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Archive for the ‘injectable fillers’ Category

Volume Comparison Between Nasal Implants and Injectable Fillers

Thursday, June 16th, 2016

 

Augmentation of the nose is a frequent element in many rhinoplasty procedures. While the use of locally harvested cartilage grafts works in may cases, more significant augmentations of the dorsum require different volume addition techniques. The choices for major dorsal augmentation rhinoplasty for Asian and African-American patients, for examples, is either that of a nasal implant or a rib cartilage graft. But any patient that needs more than a few millimeters of dorsal augmentation faces the same choices.

The emergence of injectable fillers has now allowed for a non-surgical rhinoplasty. The basic concept of a non-surgical rhinoplasty is that it can only add volume. Noses can become bigger with an injection technique but they can never become smaller. An injectable rhinoplasty can be used to trial what the augmented nose will look like but it will not be a permanent result. While there are some long lasting injectable fillers, placement of them into the nose carries some significant risk. But at the least injectable filler provides an instantaneous result and the opportunity for the patient to determine if this type of nasal enhancement is right for them.

Nasal implants offer a permanent method for dorsal nasal augmentation that does not require a harvest site. But it is an invasive procedure and requires the commitment to having a synthetic material in the nose. For this reason some patients may want tio have an injectable filler placed first.

An interesting questions is how does an injectable filler in the nose compared to a nasal implant? How does the volume of an injectable filler compared to the displacement effect caused by a solid implant?

Nasal Implants Dr Barry Eppley IndianapolisComparing facial implants and injectable fillers is done using volumetric displacement. Based on the Archimedes principle of displacement, volume of displaced water would equal to the volume of the implant. (provided that they sink in water and nasal implants do) Using the most commonly used style of nasal implants for total dorsal augymentation (Rizzo nasal implants from Implantech) of all available sizes, their weights in grams and volume displacement were as follows:

NASAL IMPLANTS

Extra Small    0.96 grams    .7 ml

Small             1.14 grams     .8 ml

Medium         1.37 grams    1.1ml

Large             1.71 grams    1.5ml

Extra Large   1.95 grams    1.7 ml

Nasal Implant vs Radiesse Filler Dr Barry Eppley IndianapolisThe volume displacement of all injectable fillers is on the syringe so the comparison to nasal implants can be directly compared. It shows that a 1cc syringe of any of the hyaluronic acid-based fillers (e.g., Juvederm) would be equal to small and medium sized styles of nasal implants. Larger nasal implants more directly compare to a 1.5cc syringe of Radiesse. (which weighs 1.7 grams)

Volume alone, however, is not the complete story of any material’s external facial augmentation effect. Besides volume there is the issue of how well the material pushes on the overlying soft tissues to create their effect. This is known as G Prime Force or the elastic modulus. By feel it is obvious that implants are stiffer than any liquid material and would have a higher resistance to deformation. (thus creating more outward effect given a similar material volume) It is therefore probable that comparing volume displacements alone overestimates the effect of injectable fillers compared to implants. This may be particularly relevant in the nose where the nasal skin is less elastic and more firmly attached than other facial areas.

The use of 1 to 1.5cc of an injectable filler can compare volumetrically to that of an implant in the nose for more significant dorsal augmentations.

Dr. Barry Eppley

Indianapolis, Indiana

Volume Comparison of Cheek Implants and Injectable Fillers

Wednesday, June 1st, 2016

Cheek augmentation is a common facial reshaping procedure that is done for both aesthetic enhancement and volume restoration due to aging. It is the one facial procedure that, while historically only done with cheek implants, is now done more often by injection methods using synthetic fillers or fat.

The emergence of injectable methods is now the most common approach for cheek augmentation. Any of the synthetic fillers can be used since the cheek is a broad area and is spread out over the cheekbone as well as below it in the submalar region.While no synthetic injectable filler provides a permanent result, it does provide an instantaneous result and the opportunity for the patient to determine if this type of facial enhancement is appealing to them.

