Fillers and Injectables: A Historical Perspective

September 2014 | Volume 13 | Issue 9 | Editorials | 1010 | Copyright © September 2014


Vivian W. Bucay MD FAAD

downturn of 2008, patients began to focus on getting more “bang for the buck,” ie, maximal results with a minimum of product. It was during this time that my use of calcium hydroxylapatite (Radiesse®) increased, with patients reporting a high degree of satisfaction, similar to that noted in the 47-month study by Sadick, Katz, and Roy.7 Robust and lacking the hydrophilic properties of HA’s, Radiesse® is an excellent option for creating a defined jawline and sculpted cheekbones. With the exception of the lip, Radiesse® is a versatile soft tissue filler8 and can be premixed with lidocaine to minimize injection-related discomfort, without affecting results.9
Injection fatigue, a desire for discrete and gradual results, severe lipoatrophy – all scenarios for which I may recommend poly-Llactic acid (PLLA), Sculptra® Aesthetic. My initial experiences with PLLA (New-Fill, as it was known in Mexico), date back to 2000 and were disappointing. A low-volume reconstitution two to three hours prior to injection was a recipe for clogged needles, nodules, and unimpressive volumization. With HA fillers being so readily available and user-friendly, I quickly abandoned PLLA as a viable option for panfacial volume restoration, despite favorable reports in the literature.10 I credit friend and colleague Cheryl Burgess for rekindling my interest in PLLA. In my view, peer-to-peer hands-on training is unsurpassed as a pathway to mastering a skill, and I sought every opportunity to train with highly experienced injectors, including Cheryl Burgess, Todd Andrews, Danny Vleggaar, and Rebecca Fitzgerald. I am additionally grateful for giving Sculptra Aesthetic® a second chance because I would have otherwise missed the opportunity to understand the aging face, about which so much has been published in the last several years.11,12,13,14 Concepts learned in the optimal use of PLLA have become the foundation for the use of all fillers.
Individualizing a treatment often calls for the use of more than one type of filler. For example, I may use Voluma® or Radiesse® in the mid face, Restylane® for the lips and Belotero® Balance to treat etched perioral lines. Aesthetic medicine involves artistry, and artistry often calls for understanding and leveraging the subtle nuances that distinguish one filler from another. Knowledge of underlying scientific principles coupled with a more complete understanding of the complexity of facial aging have taken filler use to another level.
The practice of facial aesthetics is truly a privilege, and we must not overlook our responsibility to stay current. Beyond the scope of this editorial are filler safety and complications, blunt-tipped microcannulas, Ha fillers for skin conditioning, diluting HA’s for treatment customization, hyaluronidase, injection techniques such as the tower technique, and new and emerging fillers in the US market. Many of these topics are discussed in Parts I (Vol 11 issue 3) and II (Vol 11 issue 8) of the 2012 JDD issues “The New Face of Fillers: A Multi-Specialty CME Initiative.”
A popular saying tells us that “aging is not for sissies,” to which I add that neither is the practice of facial aesthetics. Doing our due diligence and sharing the results of our quest in the pursuit of enhancing patient outcomes is integral to achieving success in this exciting and ever changing field. And so the journey continues.
Sincerely,
Vivian W. Bucay MD FAAD
Bucay Center for Dermatology and Aesthetics, San Antonio, TX
University of Texas Health Science Center, San Antonio, TX

Disclosures

Dr. Bucay is a consultant for Allergan and Merz.

References

  1. Klein, AW. Implantation Technique for Injectable Collagen. J Am Acad Dermatol. 1983, 9:224–228.
  2. Taub, A. Message from the Guest Editor. J Drugs Dermatol. 2012, 9:1030.
  3. Vleggaar, D, Fitzgerald R. Dermatological Implications of Skeletal Aging: A focus on supraperiosteal volumization for perioral rejuvenation. J Drugs Dermatol. 2008, 7(3):209-220.
  4. Sundaram H, Voigts B, Beer K, Meland M. Comparison of the rheological properties of viscosity and elasticity in two categories of soft tissue fillers:calcium hydroxylapatite and hyaluronic acid. Derm Surg. 2010, 36 (suppl 3):1859S-1865S.
  5. Stocks D, Sundaram H, et al. Rheological evaluation of the physical properties of hyaluronic acid dermal fillers. J Drugs Dermatol. 2011, 10(9):974-980.
  6. Sklar JA, White SM. Radiesse FN: a new soft tissue filler. Dermatol Surg. 2004, 30(5): 764-8.
  7. Sadick NS, Katz BE, Roy D. A Multicenter, 47-month study of safety and efficacy of calcium hydroxylapatite for soft tissue augmentation of nasolabial folds and other areas of the face. Dermatol Surg. 2007, 33(suppl 2):S122-S126.
  8. Lizzul PF, Narurkar VA. The role of calcium hydroxylapatite (Radiesse) in nonsurgical aesthetic rejuvenation. J Drugs Dermatol. 2010, 9(5):446-50.
  9. Marmur E, Green L, Busso M. Controlled randomized study of pain levels in subjects treated with calcium hydroxylapatite premixed with lidocaine for correction of nasolabial folds. Dermatol Surg. 2010, 36(3):309-15.
  10. Woerle B, Hanke CW, Sattler G. Poly-L-lactic acid: a temporary filler for soft tissue augmentation. J Drugs Dermatol. 2004, 3(4):385-9.
  11. Lambros V. Observations on perioral and midface aging. Plast Reconstr Surg. 2007; 120:1367-1376.
  12. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg, 2007, 119:2219-2227, discussion 2228-2231.
  13. Rohrich, RJ, Pessa JE, Ristow B. The youthful cheek and the deep medial fat compartment. Plast Reconstr Surg. 2008, 121(6):2107-2112.
  14. Fitzgerald R. Fillers and the “three curves of youth.” J Drugs Dermatol. 2012, 11(suppl 8):S9-S11.
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