FILLER

facial Analysis
Ideal facial proportions
 Overview of skin structure

muscle

Epidermis 0.15 mm 0.50 mm (150 m 500m)

Dermis 1.0 mm 3.0 mm (1000 m 3000 m)
 Fat Distribution

Loss from: Prominent increase in:

Preorbital Submental regions
bucccal Jowls
Temporal Lateral NLFs
perioral Lateral MLFs
Lateral malar areas
Infraorbital (atrophy
or hypertrophy)

Loss and redistribution of subcutaneous fat

Young face-------fat is diffusely dispersed
Old face-----------fat accumulates in pockets + gravity to this fat---
sagging &drooping of skin
 Loss of facial bones & cartilage

Bone resorption particularly affects:

Mandible (angle reduction, decrease chin projection)
Maxilla (loss of inferior orbital rim projection)
Frontal bone
Nose cartilage (ptosis of nasal tip)
This enhances facial skin droopiness, loss of cheek convexity
& obliteration of the demarcation between the contour of the
jaw and the neck.
Changes in expression
muscles
Due to repeated traction of facial
muscles
 How wrinkles form?
Movement of brow muscles cause the skin to crease
As skin becomes less elastic over time, repeated frowning
creates visible lines and wrinkles
Sleep lines

corrugator muscles corrugator muscles

procerus muscle
 Treatment of skin aging
Volume restoration:
Re-creation of facial convexities that reflect light & that reduce
the shadows of facial concavities has a strong effect on the
percieved age of a person.
Pulling & tightening of sagging skin
Surgical face lift
Skin tightening via thermal contraction of
collagen
The aim of cosmetic filler usage is to restore
youthful appearance rather than change the
patients natural appearance
 Fillers history
1999
1985
Restylane
Cross-linked
Early 1900s 1940 Launch
Bovine
Parrafin becomes Silicone NASHA
Collagen is
popular emerges on technology
first approved
the scene
by the FDA

1890 Human
fat is the first 1981
type of Bovine Collagen 1995-99
Dermal filler (Zyderm) is first HA animal based
used approved by the fillers appear on
FDA the market
 Fillers classification

SEMI PERMANENT
BIODEGRADABLE PERMANENT
FILLERS
Resorbable in months FILLERS
Resorbable in 1-2 years

Traditional fillers are Permanent fillers play

Semi-permanent fillers
biodegradable (i.e. an important role in
(usually containing
they are metabolised the treatment of
microspheres) offer
and excreted by the patients with HIV-
longer-lasting effects
body) related lipoatrophy.
than traditional fillers
Traditionally, they have
but some are
They have a proven been associated with a
associated with the
record, but the effects high incidence of
development of
of some can be granulomas.
granulomas
relatively short-lived
 Types of fillers
Biodegradable, resorbable Resorbable in years Permanent or
in months (Microparticles) nonresorbable

Bovine collagen (zyderm I & Calcium hydroxylapatite Paraffin

II, zyplast) (CaHA) (Radiesse) Liquid silicone

Human-derived collagen Poly-L-Lactic acid (PLLA) Polymethylmethacrylate

(cosmoderm, cosmoplast) (Sculptra) (Artecoll)

Hyaluroic acid: Polyacrylamide hydrogel

-rooster combs HA (avian) (Aquamid)
(Hylaform)
-NASHA HA ( bacterial) Hydroxyethylmethacrylate
(Restylan, Perlane, Juvederm (Dermalive)
ultra & Juvederm ultra plus)
BACTERIAL vs ANIMAL HA FILLER
 HA What is that?
A Natural Polysaccharide Carbohydrate
Found in all living organisms (HA has no organ or species specificity, highly
biocompatible, no risk of allergic reaction)

In Humans, HA resides in many tissues of the body:

Dermis of the skin (forming part of the extracellular matrix)
Cartilage, bone & synovial fluid
Vitreous body
Blood vessels
 HA The main Property
HA is highly hydrophilic
(hygroscopic capacity)

Can attract and bind water

up to 1000 times its own
weight
The hydrophilic quality is the most important
characteristic of HA, conducive to maintaining adequate
internal hydration, lubrication, and moisture retention in
the body.
 HA The functions in the skin
Traps a vast amount of moisture to keep
the skin hydrated
Provides viscoelastic properties,
acting as a shock absorber and lubricant
Helps new skin cells grow and
replace old cells (provide support for tissues)
Helps skin cells produce collagen
and other substances essential for
maintaining skin structure
Protects skin cells by preventing free
radical activity (free radical scavenger)
HA in the Skin