Cheek implants offer the only guaranteed permanent method  for cheek augmentation. But this requires a surgical commitment to an invasive procedure and has certain risks and complications. Injectable fillers can also be placed over a broader surface area greater than that which most cheek implants can.

An interesting but relevant issue when using injectable fillers for cheek augmentation is how do they compare volumetrically to that of cheek implants. To create an injectable cheek augmentation effect, what volume of injectable filler is needed to compare to what a cheek implant does? An injectable method is only a fair test in facial augmentation if similar volumes of material are placed that compares to what an implant does.

Conform Submalar Implants Dr Barry Eppley IndianapolisConform Midfacial Implant Dr Barry Eppley IndianapolisComparing facial implants and injectable fillers is done using volumetric displacement. Based on the Archimedes principle of displacement, volume of displaced water would equal to the volume of the implant. (provided that they sink in water and cheek implants do) Using the most commonly used style of cheek implants (Conform Submalar and Conform Malar Shells from Implantech) of all available sizes, their weights in grams and volume displacement were as follows:

SUBMALAR CHEEK IMPLANTS

Small        1.89 grams     0.7ml

Medium   2.13 grams     0.8ml

Large        2.36 grams     1.1ml

Large        2.58 grams     1.3ml

MALAR CHEEK IMPLANTS

Extra Small  1.47 grams   0.6ml

Small             1.71  grams   0.7ml

Medium        1.96 grams    0.8ml

Large              2.43 grams   1.1ml

Extra Large   2.62 grams   1.3 ml

Volume Displacement of Facial Implants Dr Barry Eppley IndianapolisThe volume displacement of all injectable fillers is on the syringe so the comparison to cheek implants can be directly compared. It shows that a 1cc syringe of any of the hyaluronic acid-based fillers (e.g., Juvederm) would be equal to small and medium sized styles of cheek implants.ess than even a small chin implant. Larger cheek implants more directly compare to a 1.5cc syringe of Radiesse.

Volume alone, however, is not the complete story of any material’s external facial augmentation effect. Besides volume there is the issue of how well the material pushes on the overlying soft tissues to create their effect. This is known as G Prime Force or the elastic modulus. By feel it is obvious that cheek implants are stiffer than any liquid material and would have a higher resistance to deformation. (thus creating more outward effect given a similar material volume) It is therefore probable that comparing volume displacements alone overestimates the effect of injectable fillers compared to implants.

The comparison between injectable fillers and implants in the cheeks may be different than in many other facial enhancement sites. Because the cheeks cover a significant soft tissue area not supported by bone the direct volumetric comparison may be more similar despite its lower elastic modulus.

Dr. Barry Eppley

Indianapolis, Indiana

Volume Comparison of Chin Implants and Injectable Fillers

Sunday, May 29th, 2016

 

Chin Implant Augmentation Indianapolis Dr Barry EppleyChin augmentation is a common aesthetic facial reshaping procedure that is second only to rhinoplasty. It has been traditionally performed by the placement of a preformed implant. While many different chin implant styles have been used over the years, the basic concept of an alloplastic chin augmentation is the same.

The emergence of injectable methods for facial augmentation using a variety of injectable fillers and fat has now become an accepted treatment approach for chin augmentation. While no injectable material offers an assured and permanent outcome as that of an implant for chin augmentation, it does provide an opportunity for patients to non-surgically ‘wear’ the result for awhile to determine if it suits them.

An interesting but relevant issue when using injectable fillers for chin augmentation is how do they compare volumetrically. To create an injectable chin augmentation effect, what volume of injectable filler is needed to compare to what a chin implant does? It is not a fair comparison if one is ‘testing’ an injectable filler and the volume injected does not equal what that of the effect that a chin implant does.

