The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

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Part III  Nonsurgical Cosmetic Treatments
Suggested Readings
Arikan OK, Tan FU, Kendi T, et al. Use of botulinum toxin type A for the treatment of mas-
seteric muscle hypertrophy. J Otolaryngol 35:40-43, 2006.
Arnon SS, Schechter R, Inglesby TV, et al; Working Group on Civilian Biodefense. Botulinum
toxin as a biologic weapon: medical and public health management. JAMA 285:1059-
1070, 2001.
Ascher B, Zakine B, Kestemont P, et al. A multicenter, randomized, double-blind, placebo-
controlled study of efficacy and safety of 3 doses of botulinum toxin A in the treatment
of glabellar lines. J Am Acad Dermatol 51:223-233, 2004.
Bentivoglio AR, Fasano A, Ialongo T, et al. Fifteen-year experience in treating blepharospasm
with Botox or Dysport: same toxin, two drugs. Neurotox Res 15:224-231, 2009.
Bhogal PS, Hutton A, Monaghan A. A review of the current uses of Botox for dentally re-
lated procedures. Dent Update 33:165-168, 2006.
Brandt F, Swanson N, Baumann L, et al. Randomized, placebo-controlled study of a new
botulinum toxin type A for treatment of glabellar lines: efficacy and safety. Dermatol
Surg 35:1893-1901, 2009.
Brashear A. Botulinum toxin type A in the treatment of patients with cervical dystonia. Bio -
logics 3:1-7, 2009.
Brisinda G, Cadeddu F, Brandara F, et al. Botulinum toxin for recurrent anal fissure follow-
ing lateral internal sphincterotomy. Br J Surg 95:774-778, 2008.
Carruthers A, Carruthers J. Clinical indications and injection technique for the cosmetic use
of botulinum A exotoxin. Dermatol Surg 24:1189-1194, 1998.
Carruthers A, Carruthers J. Cosmetic uses of botulinum A exotoxin. In Klein AW, ed. Tissue
Augmentation in Clinical Practices. New York: Marcel Dekker, 1998.
Carruthers J, Carruthers A. Practical cosmetic Botox techniques. J Cutan Med Surg
3(Suppl):S49-S52, 1999.
Carruthers J, Fagien S, Matarasso SL; Botox Consensus Group. Introduction to the consen-
sus recommendations. Plast Reconstr Surg 114(6 Suppl):1S-22S, 2004.
Chang CY, Chabot P, Walz CM. A survey of current practices of physicians who treat ad-
ductor spasmodic dysphonia in the U.S. Ear Nose Throat J 88:E18, 2009.
Clark RP, Berris CE. Botulinum toxin: a treatment to facial asymmetry caused by facial nerve
paralysis. Plast Reconstr Surg 84:353-355, 1989.
De Boulle K. Patient satisfaction with different botulinum toxin type A formulations in the
treatment of moderate to severe upper facial rhytids. J Cosmet Laser Ther 10:87-92,
2008.
de Mato M, Rzany B. Botulinum Toxin in Aesthetic Medicine. New York: Springer, 2007.
Dodick DW. Botulinum neurotoxin for the treatment of migraine and other primary headache
disorders: from bench to bedside. Headache 43(Suppl 1):S25-S33, 2003.
Fagien S. Botox for the treatment of dynamic and hyperkinetic facial lines and furrows: ad-
junctive use in facial aesthetic surgery. Plast Reconstr Surg 103:701-713, 1999.
Farahvash MR, Arad S. Clostridium botulinum type A toxin for the treatment of upper face
animation lines: an Iranian experience. J Cosmet Dermatol 6:152-158, 2007.

Feller G, Bayerl C, Jung E, et al. Treatment of dynamic facial wrinkles with botulinum toxin
type A (Dysport)—a pilot study. Aktuelle Derm 26:65-69, 2000.
Figus A, Mazzocchi M, Dessy LA, et al. Treatment of muscular contraction deformities with
botulinum toxin type A after latissimus dorsi flap and sub-pectoral implant breast re-
construction. J Plast Reconstr Aesthet Surg 62:869-875, 2009.
Flynn MK, Amundsen CL, Perevich M, et al. Outcome of a randomized, double-blind, placebo
controlled trial of botulinum A toxin for refractory overactive bladder. J Urol 181:2608-
2615, 2009.
George RM, Singer R. The lines and grooves of the face: a suggested nomenclature. Plast
Reconstr Surg 92:540-542, 1993.
Goschel H, Wohlfarth K, Frevert J, et al. Botulinum A toxin therapy. Neutralizing and non-
neutralizing antibodies—therapeutic consequences. Exp Neurol 147:96-102, 1997.
Grunfeld A, Murray CA, Solish N. Botulinum toxin for hyperhidrosis: a review. Am J Clin
Dermatol 10:87-102, 2009.
Gui D, Mingrone G, Valenza V, et al. Effect of botulinum toxin antral injection on gastric
emptying and weight reduction in obese patients: a pilot study. Aliment Pharmacol Ther
23:675-680, 2006.
Guyuron B, Tucker T, Kriegler J. Botulinum toxin A and migraine surgery. Plast Reconstr
Surg 112(5 Suppl):171S-173S, 2003.
Hamilton D. Classification of the aging face and its relationship to remedies. J Clin Derma-
tol 35, 1998.
Heckmann M, Schon-Hupka G. Quantification of the efficacy of botulinum toxin type A by
digital image analysis. J Am Acad Dermatol 45:508-514, 2001.
Intiso D, Basciani M. Botulinum toxin type A in the healing of a chronic buttock ulcer in a
patient with spastic paraplegia after spinal cord injury. J Rehabil Med 41:1100-1102,
2009.
Jabbari B. Treatment of chronic low back pain with botulinum neurotoxins. Curr Pain Head -
ache Rep 11:352-358, 2007.
Kane MA, Brandt F, Rohrich RJ, et al; Reloxin Investigational Group. Evaluation of vari-
able-dose treatment with a new U.S. botulinum toxin type A (Dysport) for correction
of moderate to severe glabellar lines: results from a phase 3, randomized, double-blind,
placebo-controlled study. Plast Reconstr Surg 124:1619-1629, 2009.
Karsai S, Adrian R, Hammes S, et al. A randomized double-blind study of the effect of Botox
and Dysport/Reloxin on forehead wrinkles and electromyographic activity. Arch Der-
matol 143:1447-1449, 2007.
Kim NH, Chung JH, Park RH, et al. The use of botulinum toxin type A in aesthetic mandibu-
lar contouring. Plast Reconstr Surg 115:919-930, 2005.
Kinney BM, Hughes CE III. Soft tissue fillers: an overview. Aesthet Surg J 21:469, 2001.
Knize DM. Muscles that act on glabellar skin: a closer look. Plast Reconstr Surg 105:350-
361, 2000.
Laskawi R. The use of botulinum toxin in head and face medicine: an interdisciplinary field.
Head Face Med 4:5, 2008.
Lee SJ, McCall WD Jr, Kim YK, et al. Effect of botulinum toxin injection on nocturnal brux-
ism: a randomized controlled trial. Am J Phys Med Rehabil 89:16-23, 2010.
325
Chapter 11  Botulinum Toxin Injections for Facial Rejuvenation

Lemperle G, Holmes RE, Cohen SR, et al. A classification of facial wrinkles. Plast Reconstr
Surg 108:1735-1750, 2001.
Liew S, Dart A. Nonsurgical reshaping of the lower face. Aesthet Surg J 28:251-257, 2008.
Lowe NJ. Botulinum toxin type A for facial rejuvenation. United States and United King-
dom Perspectives. Dermatol Surg 24:1216-1218, 1998.
Lukban MB, Rosales RL, Dressler D. Effectiveness of botulinum toxin A for upper and lower
limb spasticity in children with cerebral palsy: a summary of evidence. J Neural Transm
116:319-331, 2009.
Marciniak C, Rader L, Gagnon C. The use of botulinum toxin for spasticity after spinal cord
injury. Am J Phys Med Rehabil 87:312-317, 2008.
Matarasso A. Facial resurfacing and adjuncts. In McCarthy JG, Galiano RD, Boutros S, eds.
Current Therapy in Plastic Surgery. St Louis: Elsevier Health Sciences [in press].
Matarasso A. (Invited Discussion). New indications for botulinum toxin type A in cosmet-
ics: mouth and neck. Plast Reconstr Surg 110:612, 2002.
Matarasso A, Centeon RF, Boswell CB. Botulinum toxin for managing focal hyperhidrosis.
Aesthet Surg J 23:67-69, 2002.
Matarasso A, Chia C; American Society of Plastic Surgeons DATA Committee. Follow-up:
botulinum toxin. Plast Reconstr Surg 112(5 Suppl):62S-65S, 2003.
Matarasso A, Deva A; American Society of Plastic Surgeons DATA Committee. Botulinum
toxin. Plast Reconstr Surg 109:1191-1197, 2002.
Matarasso A, Matarasso SL. Treatment guidelines for botulinum toxin type A for the peri-
ocular region and a report on partial upper lip ptosis following injections to the lateral
canthal rhytids. Plast Reconstr Surg 108:208-214, 2001.
Matarasso SL, Matarasso A. “M” marks the spot: update on treatment guideline for botu-
linum toxin A for the periocular area. Plast Reconstr Surg 112:1470-1472, 2003.
Matarasso A, Shafer D. Botox cosmetic. In Nahai F, Nahai F, Codner MA, eds. Techniques in
Aesthetic Plastic Surgery: Minimally Invasive Facial Rejuvenation. Philadelphia: Else-
vier, 2009.
Miller D, Richardson D, Eisa M, et al. Botulinum neurotoxin-A for treatment of refractory
neck pain: a randomized, double-blind study. Pain Med 10:1012-1017, 2009.
Monheit G, Carruthers A, Brandt F, et al. A randomized, double-blind, placebo-controlled
study of botulinum toxin type A for the treatment of glabellar lines: determination of
optimal dose. Dermatol Surg 33(1 Spec No):S51-S59, 2007.
Moy R, Maas C, Monheit G, et al; Reloxin Investigational Group. Long-term safety and ef-
ficacy of a new botulinum toxin type A in treating glabellar lines. Arch Facial Plast Surg
11:77-83, 2009.
Olthoff A, Laskawi R, Kruse E. Successful treatment of autophonia with botulinum toxin:
case report. Ann Otol Rhinol Laryngol 116:594-598, 2007.
Pickett A. Dysport: pharmacological properties and factors that influence toxin action. Tox-
icon 54:683-689, 2009.
Pohl D, Tutuian R. Achlasia: an overview of diagnosis and treatment. J Gastrointestin Liver
Dis 16:297-303, 2007.
Porta M, Maggioni G, Ottaviani F, et al. Treatment of phonic tics in patients with Tourette’s
syndrome using botulinum toxin type A. Neurol Sci 24:420-423, 2004.
326
Part III  Nonsurgical Cosmetic Treatments

