PALM BEACH, FLA. Technical tips to optimize use of injectable facial fillers and botulinum toxin were offered during a live patient demonstration at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.
A natural-looking result is the goal. "We want to return patients to what they looked like when they were younger. That is what our patients want," Dr. Mark S. Nestor said. "Really, the idea is combining [products], such as Botox and some of these fillers, to get optimal results."
An initial patient assessment should include realistic expectations. Know what fillers can and cannot achieve. "What you see as a physician may be different than what a patient is concerned about. When you have done this for a while, it's interesting to look at why something bothers patients," said Dr. Nestor of Aventura, Fla.
Along with Dr. James M. Spencer and Dr. Joely Kaufman, Dr. Nestor treated a series of volunteers at the meeting with combined treatments of injectable fillers and botulinum toxin.
Treatment was halted for one person who experienced an adverse reaction. She was tilted back in the chair while ice was applied to her forehead. "She is having a vasovagal response, which is not that uncommon," Dr. Nestor said. "This happened in South Beach [at a meeting in February 2007]. Patients need to be laid back, and they will come out of it quickly."
The newest filler option is Perlane (hyaluronic acid, Medicis), which was approved by the Food and Drug Administration in May for correction of moderate to severe facial folds and wrinkles. Perlane's nonimmunogenic, stabilized hyaluronic acid gel particles are similar to Restylane (hyaluronic acid, Medicis) but larger. Perlane adds volume to restore surface contour in facial wrinkles and folds, including the nasolabial fold. The product should be injected into the deep dermis up to the superficial layer of the subcutis.
Dr. Nestor injected Perlane with a 27-G needle. "You can actually feel the filler going in. What you are seeing right away is the significant lift you get because this product is really robust."
After injecting the nasolabial folds, he massaged inside and outside of the mouth to get an even distribution, noting that "Perlane smooths out very, very nicely." The next step involved superficial injections of Restylane on top of the same area. He finished the treatment with botulinum toxin injections to the crow's feet area.
Perlane can also be injected to accentuate areas below the mouth, said Dr. Nestor, who disclosed a relationship with Medicis.
While treating another volunteer, he noted that Perlane can replace significant volume loss in the midcheek for an extended period. "It doesn't roll off. Studies have shown it can remain there 5 or 6 years."
In contrast, Dr. Nestor advised undercorrection of volume loss when using Juvederm Ultra (hyaluronic acid gel, Allergan). "The idea here is that you can always inject more. You don't want to inject too much to begin with." He typically injects the filler as he withdraws the syringe. "You can feel it going into the deeper aspect of the dermis."
Dr. Kaufman injected another volunteer with Juvederm. Another option would be Sculptra (poly-L-lactic acid, Sanofi-Aventis). "By using Sculptra, you would need less hyaluronic acid in the nasolabial folds," said Dr. Kaufman of the University of Miami. The direction of product flow can make a big difference. For marionette lines, for example, she injects downward toward the center of the face below a patient's mouth. In addition, one little bolus of hyaluronic acid right under the vermilion border on either side of the mouth "really turns the lip up," she said.
Another combination approach uses injection of Radiesse (calcium hydroxylapatite, BioForm Medical) to restore facial volume and botulinum toxin to lift the corners of the mouth, said Dr. Spencer, who has a skin cancer and cosmetic dermatology practice in St. Petersburg, Fla.
Dr. Spencer used a 27-G needle and a 1.3-cc syringe during the demonstration. Radiesse is "more viscous, so it takes a little more effort to inject," he said. Threading or serial puncture down are the two technique options. "I always see them back in a week to make sure everything is okay." He estimated that the volume enhancement with Radiesse will last 1-2 years.
Dr. Kaufman and Dr. Spencer had no relevant disclosures regarding the products used in the demonstration.