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Just when the options in injectable filler therapy continue to expand (three entered the commercial market this year alone), a casualty amongst them has occurred. At the end of November 2008, Artes Medical (the manufacturer of ArteFill injectable filler) ceased operations and has filed for bankruptcy. Posts on the internet have cited the downturn in the economy and corporate mismanagement as the reasons for financial failure. All sales reps have been terminated and the corporate website is no longer operational.
Artes Medical as a company was formed in 1999 and subsequent extensive clinical trials resulted in ArteFill being approved in the U.S. as an injectable filler in 2007. ArteFill is the combination of PMMA (plastic) microbeads and bovine collagen, resulting in the longest-lasting injectable filler that has current FDA approval. Lasting as long as 15 to 18 months after injection, ArteFill’s longevity was nearly twice that of any other injectable filler. Its use was restricted to the nasolabial folds and facial areas other than the lips due to the potential risk of irregularities and nodular reactions. Its use required a skin test weeks prior to injection due to the bovine collagen content.
While their may have been corporate reasons for the company’s demise, the ArteFill product (despite its long-lasting effects) had several disadvantages compared to other commercially-available injectable fillers. Its high cost priced it out of affordability for many patients. Cosmetic office injection treatments are a budget issue for many and a high initial cost, even if it lasts longer, will eliminate a lot of the market potential. Because it could not be used in the lip, the second most common area for injectable fillers, another segment of the patient market was eliminated. These two factors narrowed the market potential for this injectacble product considerably. In my practice, less than 5% of all injectable filler treatments were done with ArteFill.
We may see ArteFill back in the future (and I would be surprised if we didn’t), either as a new company or part of another companies product line. But for now, ArteFill remains unavailable for the foreseeable future.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
The newest hyaluronic acid HA) filler on the market, known as Elevess, offers a combination of new twists that do make it somewhat different. It is produced by the manufacturer of ArteFill (the most expensive filler on the market) as a companion to that product as well as an effective and less expensive alternative. It has the highest concentration of HA of any injectable filler on the market at 28 mg/ml. In theory, this should result in more long-lasting results than most other HA fillers. The manufacturer states that it has good duration up to 6 months but longer-term data may pu9t its expected duration of action to be longer.It also contains 0.3% lidocaine, providing a local anestheic effect after it is injected. Currently, it is one of the few HA fillers that has a local anesthetic in it. Its other features are similar to all other HA fillers in that it can be injected through a very small needle and it has a superb safety profile without any significant complications with its use.
How does Elevess compare to other HA fillers and where does it fit amongst the many HA fillers that are now on the market?. When it comes to HA fillers, in my practice, I am only interested in using one HA filler that has the longest period of sustained correction. Why use different HA fillers that last variable lengths of time? The prices between them are not so significantly different to justify, in most cases, using shorter-acting filling brands. Whether Elevess lasts as long as Juvaderm or Perlane (the two longest lasting HA fillers), for example, I do not know. If it is just as long-lasting, then I would prefer Elevess because of its local anesthetic component. The only other key issue, for injector and patient both, is the cost per syringe. My assessment is, as previously noted, that the cost is not appreciably higher. When it comes to HA fillers, go for the one that lasts the longest.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Injectable Fillers - The Relationship between Cost and Longevity
Author: barryeppley
Injectable fillers provide a simple and immediate cosmetic treatment that is particularly good for the areas of the nasolabial folds (cheek-lip grooves) and for lip enhancement. While there are many different name brands of injectable fillers, they basically do the same thing (plump up the skin) even though there are some differences in what they are made of. These basic differences in makeup (collagen vs. hyaluronic acid vs particulated), while not conferring any different filling properties, are different in more than just the name also.
In theory, what you are primarily paying for with an injectable filler treatment is for how long it lasts. The least expensive injectable fillers, such as old-style Zyderm and Zyplast (pig collagen) or more modern Prevelle (hyaluronic acid), last about 6 to 12 weeks or less than three months. The longer-lasting fillers, such as Radiesse (dissolvable ceramic beads) and ArteFill (non-dissolving plastic beads), are by far the most expensive but they do last anywhere from 12 to 18 months after a single injection session. The real question is then…..how much are you paying for what length of time. (no true permanent injectable fillers exist at this time) You want to be sure that the price somehow correlates to how persistent the result is.
That can be a difficult task for any patient to decipher. Many times what a practitioner may charge may not necessarily correlate with the product’s behavior. But the purchase price to the injector (which does differ for all injectable fillers) is the same throughout the country for all syringes sold. Therefore, you can ask to see a price list or ask the price (per syringe) for the types of injectable fillers that they offer. This makes it easy to do comparison shopping…although beware that price may not be indicative of the injector’s experience or expertise.