The largest amount of HA resides in skin tissue

about 7-8g per adult human (total 12gm)
about 56% of the total amount in the body (the rest in
eyes and joints)
the dermis has 2-4mg/ml
the epidermis has 0.5mg/ml
The half-life of HA in the skin is usually less than one day
One third of the HA in the body is removed and replaced
every day
 Filler General Knowledge (2)
Effects of Aging on HA natural production

Thinning of the skin

Loss of fullness of the lips
Sunken eyes or cheeks
More prominent facial bones and blood vessels (as skin loses volume)
Ptosis of the nose
Wrinkles around the eyes and mouth
 Filler General Knowledge - Cross-linking process

Biological half-life of natural HA in the skin is only 1 2 days

To prevent such rapid degradation, HA molecules are bound together

= CROSS LINKING PROCESS

More resistant to More resistant to degradation

More resistant to heat
Mechanical Stress by enzymes and free radicals

MOST IMPORTANT Cross Linking process does not prevent HA from binding large
volumes of water
 BDDE
BDDE = Butandiol Diglycidyl Ether
BDDE stabilizes the HA and makes it last longer but still leaves its
hydrophilic property
BDDE is the least toxic cross-linking agent, but is still toxic when
unbound
Reactions to HA fillers are caused by unbound BDDE

The lower the level of free BDDE, the better it is

Cross Linking Effect
 CROSS-LINKING PROCESS

Liquid Gel Solid

As you increase the degree of cross-linking, a liquid will first become a gel and then a solid.
How does cross-linking affect stability?

Easily damaged fence

Add more cross-links

More stable fence

 Concentration of cross-linker

Too little

Hyaluronic
acid
molecule

Just right Cross-linker

Number of cross-linking molecules
that bind to HA
Excess
cross-linker in
solution

Too many
cross-links in
the molecule
Efficacy of cross-linking
Low efficacy
cross-linking

Efficacious
cross-linking
Homogeneity of cross-linking
Cross-linking not
equal - heterogenous

Cross-linking is
equal - homologous
 Parameters that influence dermal filler
performance
Hyaluronic acid cross-linking is essential in influencing a
dermal fillers characteristics (vicosity & longivity). But, cross-
linking is governed by four parameters:
the concentration of cross-linker
the number of cross-linking molecules that bind to hyaluronic acid
the homogeneity of cross-linking density
the efficacy of cross-linking.

Different sizes of particles, thus products vary in their

clinical applications (used for fine lines to deep folds)
 The ideal filler
Easy to use,
Effective &
predictable
Long lasting
Has a high safety
Effect but
profile
degradable

A good filler
Has a lot of
High conc. Of
Clinical &
H.A & less
Experimental
pain
studies

Has a good range

Gives a natural
For all
Look & feel
Indications&
( homogenous)
All patients
 Safety of fillers

Biocompatible, with low immunogenicity

Stable at implantation and no risk of migration
No risk of infectious contamination
No risk of carcinogenic potential
No risk of teratogenicity
FDA approved for its safety and target indication
 Longivity of Filler

Injection technique and depth of deposition

Amount injected
Location or area treated (mechanical stress at site of Rx)
Individual response and charachteristics
The injected material itself :
Degree of crosslinking (the higher the longer)
Concentration of crosslinking
3D molecule
Gel hardness
Calcuim hydroxylapatite
(Radiesse)
 Product description
Radiesse contains biomaterials with well established and understood
safety and performance characteristics
Components
CaHA Particles (30% by volume)
Standard biomaterial
Used in orthopedics, ENT, dentistry
Extensive studies on safe use as
biomaterial
Natural - same composition as mineral in
bone and teeth
Gel Carrier (70% by volume)
Cellulose based gel with glycerin and
sterile water
GRAS Classified by FDA (Generally
Recognized as Safe)
 Product characteristics
Radiesse microspheres are formed from pure,
synthetic CaHA particles composed of Ca2+ and
PO43- & hydroxide ions

Ca2+ and PO43- ions are a natural component of

teeth and bone, making them inherently safe and
biocompatible

The CaHA microspheres are uniform in shape and

range in size from 25 45m in diameter

The gel carrier holds the microspheres together

and is fully resorbeable
 Radiesse; mode of action

Gel carrier performs as a passive filler initially, resulting in

immediate 1:1 correction
 Radiesse; mode of action

Macrophages dissolve gel carrier

 Radiesse; mode of action

Macrophages dissolve gel carrier & fibroblasts form new

collagen
 Radiesse; mode of action

New resident tissue (collagen) anchors microspherules of

CaHA
 Radiesse; mode of action

CaHA particles degrade and macrophages metabolize

microspheres (enzymatic rather than phagocytosis)
 Soft tissue behavior

Gel carrier with CaHA provides the initial correction

(0-4 months)
Macrophages dissolve gel carrier
Fibroblasts form new collagen
New resident tissue anchors particles: collagen
formation
Combined matrix (CaHA & natural tissue) results in
increased longevity (12+ months)