Volume Displacement of Facial Implants Dr Barry Eppley Indianapolisextended-anatomical-chin-implantComparing facial implants and injectable fillers is done using volumetric displacement. Based on the Archimedes principle of displacement, volume of displaced water would equal to the volume of the implant. (provided that they sink in water and all chin implants do) Using the most commonly used extended anatomic chin implants (Implantech) of small, medium, large and extra large, their weights in grams and volume displacement were as follows:

Small Chin Implant        2.1 grams     1.3cc

Medium Chin Implant   2.7 grams      1.7cc

Large Chin Implant      3.4 grams     2.2cc

X Large Chin Implant  4.0 grams     2.7cc

The volume displacement of all injectable fillers is on the syringe so the comparison to chin implants is straightforward. It shows that a 1cc syringe of any of the hyaluronic acid-based fillers (e.g., Juvederm) would be less than even a small chin implant. A small anatomic chin implant more favorably compares to 1.5cc of Radiesse. Larger chin augmentation effects requires up to 3ccs of injectable filler regardless of the type.

There are other variables that affect how any of these materials create an external facial augmentation effect. The most significant would be how well does the material push on the overlying soft tissues or push off of the bone to create their effect. This is known as G Prime Force or their elastic modulus. It is quite clear that implants are stiffer than any liquid material and would have a higher resistance to deformation. (thus creating more outward effect given a similar material volume) Therefore it is probable that comparing volume displacements alone overestimates the effect of injectable fillers compared to that of chin implants.

Dr. Barry Eppley

Indianapolis, Indiana

Product Review – Lip Augmentation with Juvederm Ultra XC

Wednesday, October 7th, 2015

 

Lip Augmentation Dr Barry Eppley IndianpolisLip augmentation is one of the most common and historic procedures for hyaluronic acid-based injectable fillers. It would surprise many then to find out that despite its popularity and common usage, few of these injectable fillers are actually FDA-approved for use in the lips. There are a variety of reasons for this lack of approval but safety and effectiveness are not among them.

On October 1, 2015 the US FDA has approved Juvederm Ultra XC for injection into the lips and perioral (mouth) area for aesthetic augmentation in adults. Juvederm Ultra XC and Juvederm Ultra Plus XC injectable fillers are already FDA-approved for injection for moderate to severe facial wrinkles and folds around the nose and mouth. (nasolabial folds) Juvederm Ultra XC is a well known modified form of hyaluronic acid with prolonged duration (up to a year) that has lidocaine in it to improve the comfort of the treatment.

juvderm ultra xc injectable filler, dr barry eppley indianapolisIn FDA trials of Juvederm Ultra XC for lip augmentation, almost 80% of patients had visible improvement in lip fullness three months after injection. A near similar percent, (78%) stated that they had persistent improvement in lip size one year after injection. The most common adverse effects for Juvederm Ultra XC injectable filler are the same as other hyaluronic acid gels such as temporary swelling, redness and lumps and bumps.

What is unique about Juvederm Ultra XC injectable filler is that it offers long-term retention of lip augmentation results. Many hyaluronic acid-based injectable fillers are used for lip augmentation but their results often last six months or less.

Dr. Barry Eppley

Indianapolis, Indiana

Injectable Facial Rejuvenation with Platelet-Rich Plasma (PRP)

Sunday, October 4th, 2015

 

PRP (platelet-rich plasma) has earned a role in a variety of facial rejuvenation procedures. One of its most well recognized uses due to social media and marketing is in the Vampire Facelift procedure. Its name is an obvious spinoff of the use of PRP which requires a blood draw to create the platelet concentrate. It is not a pure PRP procedure as it requires the use of injectable fillers to create the facial volume needed. In theory the PRP acts as a stimulant for soft tissue rejuvenation with its own growth factors and other stimulants…although that is far from proven science.