Rohrich RJ, Janis JE, Fagien S, et al. Cosmetic use of botulinum toxin. Plast Reconstr Surg
112(5 Suppl):177S-191S, 2003.
Rowe FJ, Noonan CP. Botulinum toxin for the treatment of strabismus. Cochrane Database
Syst Rev 2:CD006499, 2009.
Rubin MG, Dover J, Glogau RG, et al. The efficacy and safety of a new U.S. botulinum toxin
type A in the retreatment of glabellar lines following open-label treatment. J Drugs Der-
matol 8:439-444, 2009.
Rzany B, Ascher B, Fratila A, et al. Efficacy and safety of 3- and 5-injection patterns (30 and
50 U) of botulinum toxin A (Dysport) for the treatment of wrinkles in the glabella and
the central forehead region. Arch Dermatol 142:320-326, 2006.
Rzany B, Dill-Muller D, Grablowitz D, et al. Repeated botulinum toxin A injections for the
treatment of lines in the upper face: a retrospective study of 4,103 treatments in 945 pa-
tients. Dermatol Surg 33:S18-S25, 2007.
Saemi AM, Plante MK. Injectables in the prostate. Curr Opin Urol 18:28-33, 2008.
Saylan Z. Facial fillers and their complications. Aesthet Surg J 23:221-224, 2003.
Schnider P, Binder M, Auff E, et al. Double-blind trial of botulinum A toxin for the treat-
ment of focal hyperhidrosis of the palms. Br J Derm 136:548-552, 1997.
Shaw L, Rodgers H. Botulinum toxin type A for upper limb spasticity after stroke. Expert
Rev Neurother 9:1713-1725, 2009.
Simonetta Moreau M, Cauhepe C, Magues JP, et al. A double-blind, randomized, compar-
ative study of Dysport vs. Botox in primary palmar hyperhidrosis. Br J Dermatol 149:
1041-1045, 2003.
Slopp RR, Cole BA, Escutin RO. Reconstituted botulinum toxin type A does not lose po-
tency in humans if it is refrozen or refrigerated for two weeks before use. Neurology
48:249-253, 1997.
Tartaro G, Rauso R, Santagata M, et al. Lower facial contouring with botulinum toxin type
A. J Craniofac Surg 19:1613-1617, 2008.
Van Beek AL, Lim PK, Gear AJ, et al. Management of vasospastic disorders with botulinum
toxin A. Plast Reconstr Surg 119:217-226, 2007.
Ward AB, Molenaers G, Colosimo C, et al. Clinical value of botulinum toxin in neurological
indications. Eur J Neurol 13 Suppl 4:20-26, 2006.
Zimbler MS, Kokoska MS, Thomas JR. Anatomy and pathophysiology of facial aging. Fa-
cial Plast Surg Clin North Am 9:179-187, 2001.
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Soft Tissue Fillers in
Aesthetic Facial Surgery

TREVOR M. BORN, LISA AIRAN,
DIMITRIOS MOTAKIS, FOAD NAHAI
CHAPTER 12

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S
oft tissue fillers are an exciting tool for cosmetic surgeons striving to meet the
growing patient demand for facial rejuvenation that requires minimal down
time. For younger patients, these materials offer the potential for staving off the first
visible signs of aging without the morbidity associated with more invasive surgical
procedures. These materials are also appealing to individuals who want to look re-
freshed but do not want to take the time that a major lift would involve. Fillers also
serve as an initial therapy for a young to middle-aged patient population with min-
imal to moderate signs of aging who regard fillers as the first step in the rejuvena-
tion process. As these patients age, surgery, often combined with fillers and other
surface treatments, becomes the next logical step in their quest to restore and main-
tain a youthful, refreshed appearance.
Today the number and variety of products available are impressive. Yet the ideal filler
has not been found; neither have we agreed on the properties that would be appro-
priate for all fillers. For example, although permanence would clearly be a virtue, it
could also be a negative if the filler used did not age appropriately as the patient’s
soft tissues became ptotic and attenuated. Therefore reversibility is an important char-
acteristic. Despite these reservations, there are certain basic qualities that we seek in
the ideal filler material.
The worldwide search for the ideal soft tissue filler continues. It is exciting to see new
products as they are introduced, but a balance is needed between embracing new de-
vices and products and ensuring the safety of our patients. This chapter is intended
to guide surgeons in making these judgments. Divided into two sections, it begins
with an overview of currently available tissue fillers and provides information on
their applications and approval status in the United States and internationally. The
second section provides information on the clinical characteristics, applications, and
techniques for sculpting with the more popular and commonly available fillers.
Ideal Filler Characteristics
 Nontoxic
 Biocompatible
 Long lasting (if not permanent)
 Reversible
 Off the shelf
 Autologous
 Easy to use
 Safe
 Predictable (permanence, bulk, and behavior)
 Not discernible by touch/appearance
 Produces positive, natural, discernible change
 Involves minimal down time
 Offers multiple levels of placement (could
be placed through dermis at subcutaneous,
intramuscular, or periosteal levels)
 Performs well as a person ages

OVERVIEW OF CURRENTLY AVAILABLE
TISSUE FILLERS
A variety of excellent products have been introduced into the market over the past
few years, and an expanding range of new products are in the pipeline. Some of them
are limited in their applications, working only in defined sites and planes of the soft
tissue layers of the face. They all have short-term and long-term benefits as well as
potential risks.
For plastic surgeons evaluating these products, staying abreast of the vast array of
new fillers, the marketing information, the clinical reports, and the regulatory sta-
tus can be an overwhelming task. The material that follows provides an overview of
available products. For the purpose of this discussion, fillers will be classified in the
following categories:
 Autologous materials
 Biologic materials
 Synthetic materials
 Off-label materials
Autologous Fillers
Autologous materials are derived from the patient’s own tissue. They come closest
to matching the description of the ideal soft tissue filler in terms of safety, but they are
not as convenient to use as some other fillers. They have to be harvested from an-
other site on the body, which may produce a scar, and the process of harvesting and
then inserting these materials elsewhere requires a two-step procedure. Toxicity, al-
lergenicity, immunogenicity, carcinogenicity, and teratogenicity are not issues, but
there can be problems with infection, migration, inflammatory reactions, loss of per-
sistence, and reproducibility. Autologous fillers include the following:
 Dermis, fascia, cartilage, SMAS, breast implant capsule
 Fat grafts
 Platelet-rich fibrin matrix (PRFM)
Dermal, fascial, and cartilage grafts have a long history of use in plastic surgery, and
with careful handling and placement in an appropriate recipient bed, these grafts
may produce very good, long-lasting results. Deepithelialized skin can be used to
correct deficient contours on the nasal dorsum, depressed scars, and deficient facial
outlines. Their bulk is increased by folding the graft onto itself, and it is recommended
that no portion of the graft be more than 5 mm from the blood supply. When the re-
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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery

cipient bed is optimally vascularized and the “take” is successful, approximately 80%
of the bulk of the graft will be maintained permanently. Less volume survives when
lipodermal grafts are used, because it is the dermal surface that must derive the blood
supply from the host and serve as a vascularizing carrier for the fatty elements. Sim-
ilarly, fascial grafts from the fascia lata of the thigh, the temporalis, and the super-
ficial musculoaponeurotic system (SMAS) can be used as slings or sheets to smooth
nasal irregularities or fill facial contours. In a good recipient bed, fascia is perma-
nent and persists through a combination of creeping replacement by host fibroblasts
and continued viability of fascial fibroblasts. Although these autografts work well,
they require incisions to harvest the tissue and must be used in sheets, strips, or tubes.
Fat grafts as free en bloc transfers of tissue have the disadvantage of losing at least
half of their volume after transplantation, and cysts, calcifications, and necrotic lumps
can develop. However, with the introduction of liposuction, a readily accessible semi-
liquid form of fat became available, which in turn gave rise to injectable autologous
fat grafting. Along with correction of liposuction deformities, facial contouring with
microfat grafts became very effective in the hands of some plastic surgeons. The prin-
ciples of injectable fat grafting include harvesting small, intact parcels of fatty tissue
as atraumatically as possible. The aspirate is refined to separate the viable cells from
nonviable oil and cell debris and is then reinjected under gentle pressure by depositing
small parcels of fatty tissue in tiny amounts along multiple tracts, as the needle is
withdrawn. The purpose is to keep the fat near a blood supply for survival and in-
tegration. This can be time consuming, and there is significant edema in the short
term as well as some loss of volume over the long term. The great advantage of fat
grafting is that it is permanent if the fat survives. The disadvantages are the unpre-
dictability of the survival, the need for a donor site, and the time required to process
and inject the tissue.
Selphyl (Aesthetic Factors LLC, Princeton, NJ) is a new, patented system that allows
the extraction of a platelet-rich (and growth factor–rich) fibrin matrix (PRFM) from
the patient’s own blood. This novel technology allows processing of blood in the of-
fice in a three-step procedure that includes centrifugation and takes approximately
20 minutes. The collected PRFM is then injected into the patient’s wrinkles. Collec-
tion of a 9 ml blood sample provides 4 ml of PRFM. The development of collagen
and dermal matrix increases over a 3-week period, and there is early evidence to sug-
gest long-lasting wrinkle correction (up to 20 months). Possible applications include
correction of nasolabial folds and glabellar lines, panfacial rejuvenation, and treat-
ment of acne scars and other scars. Selphyl has been cleared by the FDA for use in
the United States and in Europe with a CE mark. Although additional long-term data
are still required to prove its efficacy, this product represents the first practical modal-
ity for collection of fibrin matrix as an autologous wrinkle treatment.
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Part III  Nonsurgical Cosmetic Treatments

Biologic Fillers
Biologic materials derived from organic sources (humans, animals, or bacteria) of-
fer the benefits of ready off-the-shelf availability and ease of use, but these introduce
issues of sensitization to foreign animal or human proteins, transmission of disease,
and immunogenicity. Often, as the tissue is processed to reduce these untoward side
effects, the molecular structure is destabilized, resulting in lack of persistence at the
recipient site. The focus in the past few years has been on finding new materials that
are better tolerated, have greater longevity, and do not need prior skin testing to rule
out sensitivity to animal proteins. Still, biologics provide only a temporary effect and
typically do not completely correct the wrinkles or creases. The three major types of
biologic tissue fillers are acellular soft tissue matrix, collagen, and hyaluronic acid
products.
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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery
FDA-Approved Biologic Fillers
Filler
Type
Cymetra
Human dermis
AlloDerm
Human dermal matrix
Dermolagen
Human collagen matrix
Surgisis
Porcine collagen matrix
Fascian
Human tensor fascia lata
Zyderm/Zyplast
Collagen (bovine)
CosmoDerm/CosmoPlast
Collagen (human-based)
Restylane
Hyaluronic acid (bacterial)
Elevess
Hyaluronic acid (bacterial)
Juvéderm
Hyaluronic acid (bacterial)
Hylaform
Hyaluronic acid (animal)
Cymetra (LifeCell Corp., Branchburg, NJ) is lyophilized acellular collagen matrix
derived from human cadaver dermis. It is FDA approved for subcutaneous injection
and is used for lips, nasolabial folds, and deep wrinkles and lines. It requires rehy-
dration before injection, and there is no lidocaine in the product, although it can be
added to the reconstituted product. Its longevity is reported to be about the same as
that of bovine collagen.
Fascian (Fascia Biosystems, Beverly Hills, CA) is a preserved particulate human fas-
cial graft that is marketed in syringes with different particle sizes ranging from 0.1
to 2.0 mm; it is injected through 14- to 27-gauge needles, depending on the particle

size. Prepared from prescreened human cadaver fascia lata, Fascian is freeze dried,
irradiated, particulated, vacuum sealed, and stored at room temperature. It requires
rehydration before use and is injected intradermally, subdermally, or in deep tissue,
depending on the application. In some cases, native collagen may replace the fascial
graft, and it is reported that Fascian particles tend to last two or three times longer
than bovine collagen products. Use of the product is technique dependent, and lumpi-
ness has been reported, as have rare local reactions and herpetic activation.
AlloDerm (LifeCell Corp.) is an acellular, structurally intact sheet of human dermal
graft that was first used clinically in the treatment of full-thickness burns. Processed
from prescreened human cadaver skin, the cells responsible for immunogenicity are
removed; the matrix structure and biochemical components are left intact. The grafted
material then acts as a template or blueprint for recipient cell repopulation, result-
ing in soft tissue regeneration. AlloDerm is supplied in freeze-dried, sealed foil pack-
ets in various sizes and thicknesses and is stable for 2 years with refrigeration. It has
been available for several years as an implant for cosmetic and reconstructive soft
tissue augmentation. Some of its applications include augmentation of the lips, cor-
rection of nasolabial folds, softening of glabellar wrinkles, rhinoplasty (dorsum and
tip) as well as septal perforation, Frey syndrome, correction of defects from lipo-
suction, and treatment of scars. Complications can include infection, persistent pal-
pability or lumpiness, and variable take of the grafted material. Reports of volume
diminution in mobile graft areas range from 30% to 40% at 1 year to 70% reten-
tion after 18 months.
Surgisis (Cook, Inc., Bloomington, IN) is a lyophilized collagen matrix that is porcine
derived and marketed in sheets of various sizes and thicknesses. Although it is used
as a fascial replacement, there is less information about its use for aesthetic appli-
cations at this time.
Bovine collagen, marketed as Zyderm and Zyplast (Allergan, Irvine, CA), became
available in 1981 and is a unique product. It was the first commercially marketed in-
jectable approved by the FDA for soft tissue augmentation; it has been used in mil-
lions of patients and is the standard against which all other injectables are compared.
CosmoDerm and CosmoPlast (Allergan, Irvine, CA) contain human collagen and
do not require a pretreatment skin test. Isolated and purified from human dermal
tissue and grown under controlled laboratory conditions, the fibroblasts are screened
for pathogens and the collagen is subjected to viral inactivation. Although the use
of all the above collagens has been discontinued in Canada, they are still available
for use in the United States.
Hyaluronic acid (HA) is a glycosaminoglycan common to most living organisms and
is a component of connective tissue of the skin, cartilage, bone, and synovial fluid.
In human skin, hyaluronic acid adds bulk and acts as a shock absorber and lubri-
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Part III  Nonsurgical Cosmetic Treatments

