" before a party or social event.
4. Those who are afraid of having a permanent 3-dimensional volume filler in their body.
5. Those that want to try out the effect before considering a permanent surgical injectable.

All injections are done during a routine office visit and require about 10 –15 minutes. Patients can return to normal activity after the procedure. Immediately after the injection, slight redness or swelling may exist at the injection site. This normally resolves within a few hours. Rarely is there bruising, but it can occur especially if patients are taking Aspirin, Vitamin E, or Ginkgo Biloba, ginseng, ginger.

Hyaluronic acid Gels –These products are natural substances of complex sugar chains (polysaccharides) that are part of the skin's interstitial matrix that support collagen in human skin. They combine with the body's own hyaluronic acid, bind water to create increased volume. Hyaluronic acid is in knee joints, eyeballs, and the skin. No pre-testing skin test is required because it is a natural substance and it contains no known allergen or animal proteins. Like collagen, hyaluronic acid is metabolized slowly in the skin and eventually broken down into carbon dioxide and water. Restylane and JuvedermTM are the best known and there are several forms. Perlane with its larger particle size lasts longer than Restylane. It is used in deeper lines like the lip-cheek groove and deeper frown lines. Restylane is used in creases in the skin where as Restylane Fine Lines is used very superficially in the finest of lines.

Juvederm comes in three forms: Juvederm Ultra, Juvederm Ultra Plus and Voluma. Voluma last the longer up to 18 months. Juvederm Ultra Plus last longer than Juvederm Ultra. Juvederm is now mixed with a local anesthetic called Juvederm with Lidocaine. Lidocaine is a local anesthetic and makes the injections virtually painless and does help people who have a fear of needles. Both Juvederm Ultra and Juvederm Ultra Plus are mixed with Lidocaine. Dr. Ellis favors these products with local anesthetic because of the patients' positive reaction to their injections. In Canada, there are many other Hyaluronic gel products: Teosyal, Esthélis, Hylaform, Revanesse. These are all imported from other countries and there have been problems with longevity and reaction under the skin in some. Restylane and Juvederm are the best products.

Collagen – Zyderm and Zyplast: These products are derived from highly purified bovine collagen and are mixed with a local anesthetic. All patients must undergo a skin test on the undersurface of the right forearm to determine if an allergy or hypersensitivity to this protein exists. There must be a slight over-correction at the time of injection. This product is rarely used now as it has been superceded by the Hyaluronic Acid Gels.

BeautiCal-5 is used in patients that do not want anything permanent. 50% of BeautiCal 5 remains after five years so in about two years we injection would be necessary. However once committed to BeautiCal 5 other injectable fillers cannot be used. This is a gel like product similar to the consistency of BioAlcamid and can be reversed in the same manner. See description below.

Radiesse is a product that has a longer life in the body lasting at least a year. It does have calcium hydroxyapatite (CaHA) mixed with a watery gel that dissipates and is replaced by the patient's own collagen. It cannot be removed if there is overcorrection but can be diminished with Kenalog injections or needle liposuction. It cannot be used in the lips because the white pieces of calcium will show up.

ArtesenseTM or Artecoll– an injectable that is composed of tiny microspheres or particles called polymethylmethacrylate (PMMA) which are suspended in a collagen solution with a local anesthetic. These microspheres or microbeads (32-40 microns in size) are well tolerated by human tissue and are 4-5 times the size of a red blood cell. PMMA have been used to glue in artificial hip prostheses for many years with no rejection. Artecoll works by using the body's natural ability to encapsulate foreign bodies by the formation of connective tissue surrounding the PMMA spheres. The process of encapsulation by one's own collagen is complete in 2-3 months. The augmentation or fill with Artecoll is a gradual process since half the product (PMMA) is permanent while the other half (collagen) dissipates while the body makes its own. Patients are informed that it will take from 3 –5 injections to provide the desired effect. As the interval between injections is a minimum of 2 months, the correction may take a year.

A skin test is now not required prior to starting the injections. Contraindications to the use of ArtesenseTM is a known allergy to the local anesthetic, collagen or bovine products. Reactions to this product are very uncommon and if it does occur, then injections of cortisone can great reduce the problem.

For several reasons Canada is further ahead than the United States in all types of injectable fillers. Canada now has large volume injectable fillers which can be used instead of fat transfer, nasal dorsal implants, chin implants, mid face implants, and cheek bone implants. Facial structures can be re-contoured. Dr Ellis can put in 2 -30 cc of product at once. Therefore the desired correction can be improved faster. This is not put in the skin but is put under the skin so it does not deal with wrinkling within the structure of the skin. A combination of BioAlcamid and laser skin resurfacing such as Fraxel CO2 laser or Pearl Fusion to smooth out the skin is ideal. Bio-Alcamid is a gel polymer of Alkyl-imide groups which is a non-toxic chemically and physically stable with a high compatibility when placed inside the body in the subcutaneous facial area.

Because these implants require a large bore needle they are considered a surgical injectable implant. The area to be injected requires an anesthetic by in nerve block or a local infiltration. Usually two sessions are needed to get the correct volume in the correct position. If Bio-Alcamid is used, prophylactic antibiotics by mouth are required starting the day before and continuing for five days.

Bio-Alcamid is primarily used for facial wasting commonly seen with the antiviral drugs used in the treatment of HIV. Any facial wasting caused by aging, trauma, and disease processes can be treated with large volume injectable fillers.

Complications from these injections are few and far between. Infection is very uncommon but is treatable with antibiotics. Partial removal of the implant may be necessary to help the infection resolve. Mal placement and migration rarely can occur but can be easily treatable with needle aspiration. Reaction to the implants has not been described in Canada or in Italy where the Bio-Alcamid has been in existence for 71/2 years. A patient with BioAlcamid in the cheeks must avoid having another doctor or dentist put the needle through the product into the mouth for anesthesia or implantation of another injectable filler. If this is necessary, then the patient should take antibiotic (Keflex or Clindamycin) one hour before the injection to minimize the chance of infection.