PRP injectable facial rejuvenation is an all natural treatment. There is no chance of allergic reactions or fear of foreign body interactions in response to these plasma concentrate injections. But what it is not is a facelift by any definition of this procedure. It does not reshape, tighten or otherwise involve removal of loose or sagging tissues as a traditional facelift does. Conversely it is a plumping procedure by adding volume through the use of the combination of PRP and hyaluronic acid-based fillers. The plumping helps stretch out some wrinkles and creates a bit of a tissue lift in some facial areas.

Platelet Rich Plasma injections Indianapolis Dr Barry EppleyWhile PRP is known for its healing properties, its success in causing cell stimulation and rejuvenation in normal people to help ‘reverse’ or treat aging tissues is more speculative. Stimulating tissue repair in injured tissues is one thing, making the body create new cells to treat otherwise normal tissues, albeit aging ones, is more of a biologic stretch. But this is the contention of the Vampire Facelift approach. Inject PRP under the skin and the body takes it from there presumably generating new collagen from stimulated fibroblasts.

There is no question that these injection treatments are safe as they involve PRP and other well known injectable fillers. There is very little possibility of any untoward reactions and complications. It is just a question of how much skin benefit is obtained from injecting the plasma and platelets and whether it provides any longevity benefit to the hyaluronic acid fillers that are also simultaneously placed.

The injection procedure does create some mild bruising and swelling for a few days that, at its worst, completely resolves within a week after the procedure. With the use of blunt injection cannulas, the creation of bruising is virtually eliminated. The effects of volume addition are seen immediately, any tissue stimulation occurs much later. (weeks to months) Whatever tissue stimulation and growth that may occur from the injections is not known how well or long it will persist. There is no question that repeated treatments produce better results. Stacking two to four treatments several months apart will create the optimal facial rejuvenative effect.

Dr. Barry Eppley

Indianapolis, Indiana

The Liquid Facelift – What It Is and Isn’t

Sunday, September 6th, 2015

The well known procedures of anti-aging facial plastic surgery continue to be debated as to which techniques are best. (e.g., facelift)  And those debates will undoubtably continue for decades to come as the differences in them are often subtle and no matter how it is done it is still a surgical procedure. In contrast, the number of options of non-surgical facial rejuvenation procedures continues with growing numbers of injectable fillers, neuromodulators and skin tightening devices.

liquid facelift indianapolisOne of the most well known but least understood injectable facial rejuvenation procedure is that of the Liquid Facelift. This office-based procedure is an amalgamation of neurotoxins (like Botox, Dysport and Xeomin) combined with a variety of different injectable fillers. (e.g., Juvederm, Voluma) These are often combined with some skin resurfacing tightening procedure like a chemical peel, fractional laser resurfacing or pulsed light therapies. Because it is non-surgical, a Liquid Facelift has next to no downtime, requires no anesthesia and its full effects are evident within days to a week after it is done.

It is touted as a procedure that can take years off the face and can maintain or restore a youthful glow without surgery. While all three techniques (wrinkle weakening, adding facial volume and skin tightening/resurfacing) work synergetically, the back bone of the procedure as the name implies is the injectable filler part. Fillers add volume and with today’s number of injectable filler options exceeding a dozen, the choices are numerous most of which are hyaluronic-acid based. But almost no matter which FDA-approved injectable filler is used, they are all temporary with the exception of one. (Bellacol which contains small plastic non-resorbable beads) It is only question of how long they will last.

The volume effect of the injectable fillers is designed for the midface to add fullness and help create more of a V effect. Whether it really does much lifting can be debated but what it can do is increase cheek and midfacial contours. This can counteract the geometric effect when facial tissues fall (inverted V) and can correct cheek hollows from fat loss. The intent of creating this midfacial effect has led to the Liquid Facelift also being called the Liquid V-Lift.

While the Liquid Facelift has its place in facial rejuvenation, it should not be confused with what a surgical facelift can accomplish. These differences make it critical for patient selection and expectations. While age along is not the only factor, a Liquid Facelift is really for younger patients with early signs of facial aging that do not have a lot of loose skin. Significant jowls and turkey waddles are not going to get improved by an amount of volume addition or superficial skin tightening.