Here in the midwest, very short-term (3 - 4 months) injectable filler treatments (one cc or a full syringe) will cost around $300 - $400, medium-lasting (6 to 8 months)injectable fillers around $550 - $650, and long-lasting (9 to 18 months) injectable fillers around $850 - $1250. While these are price estimates for just one geographic area in the country, they do reflect the relative relationship between injectable filler cost and duration of action.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana’
Clarian West Medical Center, Avon, Indiana’
Indianapolis
One of the most common facial areas that bothers many patients is the development of the nasolabial folds, also referred to as the lip-cheek groove, or in a recent television commercial known as the parentheses. You can argue whether it is a fold or a groove but it is probably closer to a fold. It develops as the cheek tissue from above ages and begins to sag….falling over its border with the upper lip. The upper lip is ‘fixed’ so the overhanging cheek tissue creates the appearance of a deepening fold. With time, aging, and the anatomy of one’s face, this nasolabial fold extends south past the corner of the mouth and sometimes nearing the lower border of the jaw in extreme cases of skin laxity.This area is commonly treated by injectable fillers and in my practice as many patients wants their nasolabial folds treated as they want their lips enlarged.
The most common method for nasolabial fold reduction is with injectable fillers. Like all filling procedures by injection, the results from nasolabial fold reduction is quick, easy to do, and the results are immediate. I usually perform them under a local anesthetic block so the treatment is as comfortable as possible. While all of the injectable fillers will work, I think some are better for this area than others. And the ones that I think are best are those that last the longest and have the greatest ‘push’.
While all of the hyaluronic acid fillers such as Restylane or Juvaderm will work, they do not last as long as any of the particulated injectable fillers. Currently Radiesse (ceramic beads) and Artefill (plastic beads) are the only two particulated fillers currently available. The evidence is clear, not surprisingly because of their solid bead component, that they consistently last longer than any of the hyaluronic acid fillers. While beaded injections can cause lumpiness and irregularities, this is not a significant cosmetic issue (nor can it usually be seen) in the forgiving area of the nasolabial fold. Conversely, in the lips this is a different matter. Also, because the bead composition makes the injectable material more thick and viscous, I think it provides more push as it goes in resulting in a better cosmetic effect and having to use less injectable filler. Because of particulated fillers longevity and thicker volume, it is my preferred injectable approach to the nasolabial folds. This injectable treatment will give a 9 to 12 month result.
There are other treatment options for the nasolabial fold as well. The best way to eliminate them is the one way which is almost never done….cut them out. That gets rid of the fold immediately but also leaves a fine line scar which may only be acceptable in an older patient. The other more commonly done alternative is to use an implant. I specifically use an Advanta implant for those patients that want a permanent volume solution. A very small incision is made in the nose crease and at the end of the lower fold line. The implant is slide into place from one end to the other. This is a procedure that can be done in the office under local anesthesia. An implant approach to the nasolabial fold is a good solution for someone who no longer wants to do injections, doesn’t mind the concept of an implant in their face, or has very deep nasolabial folds which would take a lot of injectable filler volume. My experience with an implant in this area has been quite good but it is not a first line approach for most patients.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com/
http://www.ologyspa.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
As we age, one of the many facial changes is the loss of volume in the cheek area. This is most apparent in patients that are thin or have a normal age-appropriate weight. The cheek prominences become less and more saggy. In addition, the area below the cheek bone known as the submalar or buccal cheek area will often become more indented. In some patients, this can create a ‘gaunt’ or aged look. People who are heavy rarely develop this sign of facial aging as their cheeks remain fuller and more rounded, creating the ‘Santa Claus’ effect. (round and jolly but vibrant)
While the most effective long-term solution to cheek volume loss is surgical (midface lift, cheek implants, submalar implants, or fat injections), injectable fillers offer a quick and effective method of a subtle cheek enhancement. By injecting volume into the cheeks or below in the buccal area, the face can appear more youthful and ‘uplifted’. The effect is not designed to be dramatic, nor should it be, but a subtle improvement that looks natural. This is a quick solution that has immediate effects without the swelling and potential bruising from surgery.
While the effect injectable cheek augmentation is only temporary, how long it lasts will be influenced by what type of injectable filler is used. The hyalurons, such as JuvaDerm and Restylane, will last in the range of 4 to 6 months, in some cases maybe a few months longer. When using the particulated fillers, such as Radiesse or ArteFill, I would expect the effect to last longer in the range of 9 to 12 months. (or basically double that of the hyalurons)
Injectable cheek augmentation can be enhanced by the simultaneous use of Botox injections in the crow’s feet and cheek areas. The objective being to weaked the expression lines around the eyes so that the amount of wrinkling with smiling is less. The combination of these injectable midface treatments makes for a nice rejuvenation of the middle third of the face that looks very natural and relaxed. All done in less than 30 minutes and you are on your way back to work or home for the evening without anyone being the wiser!