cant. Hyaluronic acid binds water and after injection maintains a bulking effect as
it is degraded, a process that has been called isovolemic degradation. Restylane (Q-
Med Esthetics, Uppsala, Sweden) is a hyaluronic acid soft tissue filler that received
FDA approval in December 2003 for use in the correction of facial wrinkles. It is
marketed as three products that differ in the size of the constituent particles: Resty-
lane Touch (Fine Lines), Restylane, and Perlane. Restylane Touch (Fine Lines) is avail-
able in Canada, but not in the United States. The Restylane products are manufac-
tured by recombinant technology in bacteria, thus eliminating the need for skin
testing. The shelf life of Restylane is 1.5 years, and its longevity is 6 to 12 months,
depending on the location treated and the injection technique. Elevess (Anika
Therapeutics, Inc., Bedford, MA; FDA approved in 2006) contains higher concen-
trations of hyaluronic acid as well as lidocaine and is intended for medium wrinkles
and deeper folds. Prevelle Silk (Mentor, Santa Barbara, CA) was introduced in the
United States in 2008 and is equivalent to Restylane. In 2006 Allergan’s Juvéderm
series of hyaluronic acid fillers received FDA clearance. Juvéderm fillers come in var-
ious concentrations and viscosities. In Europe they are labeled as Juvéderm Ultra 2,
3, and 4 and Juvéderm Voluma; in North America they are marketed as Juvéderm
Ultra and Juvéderm Ultra Plus. Formulations containing lidocaine are also available
(Juvéderm Ultra XC and Juvéderm Ultra Plus XC). There are a large number of non–
FDA-approved biologic fillers that are available in the rest of the world. These are
mainly HA-based products with various sources, processing, and cross-linking.
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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery
Non–FDA-Approved Biologic Fillers
Filler
Type
Approved In
R-fine
HA
Canada, Europe, Asia
Hyaluderm
HA
Europe
Revanesse/ReDexis
HA (cross-linked)
Canada
MacDermol S/MacDermol R
HA (avian, cross-linked)
Europe
Varioderm
NASHA
Europe
Amalian
NASHA
Europe
Macrolane
NASHA
Europe
Teosyal
NASHA
Europe, Canada
Zetaderm/Zetavisc
NASHA
Europe, Canada, Russia
HydraFill
NASHA (cross-linked)
Europe
Esthélis/Fortélis/Belotero
NASHA (CPM technology
Europe, Canada, Asia
cross-linked)
Puragen
NASHA (DXL technology
Europe, Canada
cross-linked)
Rofilan/Piloderm/Beautygel/
NASHA (cross-linked)
Europe, Canada, Brazil
Esthirase/Coilingel
HyalSkin
NASHA (BDDE cross-linked)
Europe
BDDE, 1,4-butanediol diglycidyl ether; CPM, cohesive polydensified matrix; DXL, double cross-linked; HA, hyal -
uronic acid; NASHA, non–animal-stabilized hyaluronic acid.

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Part III  Nonsurgical Cosmetic Treatments
*Table courtesy Lisa Airan, MD.
†Viscosity is not measured by most companies in terms of flow:   Least thickness, easiest/best flow;   In be-
tween;   Most thickness, more difficult flow.
‡Level of placement is also dependent on amount/type of desired correction.
HA, Hyaluronic acid.
Filler Characteristics*
Filler
Category
Composition
Viscosity†
Zyplast
Zyderm I and II
CosmoPlast
CosmoDerm
Perlane,
Juvéderm Ultra Plus,
Puragen
Restylane,
Juvéderm Ultra,
Elevess,
Hylaform
Restylane Fine Lines
ArteFill (Artecoll outside the U.S.)
Radiesse
Sculptra










Bovine collagen
Bovine collagen
Human collagen
Human collagen
HA (bacterially derived)
HA (bacterially derived)
HA (avian culture derived)
HA (bacterially derived)
Polymethylmethacrylate
(PMMA) beads covered
with bovine collagen
Calcium hydroxylapatite
Poly-L-lactic acid (PLLA)
Biologic
Biologic
Biologic
Biologic
Biologic
Biologic
Biologic
Synthetic/biologic
Synthetic
Synthetic

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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery
Level of
Disadvantages
Placement‡
Advantages
and Complications
Less swelling (24 hr); easy to use
Less swelling (24 hr); easy to use
Less swelling (24 hr); less inflam-
matory; easy to use
Less swelling (24 hr); less inflam-
matory; easy to use
Long lasting; can be used in deep
tissue and along bone; minimal
reactions; no skin test needed
Long lasting; can be used in deep
tissue and along bone; minimal
reactions; no skin test needed
Excellent for use in glabellar region
and fine lines; do not use along
bone
Long lasting in deep folds and acne
scars
Long lasting; can be used in deep
tissue and along bone; minimal
reactions; no skin test needed
Long lasting; can be used in deep
tissue and along bone; minimal
reactions; no skin test needed
Superficial to
deep dermis
Dermoepidermal
junction
Superficial to deep
dermis
Dermoepidermal
junction
Deep dermis
Superficial dermis
Dermoepidermal
junction
Deep dermis or
subcutaneous
Deep dermis or
subcutaneous
Deep dermis or
subcutaneous
Skin test required; more inflam-
matory; very short–term
correction
Skin test required; more inflam-
matory; very short–term
correction
Length of correc tion variable
Short- and long-term correction
More swelling—up to 3 to 5 days
More swelling—up to 3 to 5 days
Shorter term longevity than
Restylane or Perlane
Requires skin test; associated
with bumps, which may
require treatment with steroids
or surgery to remove; risk of
granuloma; collagen reactivity
More swelling—up to 3 to 5 days;
irregularities (technically
dependent)
More swelling—up to 3 to 5 days;
irregularities (technically
dependent); inflammatory
reactions; multiple treatments
required

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Part III  Nonsurgical Cosmetic Treatments
Synthetic Fillers
Synthetic materials can offer permanence. Many injectable and surgically implantable
synthetic products have been used over the years, and many have been condemned
for such complications as granulomas, acute and delayed infections, migration or
displacement, and deformities that can result from complications or removal of the
material. It is with these products that the difference between the regulatory process
in the United States and that in the rest of the world is highlighted. The FDA con-
trols access to the U.S. market and enforces strict labeling practices, which means
that the manufacturer must spell out the exact applications for which the material
has been approved. Although a number of products have been available for years in
Europe, South America, and Asia, only ArteFill (Suneva Medical, Inc.), a poly-
methylmethacrylate (PMMA)-containing product, is marketed in the United States
for permanent facial augmentation. ArteFill is FDA approved for use in the correc-
tion of nasolabial creases. Several other permanent synthetic fillers, such as Bioplas-
tique (Uroplasty BV, Netherlands), are in clinical trials in the United States. Synthetic
fillers approved by the FDA are listed in the table below.
AdatoSil 5000 and Silikon 1000 are silicone gels with improved viscosity that have
been approved by the FDA for use in treating detached retinas. Although they are
permanent, they are not approved for cosmetic use in the United States, and caution
is advised with these products. Historically, injectable silicone products have tended
to harden, migrate, and cause inflammation and skin necrosis. Bioplastique is com-
posed of solid silicone microparticles (100 to 400 microns) that have been vulca -
FDA-Approved Synthetic Fillers
Filler
Type
AdatoSil 5000
Silicone
Silikon 1000
Silicone
ArteFill (Artecoll)
Polymethylmethacrylate (PMMA)
Radiesse
Calcium hydroxylapatite
Sculptra (NewFill)
Poly-L-lactic acid (PLLA)

nized, texturized, and placed in a polyvinylpyrrolidone carrier. Injected dermally, the
carrier is resorbed and the silicone microparticles are encapsulated in host collagen,
which prevents migration and effects permanent correction. It is used in many parts
of the world but is not approved by the FDA for use in the United States because of
concerns about granulomatous reactions and permanent lumps that can be removed
only through surgery.
ArteFill is a permanent injectable implant consisting of polished polymethyl-
methacrylate (PMMA) microspheres suspended in bovine collagen in a 20% to 80%
ratio. After injection, the collagen is resorbed and the round, smooth microspheres
are encapsulated by host collagen where they are stabilized and become permanent.
Used in Europe for the past decade as Artecoll, ArteFill was approved by the FDA
in October 2006.
Radiesse is a mixture of calcium hydroxylapatite (30%) and polysaccharide gel
(70%). The polysaccharide gel is very white, which makes Radiesse inappropriate
for use in the dermis. At present, Radiesse is FDA approved (December 2006) for
nasolabial and labiomental crease correction. Potential concerns about its use as a
soft tissue filler include clumping, lumping, granulomas, and migration of the mi-
crospheres. It is reported to last from 1 to 2 years.
Sculptra is composed of poly-L-lactic acid (PLLA). Because it is not made from hu-
man or animal sources, it does not require a skin test. PLLA is a biocompatible,
biodegradable material that has been used in surgical products for more than
20 years as a component of dissolvable sutures. Sculptra has been safely used out-
side the United States since 1999 in more than 30 countries under the trade name
of NewFill for a variety of facial volume and contour deformities. It was approved
by the FDA in August 2004 as the only product for the correction of HIV-associated
facial lipoatrophy and was approved in 2009 for cosmetic use in the United States.
It is injected subcutaneously in the area of fat loss/volume loss and provides a grad-
ual and significant increase in volume. It is reported to last up to 2 years after the
third treatment session.
A large number of other synthetic fillers are available in various parts of the world;
a few of these are listed in this chapter. It is difficult to comment on the effectiveness
and safety of these products, because results of clinical trials using these products
have not yet been reported in the literature.
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Part III  Nonsurgical Cosmetic Treatments
Off-Label Use of Fillers
“Off-label” use of synthetic materials is technically possible but does carry some
risk. A number of synthetic fillers are approved for use for conditions unrelated to
plastic surgery. For example, AdatoSil silicone oil and Silikon 1000 are used for tam-
ponade of retinal detachment. Such products are available, clearly approved for other
soft tissue applications, and can be purchased and used off-label to treat wrinkles
or augment the face. But is this wise? The manufacturer is strictly prohibited by the
FDA from advertising or promoting off-label use and can incur stiff penalties for do-
ing so. The plastic surgeon is not subject to these FDA controls but is vulnerable from
a liability standpoint and would have a difficult time defending the use if the prod-
uct does not perform well.
Non–FDA-Approved Synthetic Fillers
Filler
Type
Approved In
Bioplastique
Silicone
Europe
Aquamid
Polyacrylamide
Europe and 40 countries worldwide
Beautical
Polyacrylamide
Europe
Bio-Alcamid
Polyacrylamide
Europe
Outline
Polyacrylamide
Europe
Evolution
Polyacrylamide
Europe
Formacryl
Polyacrylamide
Russia
Argiform
Polyacrylamide
Russia
Bioformacryl
Polyacrylamide
Ukraine
Amazing Gel
Polyacrylamide
Asia
DermaLive/DermaDeep
Polyacrylamide
France
Metacril
Methylmethacrylate
Brazil
ArteSense
Methylmethacrylate
Europe, Canada, Asia
Arteplast
Methylmethacrylate
Discontinued
Rhegecoll
Methylmethacrylate
Pending worldwide
Laresse Dermal Filler
Carboxymethylcellulose/
Europe
polyethylene
Atléan BTCP
Tricalcium phosphate
Europe
Bioinblue
Polyvinyl alcohol
Europe
Reviderm
DEAE Sephadex
Europe, Canada, Asia
Matridex
DEAE Sephadex
Europe
BTCP, Beta tricalcium phosphate; DEAE, diethylaminoethyl.

