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AHS 302 Wellness and Anti-Ageing Management
Week 12
Dermal Fillers
COMMONWEALTH OFAUSTRALIA
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Terry Everitt
Senior Lecturer
Week 12
Start off with a quick history of fillers – bit of anatomy –
Three major classifications of fillers
Hyaluronic acid and things that make it so different like Cross-linking
and Rheological Properties of Viscosity and Elasticity
Techniques and placement of fillers along with, with what needle or
cannula
Hyaluronidase to the rescue
Bit thicker and last longer are Poly-L-lactic acid and Calcium
hydroxylapatite
Complications
Remember these are Medical Device Class 3 – Schedule 4 Drugs
Client answers
PRP & AAT
Finishing with a little quiz – Determining the 2-Dimensional
Threshold for Perception of Artificial-Appearing Lips
Quick history
1893 – fat transplants were documented by German surgeon
Gustav Adolf Neuber
1920 – injected paraffin was popularized, again did not last
long (mainly because the paraffin did, in the form of
paraffinomas)
1960 – Liquid silicone was the theme for several varied
applications, including soft tissue augmentation. Sadly, the
soft tissue did not stay soft for long.
1981 – The Food and Drug Administration (FDA) gave approval
of injectable bovine collagen, (Ziderm) and the subsequent
marketing campaign by Collagen Corporation for the ‘Paris
Lip’, a technique focusing on the central portion of the lip and
enhancement of the cupid’s bow and philtrum
1995 – Collagen Corporation joined forces with a Swiss
biotechnology company and launched the first hyaluronic acid
(HA) filler, Hylaform, with a view to providing an injectable for
immediate use.
Dermal adipose pads
Vessels and nerves to avoid
Three major distinctions
Absorbable products (temporary; 3–6 months – HA and
collagen fillers).
Slowly absorbable products (temporary; 6–24 months – HA,
calcium hydroxyapatite and l-polylactic acid fillers).
Nonabsorbable products (permanent; >24 months –
polymethyl methacrylate and silicone fillers.
Hyaluronic acid (HA)
Non-animal stabilized hyaluronic acid (NASHA).
HA dermal fillers are composed of the disaccharides N-acetyl
glucosamine and glucuronic acid with glycosidic bonds.
Hydrogels, usually composed of approx. > 95% of water and
0.5–3% of HA.
These fillers vary in methods of cross-linking, particle size and
concentration, which are significant characteristics of each
product.
Approximately 50% of the
total quantity of HA in the
human body is concentrated in
the skin. Half-life of 24–48
hours, its average turnover
rate is 5 grams per day.
Cross-linking
1,4-butanediol diglycidyl ether (BDDE) is the crosslinking
agent used in the majority of the market-leading HA fillers
Residual, or unreacted, BDDE is considered nontoxic when it
is <2 parts per million (ppm); therefore, the quantification of
residual BDDE in the final dermal filler is mandatory to ensure
the safety of the patients (Fidalgo et al., 2018).
G prime – quantifies elasticity or stiffness of a filler, hence its
ability to resist deformation under applied pressure
Monophasic (monodesified) gels consist of a single ‘phase’ of
HA
Biphasic is two stage process – cross linked in suspended in
non cross linked gel
Rheological Properties of Viscosity and Elasticity
(Sundaram, Voigts, Beer, & Meland, 2010).
Techniques and placements
Retrograde or anterograde
Threading – delivers the filler continuously along either most
or the entire length of the defect.
Puncture – Multiple needle sticks where beads of filler are
injected
Cross-hatching – linear threads are delivered in parallel lines,
and then in lines perpendicular to these, to create a
rectangular mesh of filler material.
Fanning – single-entry point is used to create linear threads
in an arciform array
Tunnelling – a form of linear threading with deep placement
of filler, usually below the dermal–subcutaneous junction
Depot – sizable boluses into the subcutis or just above the
periosteum, and subsequent massage or sculpting to mould
an appropriate contour.
Needles have the advantage of extreme movement precision.
Cannulas cause less trauma, allow treatment of larger areas
at the selected site
Studies since Lowe and Grover (2006) concluded that using
cannulas resulted in more precise placement of the injected
material compared with needles.
The recommended cannulas are usually 22–25 gauge.
The recommended needles are usually 27–30 gauge.
Needle or cannula
Hyaluronidase
HYALASE (Sanofi-Aventis Australia Pty Ltd)
6 indications of use – none for cosmetic medicine –
all ‘off label’.
Each ampoule contains 1,500 international units of
Hyaluronidase and sodium hydroxide.
