aesthetic dermal filler injections for facial rejuvenation · he completed his residency at family...
TRANSCRIPT
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Aesthetic Dermal Filler Injections for
Facial Rejuvenation
Tam Nguyen, MD, FAAFP
Elyas Parsa, DO
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ACTIVITY DISCLAIMERThe material presented here is being made available by the American Academy of Family Physicians for
educational purposes only. Please note that medical information is constantly changing; the information
contained in this activity was accurate at the time of publication. This material is not intended to represent the
only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it
is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others
who face similar situations.
The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this
material and for all claims that might arise out of the use of the techniques demonstrated therein by such
individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care
to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical
application. This material might contain recommendations/guidelines developed by other organizations.
Please note that although these guidelines might be included, this does not necessarily imply the
endorsement by the AAFP.
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DISCLOSURE
It is the policy of the AAFP that all individuals in a position to control content disclose any
relationships with commercial interests upon nomination/invitation of participation.
Disclosure documents are reviewed for potential conflict of interest (COI), and if identified,
conflicts are resolved prior to confirmation of participation. Only those participants who had
no conflict of interest or who agreed to an identified resolution process prior to their
participation were involved in this CME activity.
All individuals in a position to control content for this session have indicated they have no
relevant financial relationships to disclose.
The content of my material/presentation in this CME activity will not include discussion of
unapproved or investigational uses of products or devices.
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Tam Nguyen, MD, FAAFP
Physician, Washington Township Medical Foundation (WTMF), Fremont, California
Dr. Nguyen is a graduate of Pennsylvania State University College of Medicine in Hershey. He completed his residency at Family Practice at San Jose-O’Connor Family Medicine Residency Program. He practices inpatient and outpatient family medicine at WTMF. His topics of specialty include dermatology and diabetes. Dr. Nguyen instructs physicians of various specialties on aesthetic procedures, including the use of botulinum toxin, lasers, liposuction, and nonsurgical facial reconstruction. He also consults with providers on how to establish an aesthetic practice. Dr. Nguyen believes family medicine’s most critical challenge is caring for the uninsured and underinsured.
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Elyas Parsa, DOProgram Director, San Joaquin General Hospital Family Medicine Residency, French Camp, California
Dr. Parsa earned his medical degree at Midwestern University’s Chicago College of Osteopathic Medicine, Illinois. He completed his family medicine residency at Advocate Christ Family Medicine Residency Program, Oak Lawn, Illinois, and is certified by the American Osteopathic Board of Family Physicians (AOBFP). Dr. Parsa has five years of teaching experience and was named Teacher of the Year from 2015 through 2017. His areas of interest are chronic disease management, practice improvement, emergency care, inpatient medicine, and procedures (including bedside ultrasound). In addition, he practices aesthetic medicine at Silhouette Med Spa and Weight Management, Livermore, California.
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Learning Objectives
1. Assemble plans to address requests for dermal fillers, particularly among patients who may want injections to reduce the signs of aging.
2. Outline appropriate treatment modalities and duration of action required for dermal filler injections.
3. Assess the costs involved in ordering and performing dermal filler injections.
4. Assess the risks and benefits involved in performing dermal filler injections.
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Introduction
• Concept of filler 1900’s or even earlier replacement of facial defects with fat
• Early cosmetic fillers
– Silicone
– Animal sources
• Bovine (collagen)
• Rooster combs
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Autologous Fat Grafts
Liposculpture
Pre-adipocytes
Stem Cells from Adipose
tissue
Bovine Collagen
Zyderm II
Zyplast
Koken Atelocollagen
Zyderm I
Procine Collagen
Permacol
FibroquelEvolence
Fillers
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Fillers
Hyaluronic Acid
Restylane
Hylaform
Juvederm
Captique
Rofilan
AcHyal
Matridur
Puragen
PMMA
Artecoll
Artefill
Aphrodite
Metacrill
Bioplasty
Precise
Others
Radiesse
Dermalive
New-Fill Sculptra
MatridexReviderm
Evolution
Bion-Blue
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Introduction
• Restylane, a hyaluronic acid (HA) introduced 1996• Animal products quickly became obsolete
• Restylane majority of market share until the
introduction of other fillers
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STRUCTURE
Hyaluronic acid is a polymer
• Polymer (from Greek many part) large molecule with repeating structural units
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Types of polymers
• 3 main classes of biopolymers
– Polysaccharides
– Polypeptides
– Polynucleotides