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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery
THE ART OF SCULPTING
WITH INJECTABLE FILLERS
Soft tissue fillers have provided aesthetic surgeons with an effective means of ad-
dressing patient requests for nonsurgical facial, hand, and body rejuvenation. Today
a plethora of excellent products are available that are appropriate for filling, aug-
menting, and recontouring. However, as with any aesthetic product or procedure,
success depends on an understanding of the specific applications for the material
and the technical nuances to ensure that these materials are used appropriately. There-
fore this section will serve as a primer for using the commonly available injectable
fillers. It will provide specific information on the following:
 Product characteristics and composition
 Indications and applications
 Injection technique
 Average volumes used in each area
 Level of placement
 Ease of injection
 Combinations
 Longevity
 Adverse effects, reactions, and complications
 Results
Hyaluronic Acid Products
We begin our discussion by focusing on hyaluronic acid products because of their
widespread popularity and range of applications. The viscoelastic properties, stabi-
lizing role, and protective action on cell membranes afforded by hyaluronic acid make
it an ideal material with which to fill skin depressions. Approval for use in Canada
was granted in 1998, and very quickly hyaluronic acid products surpassed collagen
to become the new benchmark for soft tissue fillers. Approval in the United States
was granted in late 2003.
Medicis, Allergan, Biomatrix, Anika Therapeutics, and Mentor are five of the com-
panies offering approved hyaluronic acid products in the United States. Other com-
panies, such as Anteis, have new products in use in Europe and Canada, but these
are awaiting FDA approval. To offer the most appropriate fillers for different types
of wrinkles and skin, these manufacturers generally offer several products with dif-
ferent viscosity and particle sizes.

Features
The three products available from Medicis are Perlane, Restylane, and Restylane Fine
Lines/Touch. As mentioned above, the latter is available in Canada (Restylane Fine
Lines) and Europe (Restylane Touch), but not yet in the United States. These prod-
ucts are composed of hyaluronic acid and differ from each other in molecular size.
Perlane is the largest hyaluronan, and Restylane Fine Lines/Touch is the smallest. In-
dications for the level of placement in the tissue depend on the particle size. Perlane
is injected at the deepest level in the deep dermis or subcutaneous tissue; Restylane is
injected in the mid-dermis, and the needle should not be visible; and Restylane Fine
Lines/Touch is injected at the dermal-epidermal junction. The Restylane injectables
are non–animal stabilized hyaluronic acids (NASHAs).
Allergan’s Juvéderm is another hyaluronic acid product. Juvéderm is available in dif-
ferent concentrations and viscosities: 18 mg/ml, 24 mg/ml, and 24 mg/ml high vis-
cosity (HV), 30 mg/ml, and 30 mg/ml HV. In the United States and Canada, Juvé-
derm is available in 24 mg/ml HV (Juvéderm Ultra) and 30 mg/ml HV (Juvéderm
Ultra Plus). Formulations with 0.3% lidocaine (Juvéderm Ultra XC and Juvéderm
Ultra Plus XC) are also available, helping decrease the pain and discomfort that
is often associated with filler injection. Juvéderm Ultra Plus is more cross-linked
than Juvéderm Ultra, thus making it more viscous; it is intended for use in deeper
folds. Juvéderm, similar to the Restylane group of fillers, is produced in bacteria and
then purified.
Prevelle Silk, a lidocaine-containing formulation of hyaluronic acid produced by
Mentor, has recently become available the United States. Mentor’s Puragen is a sim-
ilar product with higher cross-linking; it is intended for injection in the deep dermis.
Puragen is available in Canada and is not yet approved by the FDA.
Elevess (Anika Therapeutics, Inc.) has the highest concentration of hyaluronic acid
(28 mg/ml) and contains 0.3% lidocaine, offering peri-injection analgesia. Elevess is
also derived from bacteria and thus its injection results in virtually no hypersensi-
tivity reactions.
Esthélis Soft, Esthélis Basic, and Fortélis Extra, produced by Anteis (Geneva, Switzer-
land), are hyaluronic products analogous to Restylane Fine Lines/Touch, Restylane,
and Perlane, respectively, and are in use in Europe and have recently become avail-
able in Canada. These fillers are not FDA approved at present.
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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery
Indications and Applications
Hyaluronic acid fillers are useful for deeper folds, lips, and irregularities such as soft
acne scars, nasal deformities, and areas that require more sculpting. One of the main
indications for hyaluronic acid is augmentation of the lips. These tissue fillers are
also useful for augmentation of the nasolabial folds, marionette grooves, the mental
fold, and the hollow of the anterior jowl line. Overall complete facial sculpting may
be performed with combinations of these products. Perlane/Juvéderm Ultra Plus/
Puragen can be used interchangeably with Restylane/Juvéderm Ultra/Prevelle Silk/
Elevess in most situations, and the larger particle sizes yield better longevity. Less
bruising may result if these tissue fillers are injected as the needle is advanced.
In the subsequent discussion, we will refer to Restylane, but Juvéderm Ultra or Pre-
velle Silk could also be used in the same manner.
Restylane
Epidermis
Dermis
Subcutaneous
tissue
Restylane represents the middle-sized particles of hyaluronic acid products produced
by Q-Med. It differs from Juvéderm in that it is made up of particles of hyaluronic
acid molecules, whereas Juvéderm is a syrup. Restylane has a lower level of cross-
linking and a lower level of reported foreign protein. It is provided in 1.0 cc syringes
with a 30-gauge needle. Restylane can be used in many areas of the face and brow

with excellent longevity. Because it can be molded and massaged to a degree, precise
results can be achieved with minimal complications. Prevelle Silk is similar to Resty-
lane but contains anesthetic, requiring anterograde injection.
Indications and Applications
Restylane can be injected in the lips, nasolabial folds, glabellar creases, forehead
lines, infraorbital and supraorbital hollows, and temporal hollows. It can also be
used to raise the eyebrows, soften the chin fold, correct scars from acne or traumatic
injuries, improve nasal deformities, and reconstruct contour deformities arising from
trauma, reconstructive surgery, or acquired soft tissue atrophy syndromes. As previ-
ously mentioned, it is often combined with Restylane Fine Lines/Touch and Perlane
to achieve the best results.
Lips
Contouring the lips may be accomplished with Restylane alone or with Restylane
in combination with other fillers. However, Restylane on its own produces an ex-
cellent result. The procedure may be carried out using infraorbital and mental nerve
blocks (separate block for the corners of the mouth) or with topical anesthetic. Direct
infiltration of the tissues with lidocaine with epinephrine may also be done to limit
the degree of bruising.
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Part III  Nonsurgical Cosmetic Treatments
Ideal candidates have a good shape to their lips to begin with. In these patients, just
augmenting the vermilion is enough to produce an excellent result. In addition, proper
dental occlusion aids in getting a more symmetrical result. The left and right sides
of the lips differ in length and thickness; this must be observed and demonstrated to
the patient before augmentation. Achieving symmetry can be a challenge, but the pa-
tient should be aware of these pretreatment asymmetries so expectations for im-
provement are realistic.
In patients with long, thin lips, results may be limited because of tissue tension. For
patients with lips that are tight to the dentition or who have a class II occlusion, aug-
Center: 1, The vermilion border is enhanced to define the shape of the lip. 2, The Cupid’s bow (philtral
columns) is narrowed with injection. 3, The site of injection from the wet-dry junction to the vermilion border
is used to increase lip show at the lateral aspects. 4, Restylane is injected posterior to the wet-dry junction to
enhance lip projection.

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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery
mentation volumes should be conservative, because irregularities of dentition may
be reflected in the upper lip and will appear too prominent or “ducklike.” Scars may
not respond to the volume addition and can leave an irregularity. The Cupid’s bow
becomes wider with age and should be made narrower (see 2 on the center photo).
The depth of the mental fold increases with age and may require softening; it can
add to the result of the lip contour. Patients with a history of herpes should be given
prophylactic treatment, because the procedure may cause a herpetic outbreak and
scarring.
Augmentation in patients with long, thin lips and very broad smiles is difficult. Of-
ten patients complain that their lips are too thin when they smile; this is a dynamic
change that cannot be corrected with fillers or implants. The physician must clearly
explain that the result these patients desire may not be achievable with one or even
subsequent injections, no matter what product is used.
INJECTION TECHNIQUE AND LEVEL OF PLACEMENT
When Restylane is used for lip
augmentation, the injection process generally starts with augmentation of the ver-
milion border of the lip to enhance its definition and provide increased projection.
The philtral columns may also be augmented, and the placement of Restylane at this
level is usually in the mid-dermal level and for the vermilion border is along the
“pseudotunnel” of the lip border. Restylane must not be placed too superficially, be-
cause it will appear as a light blue color (Tyndall effect). Palpation of the tissue as
the Restylane is injected is important. Occasionally it can track in a direction per-
pendicular to the direction of injection as a result of weakness in the tissue and the
vertical lip lines. If this occurs, the Restylane needs to be massaged immediately to
eliminate this irregular contour.
Injection of the lip proper from the wet-dry junction to the vermilion border may
also be carried out at a level that is just deep to the mucosa within the orbicularis
oris muscle. If it is placed immediately beneath the mucosa, it will appear blue. Place-
ment posterior to the wet-dry junction along the wet mucosa may enhance the lip
volume as well as the projection. Again, the depth of the injection is below the or-
bicularis oris muscle to make the product undetectable. Placement of the product
must be varied, depending on the desires of the patient and the starting shape of the
lips. Care must also be taken to observe any previous asymmetries, scars, weakness,
herpetic infections, dentition (including occlusal classification), the length of the
philtral column and upper lip, the width of the Cupid’s bow, and the depth of the
mental fold, all of which can affect the results. Photographs should always be taken
before the treatment and discussed with the patient, along with a full explanation
of the potential risks and benefits for all injections.
VOLUMES
Approximate volumes for augmentation of the lips may range from 0.5
to 1.0 cc per lip with Restylane. There may be immediate swelling with the place-
ment due to the trauma of needle, bruising, or immediate swelling from Restylane