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com/
http://www.ologyspa.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Although there are a number of commercially-available injectable fillers for cosmetic facial treatments, they break down into two main categories or families, hyaluronic acids (hyalurons) and the particulated fillers. Particulated injectable fillers contain non-biodegradable beads or particles which accounts for their longer duration of persistence which is at least twice as long as most of the hyalurons. While the bead composition of each particulated filler only consists of about 20% of each syringe (any larger amount and the beads would not flow through a small needle) and the rest is the carrier vehicle, enough permanent material is placed with each injection session that a good duration of effect is achieved. In theory, with subsequent injection sessions, a greater degree of permanency is achieved each time as the bead layers are built up over time.
Amongst the particulated fillers there are only two types that are currently available, Radiesse vs. ArteFill. While there are differences in the makeup of the beads between the two, Radiesse with ceramic beads and ArteFill with plastic beads, the greater difference is in the type of carrier vehicle which makes up about 80% of the initial injected material. Radiesse uses a polyethylene glycol mixture while ArteFill uses bovine (cow) collagen. Because ArteFill uses an animal collagen, it requires a pre-injection skin test to rule out a sensitivity to it. Radiesse requires no such skin test.
One of the most interesting questions about the particulated fillers is which one is better? Or from a patient’s perspective of better, ,which one lasts longer and would therefore be best? Radiesse reports persistence of the material for up to two years based on animal (rat) studies. Having used Radiesse a lot over the past 5 years, my human experience would not support that time duration. My experience of using Radiesse in the nasolabial (lip-cheek) folds is around 8 - 9 months on average. ArteFill has clinical studies which show persistence in some patients for years but I have not used it long enough to verify these findings in my practice. ArteFill uses a different injection approach by doing a series of treatments over a several month period to build-up multiple layers of the beads, thus creating greater permanency.
The bottom line question is….which is better…. Radiesse or ArteFill? Quite frankly, at this point in time, I do not know. Both work well.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
I recently had a patient who came to see me to get lipodissolve treatments. She stated that she was a perfect candidate for it. When I asked how she knew that, she said she had been injected last month at a party at one of her friend’s spa. Out of curiosity I queried further to find out (to no surpise) that she had no idea if the person who injected her was even a doctor of any kind, she didn’t know what was injected into her, nor did she have any understanding as to how Lipodissolve therapy even worked. As it turned out she had only 4 injections across her entire stomach area.
The relative ‘ease’ of doing injection beauty treatments such as Botox, soft tissue fillers, and lipodissolve has created the concept of the spa or home party atmosphere for a girls nite out. I won’t go into the obvious, and much written about, issue of…is there a physician on the guest list? Besides the fact that these are true medical treatments that shouldn’t be done outside of a physician’s office (increased risk of complications) and it is against the code of ethics of most physicians to offer medical treatments as a prize or incentive, there is a much more significant issue that most patients/consumers miss.
These beauty treatments work best when done in the context of understanding the facial aging or body contouring process. All injectable therapies play a role in the treatment of facial aging and facial enhancment, for example, but where they fit and whether they are good for you can only be determined by sitting down with a plastic surgeon and discussing the big picture. I see lots of patients who come in for Botox, for example, but have no idea how it works and what it is really good for. Injectable fillers are the same way, they can not cure and solve all facial wrinkling issues.
The consideration of these issues brings to light the point that I am driving it…value for what you are getting. Just because you are getting a good ‘deal’ on some injectable treatment by doing it at home or in a spa setting doesn’t mean it is even what you really need. It may not even be the most appropriate type of treatment for what you want to achieve. Injectable home or spa parties miss out on one of the most important issues of any medical treatment, pre-treatment education and consideration of other treatment options. That deal you are getting may turn out to be wasted money and effort. As the old saying goes, many times you do get what you pay for.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
The newest more permanent injectable filler, ArteFill, for facial lines and folds is taking a throwback from history. Its use requires a pre-injection skin test due to its bovine (cow) collagen content. This is what the original collagen injections, Zyderm and Zyplast, required when they were the only injectable filler available from 1981 to 2000.
Unlike the original collagen injections, ArteFill is not solely collagen but contains a significant percentage of plastic beads which occupies about 20% of what is actually injected. The rest is the collagen which must have a higher ratio than the beads so that the beads will flow smoothly out of a very small needle. While the beads are permanent, the carrier collagen is not.
The purpose of the skin test is to make sure that you are not allergic to bovine collagen. From prior collagen injection experience, we know that about 5 - 6% of the population will get an allergic raection to it is. Better to know that in a small area in your forearm first before putting much more of the material into your face.
The skin test is done like a TB test on the inside of your forearm. The test takes 4 weeks before you can be injected with ArteFill. The test is positive of any amount of redness or swelling develops during this 4 week waiting period. If there is any doubt about whether a positive reacation is seen, then a second skin test is done and another 4 week waiting period is needed.