Prescribed use – one dose, one patient only
There is little consistency within the literature with
regard to recommended dosing for use of
hyaluronidase.
Hyaluronidases are enzymes (endoglycosidases)
that can depolymerise HA, leading to its
degradation by hydrolyzing the disaccharides at
hexosaminidase linkages.
Hyaluronidase has immediate effect and a half-life
of two minutes with duration of action of 24 to 48
hours.
Poly-L-lactic acid
PLLA is an aliphatic polyester composed of polymers of lactic
acid derived from the fermentation of corn dextrose.
The commercial product is a microparticle mixture of PLLA,
sodium carboxymethylcellulose, and mannitol.
Microparticles size from 40 to 63 mm diameter.
Deep plane placement.
Resorbed relatively quickly – does not directly provide
mechanical correction of volume defects.
Induces a host response of production of fibrous tissue via
stimulattion of fibroblasts to produce collagen.
Last 18-24 months.
Sculptra from Galderma.
Calcium hydroxylapatite (CaHA)
Calcium Hydroxylapatite microspheres (25-45 microns) in
carboxymethyl cellulose carrier gel with 0.3% lidocaine
hydrochloride.
Highly viscoelastic.
Diluted 1:1 (1.5 mL) normal saline.
Same chemical composition as the inorganic constituent of
teeth and bone – ss a bioceramic, CaHA is native to the body.
Radiesse (Merz).
(Lorenc et al., 2018, p. 11).
Complications
Tyndall effect – Bluish hue that is visible within the skin
caused by too superficial placement of filler.
Arterial embolisation – bolus in arterial supply.
Granuloma – hypersensitivity reaction, mediated by
macrophage or T-cell interaction.
Infection – frequently from makeup application.
CaCH nodule formation – due to superficial injection of
the product in hyperkinetic areas, such as lips, and can
lead to accumulation of the product when the gel starts
to be reabsorbed in 3 months.
Medical Device Class 3 – Schedule 4 Drugs
Juvederm (Allergan) – VOLITE – VOLBELLA with Lidocaine- Ultra
Plus XC -VOLUMA with Lidocaine
Restylane (Galderma) Fynesse – Kysse – Volyme – Refyne –
Defyne – Lyps Lidocaine – Skinboosters Vital Light Lidocaine –
SubQ Lidocaine
Stylage (AA-Med) S Lidocaine – M Lidocaine – L Lidocaine – XL
Lidocaine and Stylage S – Stylage M – Stylage L – Stylage XL
Radiesse (Merz) Injectable Implant – (+) Lidocaine
Princess (CROMA Australia) Princess Filler Lidocaine – Volume
Lidocaine – Volume – Filler – Rich
Sculptra Poly-L-lactic acid (Galderma)
Belotero (Mertz) – Lips Shape -Lips Contour – Soft LidocaineIntense Lidocaine – Balance Lidocaine – Volume Lidocaine
https://www.tga.gov.au/artg
Client answers
Dermal fillers can be used to treat almost all areas of the
face.
If only it were as simple as 2 mls for that area and 3 mls for
this area- sadly it is not.
Syringe of dermal filler contains 0.8 – 1.5 ml of product
Lips – 1 ml; malar/mental 2-3 ml; volumizing – 4-8 mls
Generally thought 2 – 4 weeks post injection prior to skin
treatments
Not recommended in pregnancy and breast feeding
Permanent fillers not recommended (although available) as
adverse reactions are common
Non-absorbable high viscoelastic polyacrylamide hydrogel
for soft tissue augmentation
Perhaps the most important of all – who will inject?
Treatment with 1,540-,
1,550-, 1927-, and
10,600-nm fractional
lasers did not result in
significant morphologic
changes of HAF, although
thermal changes from
1,540- and 1,550-nm
lasers were in very close
proximity to the filler.
The RF devices
demonstrated thermal
damage of HAF along the
microneedle tracks
(Hsu, Chung, & Weiss 2019).
PRP & AAT (AFT)
Platelet Rich Plasma
Stimulate human dermal fibroblast proliferation and increase
type I collagen synthesis. Additionally, based on histological
evidence, PRP injected in human deep dermis and immediate
subdermis induces soft-tissue augmentation, activation of
fibroblasts, and new collagen deposition, as well as new blood
vessels and adipose tissue formation (Camps, 2016).
Autologous Adipose Transfer
No single technique has emerged as clearly superior to the
others with wide range of fat graft retention rates –
unpredictable graft retention is the main disadvantage
(Mokhallalati, & Al-Niaimi, 2017).
Skepticism remains with autologous fat transfer as the
procedure has still not been perfected in a way that results
can be reliably reproduced from physician to physician (Narins,
& Mariwalla, 2018).
Pilot study of autologous noncultured dermal cell suspension
showed great improvement in dermal loss (Sahoo et al., 2019)
(Alves & Grimalt, 2018, p. 22)
Determining the 2-Dimensional Threshold
for Perception of Artificial-Appearing Lips
The baseline image is real
and all others are digitally
enhanced by 1 mm in the
upper lip, lower lip, both lips
and cupid bow.
Working from the left,
which one do you think is
the most natural and which
one is the first that you
think is ‘overdone’ being
unnatural and artificial.
Upper lip
Baseline
Lower lip
Alteration
of both lips
Cupid’s bow
1 mm 2 mm 3 mm 4 mm 5 mm
(Wim & Rousso 2017)
References
Alves, R., & Grimalt, R. (2018). A Review of Platelet-Rich Plasma: History, Biology,
Mechanism of Action, and Classification. Skin Appendage Disorders,
4,18–24. DOI: 10.1159/000477353
Camps, L. (2016). PRP in cosmetic dermatology. In R. Alves, R. Grimalt (Eds.),
Clinical Indications and Treatment Protocols with Platelet-Rich Plasma in
Dermatology (pp. 45–57). Barcelona: Ediciones Mayo.
Fidalgo, J., Deglesne, P., Arroyo, R., Sepúlveda, L., Ranneva, E., & Deprez, P. (2018).
Detection of a new reaction by-product in BDDE cross-linked autoclaved
hyaluronic acid hydrogels by LC–MS analysis. Medical Devices: Evidence
and Research, 11, 367–376
Hsu, S., Chung, H., & Weiss, R. (2019). Histologic Effects of Fractional Laser and
Radiofrequency Devices on Hyaluronic Acid Filler. Dermatologic Surgery,
45(4), 552–556.
Lorenc, Z., Bass, L., Fitzgerald, R., Goldberg, D., & Graivier, M. (2018).
Physiochemical Characteristics of Calcium Hydroxylapatite (CaHA).
Aesthetic Surgery Journal, 38(S1) S8–S12.
References
Mokhallalati, A., & Al-Niaimi, F. (2017). Autologous fat grafting. Prime, 8(4)
Narins, R. S., & Mariwalla, K. (2018). History of Fillers. In D. Goldberg (Ed),
Dermal Fillers (pp. 1-9). Basel: Karger.
Popnko, N. Tripathi, P Devic, Z. Karimi, K. Osmann, K. Wong, J. (2017). A
Quantitative Approach to Determining the Ideal Female Lip
Aesthetic and Its Effect on Facial Attractiveness. JAMA Facial Plastic
Surgery, 19(4), 261-267. doi:10.1001/jamafacial.2016.2049
Sahoo, A. K., Yadav, S., Sharma, V. K., Parihar, A. S., Vyas, S., & Gupta, S.
(2019). Safety and efficacy of autologous noncultured dermal cell
suspension transplantation in the treatment of localized facial
volume loss: A pilot study. Indian Journal of Dermatology,
Venereology and Leprology, 85(1), 44-50.
DOI: 10.4103/ijdvl.IJDVL_760_17
Sundaram, M., Voigts, B., Beer, K., & Meland, M. (2010). Comparison of the
Rheological Properties of Viscosity and Elasticity in Two Categories
of Soft Tissue Fillers: Calcium Hydroxylapatite and Hyaluronic Acid.
Dermatologic Surgery, 36, 1859–1865. DOI: 10.1111/j.1524-
4725.2010.01743.x
Wim, S. Rousso, D. (2017). Determining the 2-Dimensional Threshold for
Perception of Artificial-Appearing Lips. JAMA Facial Plastic Surgery,
19(5), 392-398. doi:10.1001/jamafacial.2017.0052
Area Ideal
attractiveness
Unnatural and artificial
Upper lip 3
rd from left 4
th from left to end
Lower lip 1
st on left 3
rd from left to end
Alteration of
Both lips
1
st on left 3
rd from left to end
Cupid’s bow 1
st on left 2
nd from left to end
(Wim & Rousso 2017)
Determining the 2-Dimensional Threshold
for Perception of Artificial-Appearing Lips
This correlated well with an independent study published two
months earlier by Popenko et al (2017) at Chicago Medial
School, who found the ideal Caucasian female lip dimensions
are a 1:2 ratio of upper to lower lip, and a roughly 50%
enhancement in total lip surface area.
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