Feature: A Look At The Filler Landscape - By Kenneth Beer, M.D. This cosmetic dermatology expert shares his insights about available fillers and his experience with them in practice. With so many fillers available and so many more on the horizon, it’s a good time to review some of the practical aspects of using these soft tissue fillers. My practice is largely comprised of patients who want to be treated with fillers and/or botulinum toxins, so I’ve gathered some information from my experience in patient care and during my preceptor/training sessions that I’d like to share regarding what’s available and what works best for me. The New Kid on the Block The newest filler to arrive in the United States is Sculptra (NewFill). This material is known to dermasurgeons as vicryl sutures, and we have a comfort level with it in this form. This patient underwent treatment with the filler Radiance. The filler was used for correction of nasolabial folds. This photo depicts the patient before treatment. Photos courtesy of Dr. Ken Beer.        Sculptra, which became available for purchase in September, comes as a powder that must be reconstituted with either sterile water or sterile water and lidocaine. Typical preparations include using 3 cc of water with 1 cc of 2% lidocaine. Other preparations I’ve heard of include using 4 cc water diluted with 1 cc of 1% lidocaine. To date, there is no “best” dilution for patient comfort, nor is it clear how the differing dilutions effect duration and degree of correction. These answers will most likely be provided by clinical trials that should begin in the very near future.        Areas of the face that are good candidates for Sculptra correction include the nasolabial crease, areas of lipoatrophy and marionette lines. I would avoid treating the lips for now. This patient underwent treatment with the filler Radiance. The filler was used for correction of nasolabial folds. This photo depicts the patient following treatment. Photos courtesy of Dr. Ken Beer.        Unlike other materials we’re used to injecting, Sculptra is not a homogenous gel or solution. It is a suspension that has a tendency to come out of suspension. When reconstituting the material, allow the material to sit for at least 2 hours. Many physicians will reconstitute the material the night before anticipated use.        During injection, Sculptra needs to be maintained in an even suspension and should be agitated before use. You’ll find that the needle frequently clogs with this product, but gently withdrawing the syringe or changing the needle will solve this problem.        Sculptra is injected into the deep dermal or dermal/subcutaneous junction. Periosteal injections are also made in the periorbital area. Typical needle angles are about 45 degrees to the skin. Injection techniques include creating small subcutaneous blebs or linear tunnels with the material. Average amounts of material that one should expect to use are about one-half to one bottle per nasolabial crease. Plan retreatments at intervals of about 4 to 6 weeks. Typically, two or three treatments are required to obtain maximal value.        Interestingly, in the HIV lipoatrophy trials used for FDA approval, patients had durable corrections that lasted for at least 1 year and in many instances for more than that. Some side effects seen with this material included bruising and small subcutaneous “papules” that were noticeable, though not bothersome, to patients. Perlane and Restylane Perlane is a material that I use at least as much as Restylane. I’m pleased with its ability to provide volume for deep nasolabial defects, mental ridges, scars and zygomatic arch sculpting. However, you shouldn’t use this material until you have experience with Restylane and are comfortable using hyaluronic acid fillers. Typically, I try to place the product in the deep dermis. This patient had her nasolabial folds treated with Restylane. This photo shows the patient before treatment. Photos courtesy of Dr. Ken Beer.        One pearl that I try to impart when teaching physicians to use this product is to pinch the area that will be treated between the thumb and forefinger and try to fill the Perlane into the groove that’s created. Do not overcorrect with this product, or it will be overcorrected for quite some time. Also, I would not recommend using Perlane in the lips (except in rare circumstances) or in the glabella because it is pretty unforgiving. Expect other products in the future that are thicker and more versatile than Perlane, but, for now, Perlane fills a great void.        I have had more fun using Restylane than any product in quite some time. Patients love the way Restylane can be used to sculpt lips. One complication that can be seen occasionally is the formation of clear gel blebs in the lips (I think this occurs when the material is extruded through the glands of the lips creating Restylane/Fordyce spots). These are easily corrected with use of an 11 blade. Restylane is easily expressed, and the blebs instantly disappear.        Restylane can also easily be used to treat nasolabial creases that are not as deep as those for which you would use either fat or Perlane. It can also be layered over Perlane to etch out the superficial epidermal lines (many patients will actually enjoy watching this). Other areas in which Restylane works surprisingly well are post-operative scars (including depressed grafts) and acne scars. Now that Restylane is available in 1-cc syringes, it’s easy to treat the zygomatic arch and other areas at the same time without having to open four or five syringes. My typical patient uses about 2 cc to 3 cc, and this amount of treatment has become much more cost-effective with the new syringe size. This patient had her nasolabial folds treated with Restylane. This photo shows the patient post-treatment. Photos courtesy of Dr. Ken Beer. Traditional Fillers Older, traditional fillers, such as collagens, are still being used. However, I would estimate that they represent about 5% to 10% of my filler practice. I tend to opt for them for patients who have used them for years and who have been pleased with the duration and cost of bovine-based products.        I have a few patients who consistently use Zyplast and have been pleased with the degree of correction for the nasolabial creases for the amount of money spent. Other patients love the texture of Zyderm and Cosmoderm in areas like the fine lines that are adjacent to prominent nasolabial creases, particularly in smokers. These, as well as Hylaform, are soft enough that they won’t cause bumps if placed at the proper level. Thicker fillers will tend to form unpleasant papules that can persist. On the Horizon Radiance will probably have some clinical trials for cosmetic use at some point, and it will certainly be interesting to see how this product compares with other fillers for degree of correction, persistence of correction, complication rate and cost/benefit ratio.        In my practice, I use Radiance less frequently than other fillers. Most of my hesitation is the lack of data that exist for this product. I have used Radiance for nasolabial creases and for marionette lines and have been satisfied with the degree and duration of correction. Probably over the next year, I will integrate it into my practice more.        When injecting Radiance, I recommend injecting deep into the dermis (avoiding superficial dermal placement). As with other fillers, it’s important to avoid intravascular injection of this material. I would also avoid treating the lips with Radiance until there are better data about the rate of complications in this area.        There are many other fillers in the pipeline, and I’ve had the opportunity to participate in clinical trials for some of them. I’m looking forward to an exciting year, and I think my annual review of fillers next year will be even more interesting.        Dr. Beer is in private practice in West Palm Beach, FL. He’s also Clinical Instructor in Dermatology at the University of Miami, a Consulting Associate in the Department of Medicine at Duke University, and Section Chief of Dermatology at Good Samaritan Medical Center in West Palm Beach. Skin & Aging - ISSN: 1096-0120 - Volume 12 - Issue 10 - October 2004 - Pages: 38 - 40