While some patients may find the need for a skin test annoying, it is an absolute necessity if one is to get the benefits of the longer-lasting ArteFill injections.
Dr Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
The newest facial injectable filler to enter the commercial cosmetic marketplace is Artefill, a semi-permanent to permanent in-office treatment for deep facial lines. This is primarily intended for the nasolabial fold area, often times called the cheek-lip groove or fold. It is the result of cheek tissue descending with age, falling over the fixed upper lip. (which fortunately does not fall much with age!)
ArteFill falls into my categorization of the particulated filler group, which is in contrast to much of what the public knows about injectable fillers, such as Restlane or JuveDerm , which are the hyaluron or non-particulated group. Like the other current particulated injectable filler Radiesse, Artefill also contains beads (or particles) and a solution into which it is suspended so it will flow through a small needle. In simplicity, ArteFill contains small plastic beads in a collagen solution which is derived from cows. This collagen solution results in its only real drawback to other injectable fillers in that it requires a skin test prior to treatment to determine if you have an obvious reaction to the animal collagen. Short of that, ArteFill does have several advantages over any of the non-particuled fillers for the nasolabial fold area.
First, ArteFill is one of the most extensively studied of the injectable fillers from the perspective of long-term patient follow-up and evaluation of its constituent filler materials. It is the only one of all of the fillers that can truly document years of sustainable results. Secondly, calling it a ‘permanent’ filler is a bit of a stretch (no filler can be truly called permanent when you are treating an aging issue), but it is true that the particles which are injected never go away. But the collagen solution which carries them through the needle does go away, and since that makes up about 80% of what is injected, the initial results from one injection are not ‘permanent’. Understanding this then allows you to eventually see where the concept of ‘permanent’ comes from and how to get there. If one undergoes a series of ArteFill injections over a 3 to 6 month period, it is possible to build up to a result that will last for years. Each injection session will add another permanent layer of beads, which when done enough times, will create a new tissue layer that will not go away. lastly, this is certainly a different approach that any of the other types of injectable fillers. More injection sessions will be needed up front but with the objective of building to a permanent layer, rather than just re-injecting when it has all gone away as with most other facial fillers.
ArteFill offers a novel approach to the ubiquitous and difficult nasolabial fold area (parentheses), If you are willing to spend more money up front and go through a series of closely-spaced injection sessions, this is likely a better long-term value for this cosmetic facial concern.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Improving the size and shape of the lips is a frequent cosmetic request and a very commonly performed aesthetic procedure done in the office. While the vast majority of lip enhancements are done by injectable fillers, and most patients are only aware of this approach, there are other less common but equally effective options.
Injectable fillers are the most common lip enhancement method and the hyalurons such as Restylane and Juvaderm are usually used. The longevity of hyaluron fillers, while touted differently amongst manufacturers, is in the range of 4 to 6 months. While longer-lasting injectable fillers exist, such as Radiesse and Aretfill, these contain particles which may be prone to lumpiness and foreign-body reactions. Because of their predictability and safety, with very few complications, hyaluron lip enhancement is the current gold standard.
There other other types of non-injectable lip fillers. Over the years, many collagen-based implants have been tried, such as Alloderm and Fascian. Unfortunately, while conceptually appealing, their longevity has not been shown to be any greater than the hyaluron fillers. But they are more expensive and cause much more lip trauma to place. As a result, they have fallen into disuse.
Despite the frequent touting of your own fat as an injectable filler, and reports of great longevity and possible permanency, most plastic surgeons have not had that experience. Fat in the lip is simply unpredictable. I will still use it…..when I am performing other procedures in the operating room where the use of fat is ‘easier’ than in the office and there is little to lose by doing so. I suspect that repeat fat injections over time do consistently work but that is fairly traumatic for a patient to go through.
Permanent lip augmentation can be done by synthetic implants known as Advanta. These very soft implants are threaded into the lips, corner to corner, by a metal trocar under local anesthesia. They are non-resorbable, fairly soft, and the volume added is permanent. They can definitely be felt in the lips but I have not had a patient yet who has reported that as a problem. I use Advanta when the patient is ‘qualified’, meaning they have tried injectable fillers first and want to move on to something permanent.
More surgical lip enhancement is known as vermilion advancements or subnasal lip lifts. While these are highly effective are making the lip bigger, they have a trade-off of permanent scars. A patient must be very willing to make this trade-off and accepting of fine-line scars. I use these in patients that have very thin lips and a very flat cupid’s bow and have ‘failed’ lip enhancement by fillers. (meaning it does not look good or do what the patient expected. Lip lifts are often most effective in the older patient whose lips (which were not big to start with) have shrunken with age.
As you can see, lip enhancement has lots of options. All work well at achieving larger lips….but not every enhancement procedure is for every patient.
Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis