Dermal Fillers: Narrowing the Field

Narrowing the Field

With more than 20 dermal fillers currently on the market in the United States and several more in the FDA pipeline, the question for practitioners is no longer, “Are my patients interested in these procedures?” Rather, the question has become, “How many of these fillers do I need to stock, and which ones offer the best results and value for my patients?”

Each filler offers its own unique characteristics. But, generally speaking, dermal fillers fall within categories based on their thickness—or G Prime—and mechanism of action as a volumizer or stimulator.

Volumizers and Stimulators

Sculptra Aesthetic (poly-L-lactic acid, Valeant) and LaViv (Fibrocell Science), which uses the patient’s own tissue to create an injectable that encourages collagen production, are stimulators. Hyaluronic acid fillers, which physically fill areas that need volume, are considered volumizers.

“If you tell people, ‘I can inject something that will turn your own body on, and it’s going to build collagen and elastin,’ that’s very appealing, in abstract,” says Anthony P. Sclafani, MD, FACS, of the Center for Facial Plastic Surgery in Chappaqua, New York. “But then you have to tell them that it is not an instantaneous effect; they have to wait several weeks, and it may require several injection sessions. That works well if you’re in your 30s and have only a shadow of a wrinkle. But if you’re severely volume depleted, that’s a big commitment that really needs to be discussed.”

There is evidence that HA fillers can perform double duty as both volumizers and stimulators, but the amount of long-term improvement tends to be minimal. “Most of these will also stimulate—the question is, what can you expect of that stimulation?” says Dr. Sclafani. “Dermal needling is popular and can lead to dermal collagen deposition. So when I inject an HA filler, the process of passing the needle back and forth through the skin may stimulate some collagen. There’s also pretty good evidence that the microenvironment around the deposition of hyaluronic acid will stimulate collagen production. How much? In most patients, very little. It’s on more of a cellular level.”

Radiesse (calcium hydroxyapatite, Merz Aesthetics) and ArteFill (polymethylmethacrylate, Suneva Medical) are true combination volumizers and stimulators, featuring tiny beads in a gel carrier. As the body absorbs the carrier, it is replaced by fibrosis around the beads. “In most people’s hands, Radiesse and ArteFill are one-to-one corrections—what you see is what you’re going to get—even though the carrier is absorbed, because you’re also developing some fibrosis around those beads,” says Dr. Sclafani.

Within the category of volumizers, fillers are categorized based on their G prime or thickness. Products with a low G prime have some spread, while those with a high G prime—such as Voluma XC (Allergan)—hold their shape. “Voluma is unique in that the cross-links in the molecules are bound very tightly and very densely, so they stack up on top of each other,” says Lorrie Klein, MD, OC Dermatology in Laguna Niguel, California. “It’s almost like one of those magnet paperweights. When I picture Voluma working, I picture little towers I’m putting in that actually push the skin up, rather than just raising the tide, which is what the other fillers do.”

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How Many Do You Need?

With so many types and brands of filler now on the market, it can be challenging to determine how many products you need to carry. Some of this depends on your patient base—their age, typical concerns and desired treatments. Most practices can treat a wide variety of indications with a fairly basic palette.

“You need at least three fillers—a light, medium and deep,” says Dr. Klein. “For fine lines or vermilion borders, you want something lighter, like Juvéderm Ultra. If you’re placing something in the dermis that’s not over the bone, such as smoothing out marionette lines, then I would use Juvéderm Plus or another medium-depth filler. For cheeks or anywhere that you’re going over the bone, you want something that goes deep—I use Voluma. You want to make sure you have something for each of those indications or you’re going to be using the same product over and over again, and you’re not going to get optimal results in some of these areas.”

Practices that do more advanced filling—such as in the tear troughs—and those working with a lot of older patients with thinner skin, may need to carry additional fillers for these concerns. “I don’t like to use Juvéderm products in the tear troughs, because they can create a Tyndall effect,” says Dr. Klein. “I like to use Restylane in this area. Belotero is another option. It doesn’t last as long, but it has some advantages in patients with very thin skin—but that’s the only time I use it, so I don’t carry a lot.”

Dr. Sclafani also carries some specialized fillers, including Belotero Balance (Merz Aesthetics) for use under thin skin. He points out that skilled injectors can modify the fillers they have in their offices for specific areas of treatment. “The problem is, you don’t want to open four tubes of filler if you only need 2cc of augmentation,” he says. “But because of where you want to put it, you’re using different ones—that gets very expensive for the patient. A well-trained injector really should have the capacity to be more subtle in their use, in terms of how those few filler materials they have can be blended and modified on the fly.”

Mixing the filler with lidocaine, for example, will change the viscosity. Using a smaller needle to inject will also affect the product’s properties. “Switching to a smaller needle size can break down the particles and reduce the G prime and cohesiveness, because you’re breaking down the material,” says Dr. Sclafani. “The needles provided are designed to maximize the particle size and cohesiveness of any of these gels. When you switch to a smaller needle, you are going break down those particles. You can use that to your advantage.”

Investigating New Fillers

Part of remaining competitive in the medical aesthetics field is staying up to date on the latest products coming to market, but deciding which of these new fillers deserves a place on your shelves is a challenge.

“It’s very difficult to filter through all the chatter
and all the noise,” says Dr. Sclafani. “Often, patients know about these fillers before the doctor knows what they are all about.” He recommends checking the U.S. Food and Drug Administration (FDA) website,, and searching the brand name to investigate new products.

“Fillers that are approved for sale in the U.S. have to be approved by the FDA—and the FDA will post all the supporting documentation for the approval of these products online, including the actual details of the clinical trials,” he says.

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The key areas for practitioners to review include the approved indications, endpoints used to determine efficacy and methods used to study the filler. The reason: These studies often include “treatment at will” or touch-ups to achieve the final results. “If the average clinical trial dose is 7cc, no patient is ever going to do that. If it turns out there is a touch-up halfway through the clinical trial, most patients are surprised to learn that,” says Dr. Sclafani. “So it’s important to read through that information as it typically isn’t included in the marketing materials that we’re presented with.”

Dr. Klein puts safety first when determining which fillers are right for her practice. “If the FDA approves it, you assume it’s safe, but you also want to look at it from another viewpoint: Can it be reversed?” she says. “Hyaluronic acid fillers tend to be the safest products because they can be reversed. There is definitely a niche for long-term fillers, like ArteFill—that lasts five years or more—because there are some people who will not come back to redo their fillers. But the majority of people will come back, particularly if they know the filler can be reversed if they’re not happy.”

Additionally, she looks at whether the new product will overlap with something she already offers. In this case, she only considers introducing a new product if it offers greater longevity of results or a better safety profile. “You can also get into the subject of partnership programs with companies where you get more perks and sometimes rebates when you order more products from one company,” says Dr. Klein. “If you’re splitting your purchases up to buy something that’s exactly equal from another company, you’re losing some of those perks.”

Professional society meetings are also valuable in examining new fillers. Attending sessions and talking with colleagues about their experiences can help physicians make an informed decision about which fillers are worth investigating. “A lot of the information we get is from colleague appraisal. ‘I’ve been using this and it’s great.’ But ask questions: ‘Where have you been using it, why is it great?’” says Dr. Sclafani. “Also, delve into the FDA report. It looks daunting, but if you get right down to the setup, it’s critical information and you can glean a lot of information from these studies.”

Inga Hansen is the executive editor of MedEsthetics.

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