absorbing water. Immediately after injection, the lip size should be equivalent to the
final result; however, some patients develop swelling from bleeding and needle-
stimulated histamine release. In the patients who develop immediate swelling, lip
shape will be consistent with final results from days 3 to 5. The lips will not increase
in size beyond the volume placed. If subsequent injections are indicated, less volume
may be required to achieve the desired correction.
LONGEVITY
Longevity is dependent on the metabolism of the individual as well as
the amount of movement with animation. In general, patients who are more ani-
mated have a shorter duration of filler. The filler remains in the tissue for up to
16 months, although with diminished intensity. For most individuals, more aug-
mentation may be achieved at secondary and tertiary injections, which build on the
remaining filler. This allows for further shaping, enhancement of volume, and con-
touring of the lips when subsequent injections are performed. The filler should last
for a period of 4 to 6 months; however, when it is repeated, the results may last for
8 months up to 1 year. In some individuals, the filler may disappear after as short
a period of time as 3 months and require repeat contouring. Juvéderm and Prevelle
have similar longevity to Restylane.
EASE OF INJECTION
For the lips, Restylane is more difficult to inject than collagen
because of the higher viscosity of the material and the same-sized needle (30-gauge).
Use of Restylane may result in more bleeding or bruising, which needs to be con-
trolled during the injection process to limit the extent of bruising after injection.
TECHNICAL NUANCES
Care must be taken to inject Restylane with an even flow
and movement of the needle so that it does not deposit as lumps or bumps in the tis-
sue. If lumps or bumps are detected, they must be massaged out immediately. Preex-
isting asymmetries should be corrected when possible. Care must be taken to bal-
ance the projection of the upper and lower lips so that a ducklike deformity does
not result.
Frequently the upper lip is atrophied above the vermilion border, particularly the
lateral aspects; restoration is done with Restylane placed at the mid-dermal level to
improve volume and projection of the upper lip. One should use minimal volume in
the upper lip above the vermilion border, because any added volume may cause
lengthening of the upper lip. (It can push the upper lip farther down over the upper
dentition.) Care must be exercised to limit the amount of filler placed in the upper
lip skin adjacent to the nasolabial fold, because excess infiltration will result in awk-
ward animation of the upper lip and nasolabial fold, particularly when the individ-
ual is smiling, and can give the appearance of a “joker-type” upper lip or create an un-
usual fold at the lateral edge of the upper lip.
If the patient has implants, the filler may be added around the implant without re-
moval unless the patient desires this. The risk of infection is minimal but is still pres-
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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery
ent. If the patient wants the implant removed, filler may be added at the same time as
the removal, with a plan for the patient to return for reassessment.
COMBINED TREATMENT
Some physicians combine Restylane injections with that
of other tissue fillers. Collagen may first be injected along the vermilion border, which
provides local anesthesia and augmentation of the white roll. Restylane Fine
Lines/Touch may also be used to enhance the white roll; however, Restylane itself
works very well in this area. The individual vertical lines of the lips may be corrected
with Restylane Fine Lines/Touch or collagen injection.
Restylane can also be used with botulinum toxin. In this situation the neurotoxin
may be used in the upper and lower lip orbicularis oris muscle to limit the pinching
of the lip and the formation of vertical lip lines. The amount of botulinum toxin will
vary, starting with 2 units per side in the upper lip, avoiding the midline, and up to
3 or 4 units per side in the upper and lower lip. Rarely, after neurotoxin injection in
the upper lip, patients have difficulty with pronunciation of P’s and B’s and an in-
ability to drink through a straw or out of a cup. If this occurs, the patient may do
active puckering of the lips for 15 minutes at a time, several times a day, to help al-
leviate these symptoms. Botulinum toxin will help prolong the longevity of the Resty-
lane in the lips and will increase lip projection and shape. The neurotoxin may be
placed at the vermilion border or approximately 5 mm from the vermilion border.
It must not be placed too far away from the vermilion, which will result in dimin-
ished shape of the lips. The closer the neurotoxin is placed to the vermilion border,
the greater the lip projection. Restylane may also be placed in areas where ArteFill
(Artecoll) has been placed previously after a minimum waiting period of 2 to
3 months.
Nasolabial Folds
As with the lips, the nasolabial folds may be of different shapes, lengths, and depths.
Some patients have preexisting telangiectasia that can be made worse with injections.
The classification system described by Lemperle is useful in evaluating patients and
discussing their goals.
Lemperle Nasolabial Fold Classification
Class
Description
0
No wrinkles
1
Just perceptible wrinkles
2
Shallow wrinkles
3
Moderately deep wrinkles
4
Deep wrinkles, well-defined edges
5
Very deep wrinkles, redundant folds

The amount of change in the average patient should be approximately 50% correc-
tion of the depth of the fold. Restylane can be used to soften the broader portion of
the fold, which is usually the upper two thirds down to the lateral oral commissure.
The product is placed at the level of the mid- to deep dermis. If the nasolabial fold
has a superficial line etched into it, this can be softened with Restylane Fine
Lines/Touch. Alternatively, Perlane may be used in place of Restylane. The product
is placed at angles to the fold, and layering may be done to enhance longevity. Also,
Perlane may be placed deep to the Restylane for the very deep folds. When Perlane
is used instead of Restylane for correction of the nasolabial folds, the difference in
longevity may be slight with the Perlane lasting longer. As with all repeated injec-
tions of hyaluronic acids, the product lasts longer and less volume of product is
needed to achieve the same volume and contour change. Care must be taken not to
overfill the fold because this will give patients an odd appearance when they animate
or smile. Taping of the fold after the injection for a few days allows the product to
be bound into place with scar tissue and can prevent the lateral displacement of the
product to the nasolabial fold when the patient smiles.
VOLUMES
Fold depth is variable; thus the amount of filler may range from as lit-
tle is 0.5 cc to as much as 1.5 cc of Restylane or Perlane. Complete correction of the
fold on the first visit is not recommended because this may give the fold an unnatu-
ral appearance. For the first-time treatment, the patient should be instructed that the
fold will initially be corrected by filling one half of the depth and further correction
will be done at a subsequent injection. This is done to avoid overcorrection; exces-
sive filler placed at one time can cause telangiectasia. This approach has several ben-
efits: it keeps the patient’s expectations at a reasonable level, the degree of change is
not too drastic, and the fold does not feel as firm. It allows precise correction of the
fold depth and avoids overcorrection, particularly at the lower third of the fold. If
too much dermal filler is placed in the fold that overlies the dentition, then it may
appear as a bump. This is particularly true of the fine but deep marionette lines lat-
eral to the commissure.
Scars and Deformities
Many deformities of soft tissue can be corrected with Restylane. It is important that
the scar/tissue be soft and distensible. The product should not be placed under high
pressure, because this may result in tissue necrosis. More than one treatment may be
required for full correction. Excellent results can be achieved in acne scars, chicken-
pox scars, and traumatic scars, and these can be very long lasting. Simultaneous re-
lease of the scar with an 18-gauge needle may improve the results. The use of Resty-
lane Fine Lines/Touch for the treatment of steroid atrophy is helpful, but it must
be used with caution, because the atrophy may be permanent. The patient should
be warned of this so that residual atrophy is not attributed to the use of the hy-
aluronic acid.
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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery
VOLUMES AND TECHNICAL NUANCES
The volumes may be variable. Very small
amounts (0.05 cc) are needed for acne or chickenpox scars; these are placed at a su-
perficial level (dermal-epidermal junction). For larger soft acne scars, up to 0.2 cc is
placed at the mid- to deep dermis. Layering of the fillers may be needed but not com-
monly. The use of botulinum toxin in conjunction is helpful for scars located in mo-
bile areas such as the glabella, forehead, and chin, where the mimetic action may be
reduced. This may also increase the longevity of the filler. Restylane can be injected
with a 32-gauge needle in lieu of Restylane Fine Lines/Touch for fine scars. Care must
be taken with the amount of pressure applied to the plunger and the needle being
firmly attached to the syringe.
Glabellar Folds
The folds of the glabella are ideally treated in combination with botulinum toxin. If
the fold is easily effaced, the neurotoxin may soften the fold on its own. The glabel-
lar fold may be a fairly superficial line with a deeper etched component that is best
treated with Restylane Fine Lines/Touch at the dermal-epidermal junction; the filler
is placed in a pinpoint manner and with serial linear injections at the same level,
thereby undermining the line and placing the filler in a crisscross fashion. If the fold
is broader, Restylane may be used; this is placed at the mid- to superficial dermis
with a linear threading technique. Small amounts must be injected to avoid tissue
necrosis. When combined with botulinum toxin, the effect can last from 8 months
to much longer as a permanent correction. This area tends to have deep, dilated
pores; occasionally some filler is lost in the pore, and it is difficult to achieve com-
plete correction.
VOLUMES
A range of 0.2 to 0.4 cc of Restylane and up to 0.2 cc Restylane Fine
Lines/Touch may be needed for correction of the fold. Layering of these fillers may
be needed on occasion. Care should be taken in a patient with very thin skin, be-
cause the filler may cause lumps or bumps.
Forehead Lines
The injection technique in this area is similar to that used for glabellar lines. If the
patient has a very dynamic forehead, botulinum toxin will be very helpful in achiev-
ing a better result and increasing the longevity. If neurotoxin is not used, the filler
may last for only a short period. Caution with the neurotoxin should be exercised
in patients with moderate to severe brow ptosis. More commonly, Restylane Fine
Lines/Touch is used and is placed at the dermal-epidermal junction by pinpoint place-
ment or in a linear threading technique.
VOLUMES
Volumes will vary markedly, anywhere from 0.2 to 0.8 cc of Restylane
Fine Lines/Touch. Restylane may be used for the deeper and broader folds.

Eyebrows
The eyebrows may be elevated 1 to 2 mm by the addition of Restylane to the deep
tissue layer of the lateral eyebrow. The volume of the temples generally decreases
with age, and the placement of 1 cc of Restylane on the deep layer will help restore
the youthful contour and raise the eyebrow. Surgical removal of the fat of the upper
eyelid is sometimes done to such a degree that it results in a hollow or skeletonized
orbital rim, or this characteristic may be seen in some individuals as a consequence
of the aging process. The hollow appearance may be corrected by placing Restylane
on the inferior aspect of the supraorbital rims. This also gives the illusion of raising
the eyebrows while restoring a more youthful appearance to the upper lid and eye-
brow region.
VOLUMES AND LEVEL OF PLACEMENT
Volumes may range from 0.2 to 0.5 cc per
side. A similar volume for the hollowed orbit can be used. In these two areas the filler
can be molded to achieve a high-quality result with minimal risk. Care must be taken
to inject small volumes with each pass to prevent emboli and injury to the sensory
nerves. The filler is placed at the level that is not mobile. Caution is necessary in the
central eyebrow, where the supraorbital nerves emerge.
LONGEVITY
Restylane is a good deep filler; Perlane is a longer-lasting alternative
and is used in a similar fashion. With the product placed on the deep layer, the
longevity is increased to 6 months to 1 year, because where there is no movement,
there is no displacement of the product.
Facial Lipoatrophy
Restylane and Perlane are ideal fillers for softening the appearance of lipoatrophy
associated with antiretroviral therapy for HIV. The areas that are best treated are the
concavities adjacent to the zygomatic-temporal bone, the zygomatic arch, and to a
lesser degree, the inframalar hollow. In the temple and adjacent to the arch, it is im-
portant to place the filler deep within or under the periosteum, taking care to inject
slowly to ensure even placement and minimize bruising. The product is easily mas-
saged, but if massaging is too aggressive, the entire effect will be minimized. The in-
jector should not completely fill the entire area of atrophy but should use a limited
volume to soften the contours so that the wasting does not appear too severe. For
the inframalar hollow, the goal of correction should be kept to a third to a half of
the hollow. Linear threading or a fanning technique may be used to achieve a grad-
ual, consistent result.
VOLUMES
On average, volumes of 0.5 to 1.5 cc per area may be used. This will
vary among individuals, depending on their requested goals. Repeat injections on a
2- to 4-week basis may help to contour areas that have a large volume deficiency.
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Comparison of Restylane With Other Fillers
For the lips, Restylane is more difficult to inject than collagen because of the in-
creased viscosity of the material and the larger needle size (30-gauge). Use of Resty-
lane may result in more frequent bleeding or bruising, which needs to be controlled
during the injection process to limit the extent of postinjection bruising. Collagen,
in comparison, will cause minimal swelling and a smaller needle is used, therefore
limiting the bruising. Restylane is easier to inject than ArteFill and has less associ-
ated bruising (a smaller needle [30-gauge] is used, compared with the 27-gauge for
ArteFill), because it is less viscous.
Restylane Fine Lines/Touch is a softer product and much easier to inject than Resty-
lane. Once injected, it can be molded very easily, thus making it more useful for su-
perficial injection than Restylane. Perlane has a larger molecule and is firmer than
Restylane. It does not flow as easily through the tissue despite the larger needle (27-
gauge). Perlane can be used instead of Restylane in many cases. Restylane gives a
more subtle result and is better used in individuals with more delicate tissues and
fine features.
Postinjection Care
Postinjection treatment includes cooling with ice packs, 20 minutes on, 20 minutes
off, for the first 24 hours, and oral administration of antihistamines (Claritin, Zyrtec,
or Allegra in usual daily doses; these may be taken before the treatment). Oral sup-
plements such as Arnica montana, bromelain, and others may help with bruising.
The patient should be informed that swelling will occur in the first 3 to 5 days after
injection, which may make the lips appear overdone. This will resolve, and there is
possible bruising that could last up to 11⁄2 weeks. There is initial swelling, which al-
most invariably is of concern to the patient immediately after the injection and for
the first 3 to 5 days as he or she becomes accustomed to the new size and loses some
volume (particularly with the first injection). If a local anesthetic or a nerve block is
used, there will be some muscle paralysis, which creates asymmetrical movement and
may make the lips appear to be completely asymmetrical. The patient should be
alerted in advance to this possibility. Even with the advance warning, the patient will
still question the symmetry after the injection. Augmentation is difficult in individ-
uals with long, thin lips and very broad smiles. Care should be taken in providing
adequate consultation and information that the result they desire may not be achiev-
able with one or even subsequent injections. The patient is seen 11⁄2 to 2 weeks after
the initial injection to assess for any irregularities, lumps, bumps, or asymmetries. If
a bump is discovered, it may be physically massaged down. If this does not alleviate
the irregularity, hyaluronidase may be injected if available.