Soft tissue histology

no antigenic or major
inflammatory response
new dermal extracellular
matrix
No migration 16 week human histology
No calcification or ossification
 X-ray & CT-scan & CaHA
Conclusions X-ray:
CaHA is not consistently visible; depending on volume present
CaHA does not obscure underlying structures
Dental work is always visible

Conclusions CT-scan:
Consistently visible
CaHA does not obscure underlying structures
No evidence of CaHA migration
 Viscosity and Elasticity :
providing volumizing and lifting capacity

2 physical characteristics of dermal fillers that dictate

their ability to volumize and lift:
Radiesse has a
High viscosity (ability to resist a force that is applied
to it) so remains in place with increase bulking

High elasticity (ability to push back

against a force applied to it (as gravity) ).
 Preoperative evaluation
Consult with patient
Define the patients expectations
Assess globally then identify area(s) to be injected
Consent
Document and discuss preexisting scars, subcut. volume
differences between facial sides and any asymmetry.
(photo prior to procedure)
Avoidence of elective blood thinning medicine
Disinfect skin
Provide anaesthesia (topical, nerve block)
Disinfect again and mark areas to be treated
 Postprocedures instructions
Cold packs (intermittently)
Supplements that reduce bruising (vitamin K
cream)
Review after 2 weeks to assess satisfaction, as
well as photographs and potential touch up.
Indications for using HA-based dermal
fillers
HA-based dermal fillers are indicated for use in
several different aesthetic procedures. These
procedures include:
glabellar (vertical frown) lines
nasolabial folds
oral commissures
vermillion borders (lip definition)
marionette lines
lip augmentation
cheekbones.
INJECTIONS LOCATIONS

Glabellar lines (frown lines)

Periorbital lines (crows feet)
Ocular Sulcus (tear troughs)
Nasolabial lines (smile lines)
Perioral lines (smokers lines)
Oral commissures
Marionette lines
Vermilion border lip enhancement
Acne scarring
 Injection techniques
Injection techniques used for delivering dermal
fillers:
linear threading
serial puncture
layering
Fanning
Bolus
 Injection Techniques

Most common
Linear threading technique
Serial puncture technique
Layering technique
 Fanning technique

5
2

4
3

1
3
2
 Guidelines for using HA-based dermal
Glabellar lines
fillers
1015

Step 1 Step 2

1015

Step 3
 Guidelines for using HA-based dermal
fillers
Nasolabial folds

45

Step 1 Step 2

Step
3
 Guidelines for using HA-based dermal
fillers
Oral commissures

30 A

C
A
B
Step 1 Step 2

30 A
B
C
10

Step Step 4
3
 Potential adverse events associated with
dermal fillers
Acute injection site reactions (most commonly seen) mild to
moderate swelling or bruising.
Superficial or inappropriate placement ( lumpiness,
nodularity or visibility) (Rx hyaluronidase for HA, for CaHA if shallow
nick the skin with blade & express nodule or dilute it out by saline inection)
Sensitivity (Rx topical &IL steroids) (later development of painful,
erythematous, inflammatory nodules)
Infection (Rx antibiotics) (rare, reactivation of HSV or contamination of
non FDA products)
Necrosis (occluding or compressing an artery) (Rx hyaluronidase)
(glabella supratrochlear a., NLF angular a., lips labial a.)
 Precautions to reduce risk of necrosis at
glabella
Inject medially and superficially

Using low volumes

Rx spread over multiple sessions

Aspirating before injecting

 Algorithm for management of angry red
bumps
Lesion fluctuant-----------needle aspiration or incision & drainage,
gram/acid fast stain, culture & sensitivity, antibiotics (14 days).
Worse----------may need chronic antibiotic suppression & IL steroids.

Lesion non-fluctuant---------antibiotics (7days), then IL steroids?

Still---------------consider a calcineurin inhibitor & consider a biopsy for
confirmation.

NB: Histopathology remains the criterion standard for identification of the

responsible filler. The variation in microscopic morphology of the
implanted particles and hydrogel allows to classify most cases
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