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Polymers & Aesthetic
Natural Polymers
• Proteins collagen
• Polysaccharides Hyaluronic Acid
Synthetic Polymers
• Poly-L-lactic acid (Sculptra)
• Poly-methyl methacrylate (Artefil or Bellafil)
• Silicone (Silikon 1000)
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Hyaluronic Acid (HA)
• Hyaluronic acid
– Naturally occurring, found in all living organisms
• Chemically identical in all species no
tissue specificity
• A carbohydrate not a protein low risk of
allergic reaction– No skin testing required
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Hyaluronic Acid (HA)
• Skin houses majority of HA
– Essential component of extracellular matrix &
connective tissue of all animal tissues
– Volume & pliability
– Cell growth
• Other locations muscles, skeleton, synovial fluid
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Hyaluronic Acid
• Basic unit is a disaccharide
• Length of the final polymer chain is the only
difference between a human HA & a bacterial HA
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Hyaluronic Acid
• Commonly use in moisturizers high capacity to
bind H2O excellent characteristic for filler
material helps holds shape
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Hyaluronic Acid (HA)• HA must be stabilized to prevent prompt degradation
• NASHA Non Animal Stabilized Hyaluronic Acid
• 1,4-butanediol diglycidyl ether (BDDE) most commonly used for stabilization
• Distinct filler intrinsic properties due to
– Particle Size
– Concentration
– Method /degree of cross-linking
– Gel hardness
– Cohesivity
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Hyaluronic Acid (HA)
• Promotes collagen deposition & volumization
• HA implanted in forearm skin– Biopsy at 4 & 13 wks
– ↑ procollagen & stretched fibroblasts
- indicative of synthetic response
• 3 HA injections/lower cheek 4 wks apart– Elasticity & surface morphology improved
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Hyaluronic Acid
• WHAT IS CROSS LINKED ?
– A liquid have no cross links
– A gel have some cross links
– A solid have many cross links
– Cross linking affects gel hardness (G’) & longevity of
HA
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Hyaluronic Acid
• HA with high amount of cross links have better longevity.
• HA would only last a few days or even hours in the body if not cross linked.
• Compromise with cross linking – longevity vs. usability
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Hyaluronic Acid
• Gel Hardness Factor G
– ↑ cross-linking ↑ hardness of gel ↑G’
• G’ is obtained by
– Placing gel between 2 plates
– Lateral force applied
– Resistance to deformation = G’
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Hyaluronic Acid
• Factors contributing to gel hardness
– Degree of cross-linking
– Concentration of HA
– Molecular size
• Products with higher G’ are used for deeper
corrections
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Hyaluronic Acid
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Hyaluronic Acid
– Higher G decrease flow characteristic
– Manufacturer controls flow characteristic
• Needle size
• G’ (cross linking is most important)
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Gel Hardness
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Ideal Filler
• Long lasting
• Natural in appearance
• No allergic potential
• Easy to administer
• No skin test
• Forgiving• No down time• Easy shipping &
storage• Painless
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Ideal Filler
• Not there yet but close!
• Current Popular Fillers– Restylane (HA)
– Perlane (HA)
– Juvederm Ultra (HA)
– Juvederm Ultra Plus (HA)
– Radiesse (Calcium Hydroxylapatite)
– Sculptra (Poly-L-Lactic Acid)
– Artefil (Polymethylmethracrylate)
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Juvederm Ultra
• Hyaluronic acid
• Bacterial source (Streptococcus)
• 24mg/cc, G’ 170
• No anesthetic
• FDA approved
– Nasal labial folds
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Juvederm Ultra
• Mid-dermis placement
• 30 g needle
• nasolabial folds, lip, glabella, teartrough,
facial contouring
• Manufactured by Allergan (maker of Botox)
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Juvederm XC
• Same as Juvederm Ultra but have lidocaine
• No need for nerve block
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Juvederm Ultra Plus
• Larger molecule give more lift for same volume of material
• 24mg/cc, G’ 200
• 27 g needle
• No anesthetic
• Deep dermis placement
• Nasolabial folds, lip augmentation, facial contouring
• Use for deeper lines
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Restylane
• Hyaluronic Acid
• Bacterial source (streptococcus)
• Firmer than Juvederm
• 20mg/cc, G’ 660
• Mid-dermal placement
• No anesthetic
• 30 gauge needle
• FDA approved nasal labial folds
• Nasal labial folds, lips, glabella, teartrough, facial contouring
• Manufactured by Medicis/Galderma
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Restylane L
• Restylane with lidocaine
• Same as Restylane
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Perlane/Restylane Lyft
• From maker of Restylane
• Larger molecule, same concept as Juvederm Ultra plus
• More lift for the same volume of material
• 20mg/cc, G’ 588
• Mid-deep dermis injection
• 28 gauge needle
• Not as forgiving as Restylane
• NLF, tear trough, deep wrinkles, more swelling if use in lips
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Radiesse
• Originally use for
– vocal cord fold & maxillofacial augmentation
– radiographic tissue marking
• Initial cosmetic use FDA approved for AIDS wasting
• Approved by FDA for NLF
• Off-label use Tear-trough, cheek, nose….