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ADVERSE EFFECTS, REACTIONS, AND COMPLICATIONS
When larger volumes of filler
are injected at the same setting, a sterile abscess may occur that will require drainage.
This may happen up to 1 to 2 weeks after the initial injection. The abscess is treated
with local incision and drainage using an 18-gauge needle. Immediate drainage of
clear fluid mixed with yellow-white debris resolves the problem, with rapid resolu-
tion of the symptoms.
Other complications that may occur are lumps, bumps, and irregularities, numbness
of the lip, pain, hematoma, and overcorrection. Uncommonly, the patient may ex-
perience intermittent swelling in the treated region. This usually resolves 2 to 6 weeks
after injection. Occasionally an individual will have massive swelling in response to
the injection, and use of a Medrol Dosepak may be considered to alleviate this im-
mediate swelling. The risks associated with steroid use should be explained to the
patient. If he or she has preexisting telangiectasia or rosacea, may more telangiecta-
sia may develop, and this should be discussed before injection. This is particularly
common at the nasal base for nasolabial fold correction.
Rarely, individuals may develop erythema of the overlying skin for the first several
weeks. Clinically it does not behave like an allergy. A light topical steroid may be
used as an initial treatment. In general, this reaction resolves without therapy over
a short period. Even rarer is embolization of a vessel with necrosis of the tissues.
Immediate blanching of the tissues is a bad sign and should be treated with mas-
sage, warm compresses, nitropaste, and if needed, hyaluronidase to remove the hy-
aluronic acid.
Results
This 51-year-old woman requested lip augmentation. Restylane was injected into
the vermilion border (1) and philtral columns (2) to achieve a narrower appearance.
The Restylane was injected from the inside of the lip from the vermilion border to
the wet-dry junction (3). She is shown 3 months after injection with good persis tence
of the filler. This patient is a good candidate for treatment with Restylane and main-
tains good volume correction for 6 to 7 months, requiring less volume when she re-
turns for a touchup with Restylane. With care, irregularities can be avoided. The pa-
tient was started on acyclovir for herpes prophylaxis.

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This 30-year-old woman had concerns about the irregular appearance of her nasal
tip cartilage. Restylane was used to fill in the hollows and shape the tip of her nose.
Restylane 0.4 cc was used to soften the appearance of the nasal cartilage. The pa-
tient had inquired initially about rhinoplasty with tip alteration. She had not had
previous surgery, and the nasal tip had not changed other than the irregularity be-
coming more noticeable with time. The skin at the tip of the nose was very thin, and
any slight surgical irregularity may have been noticeable; additionally, the skin may
have been compromised by an open rhinoplasty. The new tip contour was achieved
under a block with local anesthetic and Restylane 0.4 cc in the office in 10 minutes.
It took 5 days for the patient to recover, and she has shown persistence of the con-
tour for more than 5 months. She is seen 5 months after injection (far right).
Perlane
Indications and Applications
Perlane is a very good filler for the deeper folds of the face. These include the nasolabial
folds, deep marionette lines, and the hollow adjacent to the jowl along the jawline as
shown (comparable products include Elevess and Juvéderm Ultra Plus). Perlane is also
an excellent filler for use in the periorbital region to soften the nasojugal groove as well
as the periorbital hollow and can be used to achieve a “nonsurgical eye lift” (see p. 357).
It must not be placed at the superficial or mid-dermis level, because there will be a light
reflection off the material, giving it a blue color. Also, a superficial injection may cause ir-
ritation to the skin, resulting in local redness and swelling.

Lip Augmentation
Perlane may be used as an alternative to Restylane for lip augmentation and con-
touring. Perlane can be placed along the vermilion border and along the wet-dry
junction of the submucosal plane or the intramuscular injection plane. It is best used
in patients with lips that are not very mobile, because the material is stiffer than
Restylane and will not allow proper movement of the lips if larger volumes are used.
Care must be taken in using Perlane for persons with soft, supple lips that move a
lot with animation; these patients may not respond well to Perlane augmentation,
and their lips may appear too stiff.
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LEVEL OF PLACEMENT AND INJECTION TECHNIQUE
Perlane is placed in the deep
dermal layer with a 27-gauge needle. When injecting Perlane, one must avoid the for-
mation of lumps or bumps, because these are difficult to massage out of the tissue.
With the larger needle size in comparison to that used for Restylane, there is a greater
chance of bleeding and bruising.
VOLUMES
For the lips, volumes may range anywhere from 1.0 to 2.0 cc with ex-
cellent results. Occasionally an individual may need less or more; the remainder may
be placed in other areas, such as the nasolabial folds. For the marionette grooves,
0.5 to 1.0 cc per side may be used.
Epidermis
Dermis
Subcutaneous
tissue

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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery
Deep Tissue (Periorbital and Jawline Contouring) Augmentation
In the areas along the jawline (filling the hollow anterior to the jowl) and in the peri -
orbital region (nasojugal groove and periorbital hollowing), Perlane is best placed
on the very deep plane on the bone (beneath the periosteum) to augment the soft tis-
sues similar to a solid implant. Perlane (or Restylane) may be used as a nonsurgical
option instead of microfat grafting.
VOLUMES FOR THE JAWLINE
The volume may range from 0.5 to 1.5 cc per side.
Placement of the material in the deep dermis may be required for complete correc-
tion of a jowl deformity.
VOLUMES FOR THE PERIORBITAL HOLLOW AND NASOJUGAL GROOVE
The volume
will range from 0.5 to 1.5 cc, depending on the extent of the desired projection of
the cheek and malar region. This region is difficult to overcorrect, and with the ma-
terial being placed on the deep layer, it can be massaged down for a relatively long
time after the injection (2 to 3 weeks).
TECHNICAL NUANCES
It is important to mark the patient before injection of the
local anesthetic and to wait for at least 10 minutes to allow for the epinephrine ef-
fect to take place. Perlane is placed in the deepest point of the hollow on the bone;
this will correct most of the deformity. When the needle is passed through the skin
down to the bone, it is advanced along the bone, placing small amounts of Perlane
along the depth of the hollow. The injector must watch for immediate bleeding and
swelling. Pressure is applied to prevent a large bruise. After the correction is complete
on one side, the patient should be shown the result with the mirror. Patients are im-
mediately impressed with the dramatic improvement.
Epidermis
Dermis
Subcutaneous
tissue
Muscle
Periosteum
Bone

Nasolabial Folds
Correction of the nasolabial fold with Perlane is similar to correction of this area us-
ing Restylane. The exception is a deep nasolabial fold that extends past the com-
missure inferiorly. Care must be taken in this area when estimating the amount of
Perlane to be placed; too much may make the tissues appear stiff (particularly during
smiling) and can create a peculiar appearance.
VOLUMES
In the nasolabial folds, the volumes may vary from 0.5 to 1.0 cc per side,
depending on the depth of the fold. Very deep nasolabial folds or severe nasolabial
folds are very difficult to correct and will not respond any better to Perlane than to
Restylane, collagen, or ArteFill.
LONGEVITY
Perlane lasts from 6 to 8 months in soft tissue, depending on the mo-
bility of the tissues. Perlane lasts from 6 months to a year in the deeper plane of in-
jection and along the bone, because there is little movement of the tissue.
EASE OF INJECTION
Perlane is slightly more viscous than Restylane, but with prac-
tice it is really no more difficult to inject. It requires a deeper placement, but the vol-
ume used will be similar to that of Restylane.
TECHNICAL NUANCES
Perlane can be used to correct deeper folds and hollows, and
when used in combination with Restylane or Restylane Fine Lines/Touch, more de-
tailed and precise correction can be achieved. It is important to remember to use the
layering concept with these products to maximize their effect.
Combination With Other Fillers and Implants
As noted earlier, Perlane can be used safely and effectively to achieve excellent re-
sults over fixed implants or permanent fillers such as ArteFill. Restylane may be lay-
ered on top of the Perlane to maximally reduce the appearance of a fold. If the fold
has a superficial line etched into it, Restylane Fine Lines/Touch is placed at the dermal-
epidermal junction.
Postinjection Care
See postinjection information for Restylane.
Adverse Effects, Reactions, and Complications
Complications and adverse effects are similar to those for Restylane. If too much Per-
lane is placed in one area, it may become mobile (like a marble) in the deep layer. If
this occurs, the material may be massaged down or removed through a puncture
with an 18-gauge needle.
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Results
This 48-year-old woman had periorbital hollowing as well as prominent periorbital
fat in the central and medial aspects of her lower lids. She described this as her “po-
lar bear” appearance and sought a more normal look and contour in her orbital and
midface areas. A nonsurgical eye lift was planned as well as a midface augmentation.
The malar bone was augmented with Perlane to increase malar projection and cam-
ouflage the prominent lower lid. Perlane was placed at the depth of the periorbital
hollow on the bone and was also placed on the malar bone to augment cheek pro-
jection and minimize negative vectors. A total volume of 1.1 cc was placed per side,
mainly in the periorbital hollow (1), but a smaller amount was placed on the malar
bone to increase malar projection relative to the globe (2). The patient is seen
6 months after treatment. She is pleased with the improvement around her eyes and
the increased projection and contouring in the midface.

Restylane Fine Lines/Touch
Indications and Applications
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Part III  Nonsurgical Cosmetic Treatments
Epidermis
Dermis
Subcutaneous
tissue
Restylane Fine Lines/Touch is the smaller cousin of Restylane and is comparable to
Juvéderm 18. Although it is available in Canada, it has not yet received FDA ap-
proval. It is excellent for filling of the vertical lines of the lips as well as the fine lines
of the glabellar region. It can also be used for superficial dermal lines that occur on
the cheeks and for small soft scars, as seen on the left.
INJECTION TECHNIQUE AND LEVEL OF PLACEMENT
Restylane Fine Lines/Touch is placed at a very superficial level of the dermis or the
dermal-epidermal junction with a 31-gauge needle with a very fine tip (supplied with
a 30-gauge needle in Canada). The needle is placed just beneath the skin surface, and
the material is injected to raise the bleb; this is then massaged smooth. The applica-
tion is done along the length of the visible line. If needed, the material may be in-
jected at the same depth along the length of the line in a linear fashion. The skin may
appear blanched at the local site of injection initially, but this resolves within 5 to
15 minutes, unless local anesthetic with epinephrine has been injected. If there is any

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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery
concern about local skin ischemia, nitropaste 2% should be applied (a small amount
only). In a patient with a great deal of sun damage, superficial placement may lead to
long-term residual lumps or bumps (9 months to more than a year). These may be
improved with massage, ultrasound treatment, and the application of hyaluronidase.
Crow’s-feet may be treated, but very fine lines should be approached with caution
because of the potential for long-term bumps and possible bruising.
VOLUMES
The volume of Restylane Fine Lines/Touch needed will vary, depending
on the areas and depth of the lines. In general, for forehead lines 0.5 to 1.0 cc is used.
For the fine marionette lines 0.2 cc is recommended. Care should be taken when this
is placed in the vertical lip lines; if too much product is placed, it may make the lip
appear stiff.
LONGEVITY
This product will last 3 to 4 months, depending on the region, and 5
to 6 months in less mobile areas. Permanent scar correction can be obtained with
Restylane Fine Lines/Touch, depending on the size and shape of the scar.
EASE OF INJECTION
Restylane Fine Lines/Touch is very easy to inject, and care must
be taken not to inject too much in the area of treatment. It generally takes less than
0.05 cc of material per placement of the needle. If the skin is thick and has multiple
pores, injection may be more difficult, with small amounts of the product leaking
into pores. If excess Restylane Fine Lines/Touch is injected, this can be corrected quite
easily with massage.
TECHNICAL NUANCES
Care must be exercised in patients with very thin skin, be-
cause superficial injections can result in long-term scarring that may not resolve. An-
other caveat is to avoid injecting Restylane Fine Lines/Touch in areas that are anatom-
ically thin (the lower eyelid skin and lateral rhytids caused by the orbicularis oculi
muscle). A topical anesthetic may be used, but this and local anesthetic can cause
distortion (swelling) of the skin; therefore the line must be marked.
Combined Treatment
In the glabellar region, lines can be softened or eliminated for 8 months to a year
when Restylane Fine Lines/Touch is injected in combination with botulinum toxin
to limit corrugator function. Restylane may be needed to augment the deep layer of
the dermis to attain maximal correction of the glabellar folds.