Dr. Barry Eppley

Indianapolis, Indiana

Product Review – Restylane Lyft

Wednesday, July 8th, 2015

 

Restylane Lyft Dr Barry Eppley IndianapolisThe anticipated approval of new injectable fillers shows no sign of stopping with the development of ‘niche’ filler products. This was demonstated this week as the FDA (US Food and Drug Administation) approved Restylane Lyft for cheek augmentation. Restylane Lyft, formerly known as Perlane-L, was approved for the standard injectable filler indications of treating nasolabial folds.

Per the manufacturer Gladerma In a clinical trial of 200 patients, almost 90% of treated patients with Restylane Lyft showed increased and persistent fullness in the cheeks. More than half of the treated patients demonstrated such persistent fullness out to one year followup. Adverse reactions for this hyaluronic-based injectable filler were typical with a low incidence of redness, swelling and itching, all of which resolved within two weeks after injection.

Restylane Lyft is the fifth member of the well known Restylane brand name that has been approved over the years.  Other well known companion injectable products include Restylane, which is used to correct smile lines and augment the nasolabial folds, and Restylane Silk for lip augmentation and wrinkles and lines around the mouth.

Restylane Lyft is clearly a competitive analogue to Allergan’s Juvederm Voluma. It is ongoing evidence that all companies offering injectable filler products will need to develop and market a broader spectrum of treatment offerings for very specific facial indications. What differentiates the injectable filler products is that the viscosity or so called G prime of the filler is modified to treat the array of soft tissue defects from superficial fine wrinkles to deeper areas of volume loss. Long gone are the days when one tried to use one type of filler for every aesthetic facial need.

Dr. Barry Eppley

Indianapolis, Indiana

Product Review – Radiesse for Hand Rejuvenation

Saturday, June 6th, 2015

 

One important aspect of hand rejuvenation is volume restoration of the back (dorsum) of the hand. Skeletonization of the hand occurs through loss of subcutaneous fat allowing the tendons and bones to be easily seen which is associated with aging.  (bony hands) This has been shown to be effectively treated using a variety of filler materials. The most commonly used are many of the off-the-shelf synthetic fillers since they can be done in the office under local anesthesia for a quick plumping of the back of the hands.

Radiesse Plus Injections Dr Barry Eppley IndianapolisRadiesse Injectable Filler Dr Barry Eppley IndianapolisOne of the potential synthetic injectabl efillers to use in the hand is Radiesse. This is an opaque injectable filler that contains calcium hydroxyapatite microspheres in a water-based gel carrier. It has been used for facial augmentation since it was introduced in 2001 and has a longevity of around one year after injection.

The US Food and Drug Administration (FDA) just announced that they have approved Radiesse for hand augmentation to correct volume loss in the dorsum of the hands. FDA approval essentially means that it is both safe and effective for this use and that its benefits outweigh the potential risks. The clinical study data to support its use was done in the hands of over 100 middle-aged women using grading scales of aesthetic improvement. Compared to a placebo (control) filler, Radiesse treated hands had at least a one-point improvement at three months after treatment compared to just 3% for the controls and 98% of the patient reported visible improvement by their assessment. Any adverse effects that occurred from the treatments were common to what is known for any injectable filler such as temporary redness, swelling and bruising which all resolved within one week after injection.

Fat Injections to Hands Dr Barry Eppley IndianapolisRadiesse provides an effective method of hand rejuvenation that has some of teh better persistence of any filler on the market today. Despite its white opaque color it is not seen through the skin as such and is not visible through the skin.