• 28 gauge needle
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Radiesse
Composition
– CaHA particles 25-45 microns (30%)
– Gel carrier (70%)
– Approx 12-18 months duration
– Gel carrier & particles give immediate effects
– Gel carrier degrade in 3-4 months
– CaHA particles replace by collagen
– New collagen formation increase duration compare to HA
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Radiesse
– No particles migration or adverse effects
– Duration & response may vary from individual to
individual
• CaHA are phagocytized & replaced with collagen by
fibroblasts
• Duration may depends on
– Age
– Rate of metabolism
– Area of correction
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Artefil/Bellafill
• Permanent!
• PMMA (polymethylmethacrylate) beads in 3.5 %
bovine solution carrier
• PMMA beads are the permanent filler
• Components 25% PMMA & 75% bovine solution
• Contains 0.3% lidocaine
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Artefil/Bellafil
• PMMA beads 40 microns
• No evidence of migration
• Smooth correction with correct technique
• Collagen matrix forms around beads after dissipation of bovine carrier
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What to use?
• Factors to consider
– Skill level
– Experience with products
– Patient desires
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Evaluation/Patient Selection
• Realistic expectation!
– ? Excessive skin sagging
– ? Large folds
– ? Perhaps facelift
• Volume replacement
• Scar correction
– ? Ice pick
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Contraindications
Absolute
• Prenancy
• Hemophilia/coagulation disorder
• Anticoagulant (warfarin)
• Previous Allergic Reaction
• Active Herpes Simplex
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Contraindications
Relative
• ASA/NSAIDS
• Herbs (Gingko Biloba, Garlic)
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Volunteer
• Consult
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Technique
• Anesthesia
– Topical
– Nerve Block
– Ice
– Mixing Filler with lidocaine
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Technique
• Clean treatment area with alcohol
• Insert needle at 10-15 degree bevel up
• Placement mid dermis
• Needle contour visible but not color of it.
• Even pressure while pulling backward
• Stop injecting before needle is pulled out
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Technique• Objective is to fill the depression and
structurally support the line and provide volume
– Inject filler into the deep dermis and subdermal plane
– Use non-dominant index finger to guide needle
– Deeper threads can be placed to bolster depression
– Use thumb and forefinger to massage and mold filler
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Marionette Technique
• Use 0.5” or 1.25” 27g needle• Lidocaine infiltration may be suitable• Use fanning technique with retrograde
threading to lift and fill marionette line• Be conservative with volume and do not
place material too deep• Treat the entire zone- may include lateral
chin area, not just the line• Progressively bring to full correction• Massage with thumb and forefinger as
needed
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LIPS
– Technically more difficult
– Tissue planes dissect less evenly than NLF’s
– Symmetry more difficult & asymmetry easier to
detect
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LIPS
– Injection to vermillion border least difficult
– Symmetry harder to control to body of lips
– Practice on NLF first !!!
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Lips
• Lip Augmentation
– Be conservative
– Symmetry is important
– Danger area Cupid’s Bow “Trout Mouth”
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Techniques
• The more superficial the injection the smaller the
needle
• Less forgiving material requires deeper injection.
• Blanching Stop! Massage, Massage,
Massage……
• Typical usage <2cc per site
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COMPLICATIONS
• Infection– Biofilm
• Aggregate of microorganisms in which cells are
stuck to each other and/or to a surface
• Biofilms well recognized in implants (prosthetic
valves, breast implants, fillers)
• Delayed reaction, may occurs weeks after injection
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COMPLICATIONS
• Biofilm /infection
– Sterility is essential ? povidone iodine prep.
– Antibiotic
• Dicloxacillin
• Keflex
• Ancef
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COMPLICATIONS
• Skin necrosis, Blindness
– Vascular occlusion
– Hyaluronidase (+/- 25 units), nitropaste, warm compress
• Allergy
• Bruising
– Arnica ointment or tablets
• Swelling
• Tyndall Effect superficial placement blue/purple color
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COMPLICATIONS
• Lumps & Nodules
– Lumps Improper placement or techniques
• Massage
• Hyaluronidase
• Stab incision
– Granuloma Steroid injection(Triamcinolone 5mg/cc)
• Make sure not infection!
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Best Practice Recommendations
• Treat any one area to full effect
• Expect mild-moderate swelling
• Bruising always a possibility
• Do not over correct
• Correction may be better in 2-3 days post swelling
• Practice on friends and family first!
• Show confidence
• Patients can smell fear!!!!
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Various aesthetic procedures
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Various aesthetic procedures
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Hands-on
• Consult (if time allow)
• Small group consult
• Techniques/Pigs’ feet
• Manequin practie
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Techniques
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THANK YOU!!