Injectables menu offers options for most patients.(Aesthetic Dermatology)

WASHINGTON -- As more aesthetic patients seek instant results without the downtime or expense of surgery, their needs can be met by choosing from a menu of injectable products that include permanent, semipermanent, and short-term fillers.

Physicians shared their expertise and tips for using injectables at the annual fall meeting of the American Academy of Facial Plastic and Reconstructive Surgery. They noted that knowledge is the key to choosing the right products.

Injectables are not one size fits all, they expressed. What is best depends on a patient's age, skin type, and expectations. Filler options include:

Sculptra

"I use Sculptra as a liquid face-lift," said Dr. Jennifer Linder, a dermatologist and plastic surgeon in private practice in Scottsdale, Ariz. Dr. Linder is on the speakers' bureau for Sanofi-Aventis, manufacturer of Sculptra, and she also trains other physicians on its use.

Sculptra rounds the face and thickens the skin, so it can be helpful for someone who may eventually choose facial reconstructive surgery. Sculptra was approved by the Food and Drug Administration in 2004 for lipoatrophy in HIV patients and is awaiting U.S. approval for cosmetic use.

"You have to be board certified to be allowed to buy the product," she noted. The company also requires that prospective purchasers undergo a one-on-one training session with a certified trainer.

Dr. Linder mixes Sculptra with bacteriostatic water several hours before a procedure. "The longer it hydrates, the milkier it gets, and you are less likely to have clogs in the needle," she said.

Store the mixture in the refrigerator, then bring it to room temperature and shake it well before injecting and between injections. Whether your injection technique involves tunneling or fanning, be sure to go deep. "Go down and touch the bone but be careful to stay above the periosteum," Dr. Linder explained. Keeping a drip on the needle during the procedure reduces the risk of clogging.

Papules are the most often reported side effect, and they usually occur because too much of the product has been injected.

Radiesse

Radiesse promotes the production of collagen, said Dr. Michael E. Jasin, a plastic surgeon in Tampa, Fla. It was approved in 2006, but many surgeons have been using it off label for cosmetic use for several years, said Dr. Jasin, a member of the physician advisory board and the national education faculty for Radlesse manufacturer BioForm Medical Inc.

The techniques for injecting Radiesse have evolved as primary use has moved from nasolabial folds to the greater periorbital area and other parts of the face.

"We are starting to inject [larger] areas rather than injecting along an axis," he said. "I inject perpendicular to the nasolahial fold rather than going along the axis to the fold." Cross-hatching and fanning injection techniques create a more natural result, he added.

Like many other injectables, Radiesse has been seen as an alternative to surgery, but surgeons are increasingly using it as an adjunct to plastic and reconstructive procedures. "What we are Finding is that, if we include Radiesse as a filler with a surgical procedure, we are getting much nicer results," Dr. Jasin said.

Radiesse works well for nasal recontouring in patients who may want a rhinoplasty but hesitate at the idea of surgery.

Hyaluronic Acid

The main difference among the hyaluronic acid (HA) products is the manufacturing process, said Dr. Anthony P. Sclafani, an otolaryngologist and plastic surgeon based in New York. Restylane contains 50-mcm particles of HA, and it can be injected into the mid-dermis. Perlane has larger particles, so there are fewer particles per cc, explained Dr. Sclafani, who is on the speakers' bureau for Medicis Pharmaceutical Corp., maker of Restylane and Perlane.

Juvederm is more highly cross linked, which means that the molecules are more stable, but it is less natural. Studies show, however, that adverse events are about the same among all HA products, so physician and patient preference should guide use, he said.

A recent study suggested that HA may promote collagen production--the material appeared to cause fibroblasts to stretch and secrete more collagen--but the findings are preliminary.

HA fillers are good choices for patients who are new to injectables because the effects are immediate and down time and side effects are minimal. The effects, however, are short lived. Most results last 3-6 months, and some bruising may occur in the suborbital area, Dr. Sclafani noted.

But HA fillers can be the right choice for the patient who comes in saying, "My niece is getting married in 3 days, and I need to do something," he noted. "It is a nice easy treatment that makes them look good."

Artefill

"ArteFill is not Artecoll," said Dr. John Joseph, a plastic surgeon in Beverly Hills, Calif. ArteFill contains bovine collagen, lidocaine, and microspheres. "The spheres are where the magic is. They need to be 40 mcm and completely smooth," said Dr. Joseph, who is on the speakers" board for several companies, including Medicis and Sanofi-Aventis.

ArteFill is the only nonabsorbable filler currently approved by the FDA for cosmetic use. Of note, the study on which the approval was based used Artecoll (a variation of the product used outside the United States) rather than ArteFill. The microspheres in Artecoll are not uniform (they range from 32 to 40 mcm), so the uniformity of the ArteFill spheres should make it even safer and more effective, although no scientific studies have compared the products, he said.

A debate persists over the long-term safety of ArteFill and similar long-lasting injectables and whether the risk of developing granulomas that must be treated or removed outweighs the cosmetic benefits.

Although the 5-year follow-up data include only 61 patients from the more than 200 patients in the safety and efficacy study used to justify FDA approval, 90% of these patients reported that they were satisfied with their results, and only two granulomas were reported, Dr. Joseph said.

ArteFill is easy to inject in the right areas. Dr. Joseph's technique involves retrograde linear threading into the deep dermis. Don't inject where the skin is too thin.

Botox

"Our patients are demanding less invasive treatments, but it doesn't mean that they aren't going to move on to surgery at a later time," said Dr. Andrew Jacono, a plastic surgeon based in New York.

He said that his use of Botox has evolved--he now uses smaller amounts to create a more natural look. "'I use a small syringe, so if I am using 1 cc of solution, it is easy to measure. If you have a 25-unit syringe, you have 25 units of Botox," said Dr. Jacono, who is on the national education faculty for Allergan Inc., which manufactures Botox.

"If there are any neurological or neuromuscular disease processes, I always get a clearance from the neurologist before I treat the patient," he noted.

Be sure to ask the patient what he or she expects--some people have preconceived notions about what Botox does in terms of reshaping the face. Note any asymmetries and wrinkles prior to the procedures.

"I tend to do injections for crow's-feet very high on the face," he said. Injecting the forehead high and laterally will help prevent the quizzical look that patients sometimes get from paralyzing the central part of the face.

Be sure to document how much filler was injected in each area for future reference.

For more information about injectables, visit the Web site of the Physicians" Coalition for Injectable Safety at www. injectablesafety.org.

BY HEIDI SPLETE

Senior Writer