of collagen fillers in the US market, we can leverage the cohesive polydensified matrix found in Belotero Balance® (Merz) for the
treatment of etched in or in areas where superficial placement of filler is desirable. It is in this spirit that I would like to share with you what fillers I use in my practice and why, with a focus on what I consider to be the strengths of each.
The year is 1996, and by now, I am quite comfortable with combining ablative laser resurfacing for improving the cutaneous aspects of
photodamage and Botox (the only neuromodulator available to me in Mexico at that time) pre- and post- resurfacing to keep lines away.
Proud of the smooth, even toned, wrinkle-free skin of those who trusted me with their cosmetic needs, it was not hard to overlook an
element that was missing but not evident in the well documented two-dimensional before and after photos. It took only a glance at the
profile and oblique views of these satisfied patients to see the obvious – the absence of that fullness inherent to the youthful face.
The introduction of the hyaluronic acid filler, Restylane®, was effortless in a practice comprised of savvy patients who wanted the
latest and greatest; and the premise of using a substance so similar to one found in our bodies to be able to correct folds and
lines that did not respond to other technologies made perfect sense to them and required little explanation from me. I embraced
Restylane and, later Perlane®, with gusto, confidently treating nasolabial folds, marionette lines, and lips.
Not surprising, solving one problem was accompanied by the emergence of new challenges. Why were some nasolabial folds bottomless
pits that no amount of filler seemed to correct? Why did the appearance of tear troughs worsen in some people after treatment of
their nasolabial folds? I made note of these and other puzzling observations and put them into my “I’ll think about this tomorrow†file.
Our family relocated to San Antonio, Texas, in July 1999, and the culture shock that awaited me was professional, not personal. Although readily available, Botox was not yet FDA approved for cosmetic use, and HA fillers were not even on the horizon or vocabulary of the private practitioner. During this aesthetic “famine,†I continued to travel to Mexico City to treat patients every few weeks and continued to gain expertise with HA fillers. It was probably 2002, and I wish I could pinpoint the exact moment that I looked at a patient a little differently and was struck by the obvious – nasolabial folds have their origins elsewhere. Scientific and methodic as I considered myself to be, this time I tried something empirically, placing a little bit of Perlane® in the cheek. The immediate lifting effect was obvious and all I needed to modify my injection strategy. Treating the cheeks was now a matter of routine, with temples quickly following similar suit.
The growth of the aesthetic portion of my practice literally exploded with the approval of Restylane® by the FDA in December
2003. Added bonuses were invitations to share my experience with Restylane® with dermatologists and plastic surgeons at national
meetings and through other venues for continuing medical education. An opportunity to present to colleagues and experts
carries with it the responsibility to learn as much as possible during the preparation.
I may have been sophisticated in designing and executing treatment plans, but I was forced to confront some significant knowledge
gaps following the approval of the Juvéderm family of HA fillers in 2006. Eager to try these new fillers with an even higher
concentration of HA than the Restylane family, I noticed differences in their flow characteristics and also differences in what each
could accomplish. What factors contributed to differences in lifting capacity, smoothness, or degree of swelling? Viscosity, elasticity, and rheology were terms vaguely familiar from college physics but suddenly acquired a new relevance in the process of
filler selection, a topic well presented in some noteworthy publications.4,5 Puzzling as well were differences in duration of the different HA fillers. Was longevity affected by the depth of injection, area injected, or amount of filler used? Experience has shown us that longevity of a given filler is influenced by many factors, but the variability in longevity between individuals still remains a mystery. It is my belief that duration of results can be extended by what is referred to as full correction, whether the treatment
is performed all in one session or over several treatment sessions.
By 2004, some of my otherwise happy Restylane patients had begun to express a desire for something longer lasting, which led me
to explore other options for volumization. A report of a new soft tissue filler containing calcium hydroxylapatite spheres suspended
in an aqueous carrier gel6 prompted me to try Radiance FN (known today as Radiesse®). The concept of immediate correction followed
by subsequent collagen production was appealing, coupled with results showing duration at 12 months. With the economic