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Postinjection Care
Postinjection bruising is less likely to occur than with Restylane Fine Lines/Touch,
but treatment with cold packs and antihistamines is very helpful in reducing the re-
covery time.
Adverse Effects, Reactions, and Complications
Long-term scarring or bumps may occur rarely (0.1%) with very superficial injec-
tions. In our experience, in all cases to date, these have resolved almost completely,
with the longest present for 1 year. As with any filler, good preinjection photographs
are necessary, and documentation of other treatments (other fillers, laser, derm -
abrasion, and infections) will help to make the patient aware of preexisting defor-
mities and improve long-term satisfaction for the patient and physician.
Results
This 39-year-old woman presented with perioral lines that she wanted to improve
or eliminate. Such lines are difficult to correct. Restylane Fine Lines/Touch is the best
filler and must be placed very superficially. Postinjection taping with clear tape for
the first 3 to 5 days can also help. It serves as a reminder to limit expression while
the fibroblast and inflammatory response is taking place in order to prevent product
migration. The patient is shown before treatment and 3 months after injection of
0.1 cc of Restylane Fine Lines/Touch. Note that the lines lie over the teeth, and if too
much product is placed, it will give the mouth an odd appearance and may persist
as a bump for a long time. Undermining of the line with an 18- or 20-gauge needle
may help to soften it. This is done at a separate visit after the injection with a warn-
ing of possible bruising. This patient is very satisfied with the result and returns every
4 to 6 months for a touchup. Because of the repetitive movement of the fold, a per-
manent correction is very difficult to achieve.
Center: 1, This line lies over the dentition, and if too much filler is placed in this area, it will show as a bump.
2, A peri oral line in this area is generally easier to correct than in position 1.

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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery
Collagen
Features
The collagens include Zyderm and Zyplast, and CosmoDerm and CosmoPlast. Zy-
derm comes in two concentrations, 3.5% purified bovine collagen (Zyderm 1) or
6.5% purified bovine collagen (Zyderm 2). Similarly, there is CosmoDerm 1 (3.5%
human fibroblast culture–derived collagen) and CosmoDerm 2 (6.5% human fi-
broblast culture–derived collagen). All collagens come premixed with 0.3% lido-
caine, but lidocaine can be safely added to the latter. Two advantages of collagen
over other injectable fillers are less pain with injection and less short-term swelling.
So if a patient needs to attend an event the evening after an injection, short-longevity
collagens would be an excellent choice of filler.
Indications and Applications
Zyderm and Zyplast are bovine collagen products; CosmoDerm and CosmoPlast
are human collagen products. Although all products above are no longer available
in Canada, they are still in use in the United States. Zyderm and Zyplast require two
skin tests: the first test is followed 2 weeks later by a second test. Three to 4 weeks
after the second test, if the patient does not have a reaction, the bovine product can
be injected. Even with two negative skin tests, one in 1000 patients may still react to
the bovine collagen injection. Skin reactions to bovine collagen can be debilitating. At
their extreme, they can last for up to a year, with very little improvement with either
topical or oral corticosteroids. For this reason many injectors are using bovine col-
lagen only in patients who have previously had it and are requesting it. Zyplast is
used in the mid-dermis in the nasolabial folds, melolabial and mental folds, angles
of the mouth, vermilion border, and body of the lip to correct volume deficiency in
these areas. Zyderm is used more superficially at the dermal-epidermal junction to
correct fine lines. Zyderm would be used, for example, to correct the lines in the
glabella that remain after a neurotoxin treatment. Additionally, Zyderm can be lay-
ered over Zyplast to give a more polished, longer-lasting effect than could be achieved
with Zyplast alone.
Since the introduction of human collagen (CosmoDerm and CosmoPlast), it has be-
come the choice of most injectors, because there is no risk of adverse allergic reac-
tions. CosmoDerm is the equivalent product to Zyderm, and CosmoPlast is the equiv-
alent product to Zyplast. CosmoPlast can be injected into the nasolabial folds to
reduce the appearance of a valley between the nose and the mouth. Additionally,
CosmoPlast can be injected into the vermilion border and the body of the lip to re-
store volume that the lips may have lost over time. CosmoPlast can also be used in
the melolabial folds and mental folds to increase the volume and reverse the effects of
aging in these areas. CosmoPlast may be injected into acne scars to correct them.

This effect can last up to 1 year. For the glabellar region, CosmoDerm and Zyderm
would be used exclusively because of the risk of skin necrosis. Also, when attempt-
ing to correct the smile lines at the corners of the mouth, the injector should use Cos-
moPlast or Zyplast in the deep layer and would inject CosmoDerm or Zyderm more
superficially over these lines to give maximal correction in an area in which typically
a 50% correction is considered very good. These lines are difficult to correct because
of the tissue pressure of folding created by smiling; we certainly do not want our pa-
tients to stop smiling to preserve the appearance of no lines.
VOLUMES
All of the collagen products are supplied in 1 cc aliquots, and the vol-
umes needed can vary from patient to patient. The lips may require a minimum of
1 cc and up to 3 cc, whereas the nasolabial folds may require 1 to 2 cc per side. Melo-
labial folds will require 1 to 3 cc total for correction. Usually 1 cc is more than enough
to correct the mental fold, and often 0.5 cc is sufficient. Also, 1 cc is usually more
than enough volume for all of a patient’s acne scars. Adjustable needles are supplied
to aid in injecting collagen to a precise depth, either to the mid-dermal region or at
the dermal-epidermal junction.
LEVEL OF PLACEMENT
CosmoDerm/Zyderm is placed at the most superficial level
of the dermis (dermal-epidermal junction) with a 30-gauge needle; an overcorrec-
tion of 10% to 20% may be required. CosmoPlast/ZyPlast, in comparison, is used
for deeper folds and lines. This includes the nasolabial folds, marionette lines (melo-
labial folds), and mental folds. Injection to the glabellar area should be approached
with caution because necrosis may result and has been reported with ZyPlast, but
has not been reported with CosmoPlast. This filler is placed at the mid- to deep retic-
ular dermis, and care should be taken with the amounts injected so that lumps and
bumps do not occur.
LONGEVITY
CosmoDerm/Zyderm may last up to 4 months, with a shorter dura-
tion of 4 to 6 weeks on the lips. CosmoPlast will last from 4 weeks to 3 months.
EASE OF INJECTION
Both Cosmoderm/Zyderm and CosmoPlast/Zyplast are rela-
tively easy to inject compared with the hyaluronic acids, and with an experienced
injector, good results can be achieved.
TECHNICAL NUANCES
The human collagens are slightly easier to inject compared
with the bovine collagens because the human collagens have an ease of flow that is
probably unparalleled in comparison with any other filler. Additionally, both human
and bovine collagen are prepackaged with lidocaine; as injection proceeds, the pa-
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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery
tient is more comfortable and experiences less pain. Massage is not a critical com-
ponent of injection with collagen. Vigorous massage after collagen injection may ac-
tually result in decreased longevity; thus minimizing massage to the injected area is
recommended. Unless the material has clearly resulted in a lump or bump, massage
is not needed. Additionally, both collagens do not have much associated swelling and
this is usually completely resolved within 24 hours in most cases. This added benefit
translates into patients having injections in the morning and attending events in the
evening. Technically the collagens are easier to use, although the correction achieved
in patients with very deep folds may not rival the correction that can be achieved
with the hyaluronans. For beginners, we suggest using the short-lasting collagens,
perfecting their results, and then moving on to the hyaluronans, which have a steeper
learning curve.
Combined Treatment
CosmoDerm/Zyderm is very useful in conjunction with Botox in the correction of
vertical lines of the lips and for softening of crow’s-feet and fine lines of the face and
neck area. CosmoDerm may be used in combination with the hyaluronic acids to at-
tain longer-lasting correction. There is little advantage in using CosmoDerm over
Restylane Fine Lines/Touch. Both products have similar use and level of injection in
the dermis. Restylane Fine Lines/Touch has much greater longevity than Cosmo Derm
and less chance of causing an inflammatory response.
Postinjection Care
Immediately after injection, if the patient takes 15 to 20 minutes to ice the face, very
little swelling should result. If a bruise does develop as a result of the injection, it
should resolve within 5 to 7 days. Provided that the patient does not ingest antico-
agulants and anti-inflammatory agents before injection, the occurrence of bruising
should be minimal and certainly less than that seen with the hyaluronans. Other-
wise the patient should be able to carry on with the day’s activities.
Adverse Effects, Reactions, and Problems
It must be noted that allergic reactions to the collagen products may occur. Skin test-
ing is not required for CosmoDerm and CosmoPlast; however, patients receiving Zy-
derm and Zyplast require at least one skin test. We perform two skin tests; the first
test is at the first visit and the second is performed 2 weeks later. The second skin
test is evaluated 4 weeks after it is placed. In evaluation, one is looking for redness,
swelling, and plaques. Reactions can occur even if the test result is negative. It has
been reported that a patient with two negative skin tests to bovine collagen can still
have a 1:1000 chance of a reaction with subsequent injections. In our experience re-
actions to bovine collagen are rare but can be prolonged and incredibly difficult to

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manage. Patients may experience redness, plaques, and scaling dermatitis that is un-
responsive to application of topical steroids. The response to steroid injection is un-
predictable, and sometimes patients are required to take oral prednisone for control
of inflammatory responses. Scarring may be the end result. For this reason, we pri-
marily inject CosmoPlast and CosmoDerm, the human collagen products, which
have been shown to have low immunogenicity.
Repeated injection may result in scar formation in the soft tissues providing some
longer-term permanent augmentation. With bovine collagen (Zyplast/Zyderm), in-
flammation was thought to contribute to long-term improvement. Human collagen
(CosmoPlast/CosmoDerm) will not stimulate as much inflammation, because it is
species compatible. In some patients, bovine collagen is not long lasting, and reac-
tions still may occur. There have been reports of necrosis in the glabellar region when
Zyplast was injected.
Radiesse
Features
Radiesse (BioForm Medical, Inc., San Mateo, CA) consists of 30% calcium hy-
droxylapatite (CaHA) and microspheres surrounded by a carboxymethylcellulose
gel carrier. The technology is similar to that of ArteFill, but there are some differ-
ences. Radiesse is a little more biocompatible, because calcium hydroxylapatite is
the same mineral component found in bones and teeth. This is a synthetic product,
and the aqueous carrier gel is composed of glycerin and sodium carboxymethyl-
cellulose and constitutes 70% of this product’s volume. The carrier gel is replaced
with the patient’s own connective tissue 3 to 6 months after injection. Therefore no
sensitivity testing is required. The carrier gel makes it a little bit thicker and a little
more cohesive.
Indications and Application
Radiesse has been injected into the lips (not recommended), nasolabial folds, glabel-
lar region, marionette grooves, and the mental fold. It has been approved by the FDA
for the treatment of nasolabial/labiomental folds, HIV lipoatrophy, vocal cord in-
sufficiency, radiographic marking, and facial skeletal reconstruction. It is also par-
ticularly appropriate for treating glabellar lines, acne scars, posttraumatic/poststeroid
atrophy, and achieving cheek/chin/mandibular augmentation, and correction of nasal
depressions or nasal augmentation. Injection of this product in the lips or superfi-
cial rhytids should be avoided, because doing so results in high rates of visible nodu-
larity (20%). CaHA can also be used in hand rejuvenation.