Dr. Barry Eppley

Indianapolis, Indiana

Product Review – Radiesse Plus Injectable Filler

Monday, March 23rd, 2015

 

Radiesse Injectable Filler Dr Barry Eppley IndianapolisRadiesse is a semi-permanent injectable filler that has been in clinical use for over a decade since its initial FDA approval inj 2004.. It is unique amongst injectable fillers because of its composition and mechanism of action. It is composed of approximately 30% calcium hydroxyapatite spheres contained in a 70% aqueous gel carrier. The aqueous gel carrier is comprised of sodium carboxymethycellulose, glycerin and water. There are no human or animal derived components in it. While the aqueous gel carrier gets absorbed, the calcium hydroxypatite spheres remain much longer leading to a collagen reaction that creates a sustained volume retention result.

Radiesse Plus Injections Dr Barry Eppley IndianapolisRadiesse Plus contains 0.3% lidocaine and has recently received FDA approval. Its approval was based on a clinical study with over 100 patients who had ‘regular’ Radiesse injected on one side of their face and Radiesse plus on the other side. Based on pain ratings patients rated their pain about 6.7 on a scale of 0 to 10 for the side of the face injected with ‘regular’ Radiesse  compared to about 2.3 on the same scale for the side of the face treated with Radiesse Plus. One hour after treatment, patients rated their pain about 1.1 on a scale of 0 to 10 for the side of the face injected with Radiesse compared to about 0.3 on the same scale for the side of the face treated with Radiesse Plus.

Not surprisingly, Radiesse that contains a local anesthetic is less painful to inject. This is compatible with what all of the hyaluronic acid-based fillers that have previously incorporated a similar approach have shown. This is particularly useful in an injectable filler like Radiesse which by its composition is thicker to inject and takes a bigger needle to do so.

Dr. Barry Eppley

Indianapolis, Indiana

Treatment Of Permanent Injectable Filler Nodules By Microliposuction and Fat Injections

Saturday, March 7th, 2015

 

Injectable fillers are a very effective method of adding volume to facial wrinkles, folds and regional areas such as the cheeks. The most popular injectable fillers are made of hyaluronic acid materials which have the lowest incidence of complications as they are completely resorbable. Lumps and bumps may occur with their use due to overcorrection and non-linear deposition but they are either self-solving or can be treated by prompt enzymatic digestion with hyaluronidase solutions.

But complications with longer lasting injectable fillers can be more problematic. What makes an injectable filler longer lasting is either a liquid material that does not resorb (e.g., silicone) or the incorporation of non-resorbable particles in the injectate. (e.g. Artefill or Bellafil, Aquamid) While these longer lasting or permanent fillers are generally well tolerated, delayed onset complications with them can occur.  These appear as nodules or graulomas that may become periodically inflamed or even infected. Biofilms, aggregates of cells adhered to living or nonliving materials, have been implicated. Areas at higher risk for these type reactions include the nasolabial folds, lips, periorbital and perioral lines, and tear troughs although they can occur anywhere they are injected.

Steroid Injections for Injectable Filler Nodules Dr Barry Eppley IndianapolisTreatment of these type of injectable filler reactions are more problematic as their non-resorbable nature makes them difficult if not impossible to remove. Treatment options include steroid and 5-fluorouracil injections, oral antibiotics (minocycline), puncture and expression, or surgical excision. Cutting them out is rarely an option due to the scarring and deformity that can result.

Microliposuction and Fat Grafting for Injectable Filler Nodules Dr Barry Eppley IndianapolisAnother less well described but effective treatment option is microliposuction and fat injections. A very small cannula, usually used for injecting fat, is inserted to help break up the nodules or mass of injected material. Some small amount of it may be able to be removed by suction through the small cannula but at the very least the material and scar tissue is broken up. The area is then injected with fat which ends up interspersed amongst the particulated nodular material. This should help lessen the size of the nodule and place healthier cells and tissues around it.

Particulation (microliposuction) and fat injection should be reserved for those long-term injectable filler nodules that failed to adequately respond to more traditional injection treatments. The very small size of the cannulas make it capable to be used anywhere on the face without risk of adverse scarring.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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