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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery
Preoperative and 6-month postoperative results are shown after injection of 1.3 cc
of Radiesse to the left hand in a 60-year-old woman.
Level of Placement and Injection Technique
Radiesse is supplied in 1 cc syringes. The placement is at the deep dermal level sim-
ilar to ArteFill. The technique for injection and the planning for volume and line cor-
rection are much different than with the other fillers. The material is placed as the
needle is withdrawn in a linear injection technique. Layering of the product at the
deep level may help for areas such as the nasolabial folds. Cutaneous subcision will
aid for very deep lines. Postinjection massage should be carried out to attain proper
soft tissue contouring.
Similar to ArteFill small amounts of Radiesse must be placed with care to avoid ir-
regularities, lumps, and bumps. Unlike with ArteFill most of the correction is achieved
from the calcium hydroxylapatite particles within the product rather than tissue in-
growth around the particle matrix.
Volumes
This product is available in 0.3, 1.3, and 1.5 cc syringes and does not require re-
constitution, as Sculptra does. Since it does not contain anesthetic, lidocaine 1% can
be added at varying volumes, depending on the desired viscosity (this is an off-label
use). Usually, in areas that require structural support, such as the cheek, 0.1 to
0.5 ml of lidocaine is used, whereas in areas of thinner skin, such as the tear trough,
1.0 ml of lidocaine is preferable. A 27- or 28-gauge needle can be used without clog-
ging problems. The volume placed is similar to that of other fillers. Initially the in-
jector should be conservative, because the material is long lasting; a relatively small
volume provides a little larger correction than some of the other products. Approx-
imately 1 cc of this product is comparable to the corrections that can be attained
with 3 cc of Zyplast. The volume of augmentation is maximal at 4 to 6 weeks. Care
must be taken with the amount of filler placed and that it is placed very evenly. For
hand rejuvenation the recommended injection volume is 0.7 to 1.0 cc injected in
small boluses subcutaneously and massaged to provide an even distribution. Lido-
caine 1% 1 ml can be mixed with each 1 cc of CaHA injected to provide anesthesia.

Longevity
Radiesse has less long-term clinical follow-up in the soft tissues of the face compared
with ArteFill and the hyaluronic acids, since its original indication was for use as a
radiologic marker. It has a reported longevity in soft tissue of 1 to 5 years and in
some reports up to 7 years, but the declared persistence is 1 year. An incidence of
lump or bump of 8% to 10% has been reported by experienced injectors for con-
touring of the lips.
Ease of Injection
Radiesse has a higher viscosity and requires a larger needle size; however, the man-
ufacturer supplies a special 28-gauge needle that facilitates injection, making it sim-
ilar to that for hyaluronic acid fillers; injection is even easier if lidocaine is added. In-
jectors should start with the easier areas of correction, such as the nasolabial folds.
Technical Nuances
Care should be taken with injections, because the incidence of irregularity is higher
than that of other fillers in the hands of new injectors. Deep dermal placement is im-
portant, since superficial placement may cause local irritation, bumps or rare gran-
uloma formation. Furthermore, small-volume injection (less than 0.1 cc) and a uni-
form injection technique may help to prevent granuloma formation. After injection,
massage will help to create a uniform contour; the product is pastelike and can be
manipulated for several days following the injection.
Combined Treatments
Radiesse may be layered with other nonpermanent fillers. Taking preinjection pho-
tographs is as important for all patients having tissue filler injections as for patients
undergoing cosmetic surgery.
Postinjection Care
Lumps, bumps, or irregularities may be treated by injecting them with dilute triam-
cinolone (Kenalog) on a monthly basis until they have resolved. Avoidance of blood-
thinning medications and supplements before injection and topical icing for the first
24 hours after injection are also important.
Adverse Effects, Reactions, and Problems
Complications occur most often in the lips where there can be a 10% to 20% early
nodularity rate. If a lump, bump, or irregularity occurs, it may be treated with a di-
lute steroid injection and massage. However, irregularities may require excision if
they persist and do not respond to steroids. It has been found that when the volume
injected into the lips is adjusted to 0.6 cc in the upper lip and 0.4 cc in the lower lip,
the rate of nodularity decreases to half, or approximately 5%. Radiesse is radiopaque,
so patients should be informed of this to avoid surprises during routine dental x-ray
examination. The volumes required with Radiesse are similar to or somewhat less
than those needed with other fillers.
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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery
Results
Preoperative and 6-month postoperative results after lip augmentation with 1 cc of
Radiesse are shown. At 15 months the patient exhibits only a small amount of vol-
ume loss.
This woman underwent injections of 1.4 cc of Radiesse to her radiating lip lines,
nasolabial folds, and white roll. The close-up view (lower right) clearly shows her
more youthful appearance.
Preoperative
15 months postoperatively
6 months postoperatively
Courtesy Miles Graivier, MD
Courtesy Miles Graivier, MD

Sculptra
Characteristics
Sculptra (Sanofi-Aventis, Bridgewater, NJ) is an injectable filler composed of a sus-
pension of poly-L-lactic acid (PLLA) microparticles (40 to 63 m). This is the same
type of material used in absorbable sutures such as Vicryl, or absorbable plates. It
is a biocompatible and biodegradable polymer that breaks down, eliciting an in-
flammatory reaction, which contributes to collageneogenesis and fibrous tissue for-
mation. Soft tissue augmentation is accomplished initially by the direct deposition
of PLLA particles as well as the diluent. PLLA particles are suspended in carboxy-
cellulose, mannitol, and normal saline solution. Once the diluent is absorbed, the
volume-enhancing effect is partially lost; the PLLA particles remain to undergo a
much slower degradation that takes place over a year. Macrophages break these par-
ticles down to lactic acid, water, and carbon dioxide, and the inflammatory process
attracts fibroblasts, which in turn result in particle encapsulation and increased col-
lagen tissue deposition. Therefore the final effect is somewhat delayed (weeks to
months); that delay should be kept in mind while injecting Sculptra. As a result, mul-
tiple conservative sessions may be required. The longevity of PLLA can range from
1.5 to 2.5 years; however, additional injections may be required once the desired re-
sult starts to diminish.
Indications and Applications
PLLA has been successfully used in more than 30 countries under the name of New-
Fill for a variety of facial volume and contour deficiencies including facial aging. In
the United States, Sculptra is approved for the treatment of facial lipoatrophy seen
with antiretroviral therapy in HIV-positive patients, and it recently received FDA ap-
proval for cosmetic use (Sculptra Aesthetic, approved July 2009). It is indicated for
the correction of shallow to deep wrinkles, such as the nasolabial folds and mari-
onette grooves, as well as contour deformities. Injection should be either in the deep
subcutaneous planes or deep dermal layer or on the skeleton (forehead, malar re-
gion, jawline, and the base of the nose), avoiding more superficial deposition. The
use of PLLA in superficial rhytids and the lips is contraindicated, because it can eas-
ily lead to visible and palpable inflammatory nodules.
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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery
Preoperative and 1-year postoperative results are shown after augmentation to the
brow, cheeks and jawline with three sessions of Sculptra (2 vials per session) in a 51-
year-old woman. The dilution of each vial of Sculptra consisted of 7 ml of sterile wa-
ter and 3 ml of 1% lidocaine with epinephrine.
Product Preparation
Sculptra is a crystalline, amorphous, freeze-dried mixture with a 2-year shelf life in
the unconstituted form. Dry PLLA is reconstituted with sterile water. The volume is
5 cc on average, but volumes as low as 3 cc (not recommended) and up to 20 cc have
been reported, usually depending on the location being injected. Unlike other fillers,
this product requires preparation by reconstitution at least 2 hours before injection.
Some physicians prefer reconstitution 12 to 24 hours before injection. Once the wa-
ter has been added, the vial is allowed to stand without shaking or agitation for at
least 2 hours. The reconstituted suspension is stable for up to 72 hours and does not
require refrigeration. After the 2 hours and immediately before injection, the vial
must be agitated or rolled to ensure a uniform, translucent suspension. Although the
manufacturer recommends discarding any unused product after 72 hours, there are
reports of PLLA use 30 days after it has been reconstituted and kept at room tem-
perature. Lidocaine 1% or 2% (1 ml), with or without epinephrine, can be added
when preparing Sculptra to decrease the discomfort associated with injection. In-
jection is carried in the deeper layers first, usually by a depot technique. Then a more
superficial layer is injected to provide a more “polished” volume augmentation.
Postinjection massage is necessary to prevent nodule formation and optimize the
outcome. Sculptra, a synthetic, is not derived from animal or human tissue; there-
fore it is not very immunogenic, and skin testing is not required.

Injection Technique
There are two basic injection techniques: tunneling and depot. The tunneling tech-
nique for deep dermal and subdermal injection is most suited for the lower face,
cheeks, and nasolabial folds. The depot technique is for deeper placement of the
product directly over the periosteum, such as the periorbital area and rim zygoma.
Tunneling Technique
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Epidermis
Dermis
Subcutaneous
tissue
Muscle
Periosteum
Bone
For the tunneling technique, used for placement of the product in the deep dermis
or subcutaneous tissues, the needle is placed at the appropriate level and the Sculp-
tra is deposited as the needle is withdrawn, leaving 0.1 to 0.2 cc per injection or nee-
dle pass. In the cheeks, 20 such passes may be needed for contour correction.
Depot Technique
The depot technique allows product placement deep into the tissues just above the
periosteum. The needle is guided through the tissues to the periosteum of the un-
derlying bone, and then a depot of 0.05 cc is deposited. This should produce a visi-
ble and palpable elevation of the area.
Epidermis
Dermis
Subcutaneous
tissue

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Chapter 12  Soft Tissue Fillers in Aesthetic Facial Surgery
In the depot technique, the area should be massaged to spread the product evenly
over the bone, and then a second injection is performed. This is the technique for zy-
gomatic enhancement and periorbital correction over the orbital rim deep to the or-
bicularis muscle. (Caution must be exercised in this area, because if nodules occur,
they can persist for a long time.)
Volumes
The volume of injection will vary from individual to individual and area to area.
Typically, for the nasolabial folds, volumes of 1 to 2 cc per side may be required. For
correction of lipoatrophy of the cheeks and temple area, several milliliters per side
may be needed and, in fact, multiple injection sessions may be required.
Longevity
Sculptra is a relatively long-lasting soft tissue filler. There have been reports of per-
sistence of the product and volume correction up to 2.5 years in patients who suffer
from lipoatrophy of the face.
Ease of Injection
The ease of injection depends on the consistency of the reconstituted product, which
depends on the dilution with 5 to 10 ml of sterile water. Sculptra requires a 26-gauge
needle or larger. Unlike most other fillers, it cannot be injected through a 30-gauge
needle. If difficulty is encountered with the 26-gauge needle, a larger-gauge needle
such as a No. 25 or 23 (rarely) should be used.
Epidermis
Dermis
Subcutaneous
tissue
Muscle
Periosteum
Bone
Finger
performing
massage

Technical Nuances and Tunneling Techniques
First, the entire area to be injected is marked; then the skin is stretched opposite to
the direction of injection to facilitate skin penetration. The syringe plunger is drawn
back to ensure that a blood vessel has not been entered, and then a thin trail of Sculp-
tra is injected as the needle is withdrawn, no more than 0.1 to 0.2 cc per tunnel. This
injection will produce a visible and palpable skin elevation in the area of injection.
The injected area is massaged, and then another injection is made next to the pre-
vious one. Multiple injections in a crisscross pattern produce the best results. In
patients requiring large volumes, it is best not to do the entire volume correction
at one time. The injections can be repeated during a second session a week or two
later. It is important not to overcorrect and to massage the area to distribute the
Sculptra evenly.
Combination Treatments
Because Sculptra is designed for deep dermal or subcutaneous use, it is not a suit-
able product for correction of perioral, periorbital, and facial lines requiring depo-
sition of a product more superficially. Deep treatment with Sculptra could be com-
bined with the more superficial treatment with other suitable products.
Postinjection Care
Immediately after the completion of the injection, moisturizer is applied to the area
and at least 5 minutes of massage is performed by the physician. Ice packs are then
applied to the area to minimize bruising. The patient is also instructed to massage
his or her face daily at home. The patient should be advised that much of the initial
injected volume will be lost within the first weeks as water and postinjection edema
are absorbed, leaving the microparticles of PLLA within or under the skin; that
the full effect of the treatment may take a few weeks or months to be visible; and
that a number of treatment sessions may be needed, depending on the severity of
volume loss.
Adverse Effects, Reactions, and Complications
As with most injectables, bruising, swelling, and inflammation can develop after in-
jection with Sculptra. More specifically, inflammatory nodules or papules can de-
velop and are usually associated with injection at the superficial dermal/epidermal
layers or injection in the lips. Skin discoloration can accompany such superficial nod-
ules. The role of massage is critical in preventing such inflammatory nodule forma-
tion. Some data suggest that certain conditions, such as connective tissue disease or
sarcoidosis, may predispose to a more pronounced inflammatory reaction (extensive
granuloma formation and facial edema) with Sculptra injection.
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