filler.pptx

FILLER

facial Analysis

Ideal facial proportions

Overview of skin structure

Epidermis – 0.15 mm – 0.50 mm (150 µm– 500µm)

Dermis – 1.0 mm – 3.0 mm (1000 µm– 3000 µm)

muscle

Fat Distribution

Loss and redistribution of subcutaneous fatYoung face-------fat is diffusely dispersedOld face-----------fat accumulates in pockets + gravity to this fat---

sagging &drooping of skin

Loss from:Preorbital bucccalTemporal perioral

Prominent increase in:Submental regionsJowlsLateral NLFsLateral MLFsLateral malar areasInfraorbital (atrophy or hypertrophy)

Loss of facial bones & cartilage

Bone resorption particularly affects: Mandible (angle reduction, decrease chin projection) Maxilla (loss of inferior orbital rim projection) Frontal bone Nose cartilage (ptosis of nasal tip)

This enhances facial skin droopiness, loss of cheek convexity & obliteration of the demarcation between the contour of the jaw and the neck.

Changes in expression muscles

Due to repeated traction of facial muscles

How wrinkles form?

• Movement of brow muscles cause the skin to crease• As skin becomes less elastic over time, repeated frowning

creates visible lines and wrinkles• Sleep lines

corrugator muscles corrugator muscles

procerus muscle

Treatment of skin aging

• Volume restoration:Re-creation of facial convexities that reflect light & that reduce

the shadows of facial concavities has a strong effect on the percieved age of a person.

• Pulling & tightening of sagging skinSurgical face lift

• Skin tightening via thermal contraction of collagen

The aim of cosmetic filler usage is to restore

youthful appearance rather than change the

patient’s natural appearance

Fillers history

1890 Human fat is the first

type of Dermal filler

used

1940Silicone

emerges on the scene

Early 1900’sParrafin becomes

popular

1981Bovine Collagen (Zyderm) is first approved by the

FDA

1985Cross-linked

Bovine Collagen is

first approved by the FDA

1995-99HA animal based fillers appear on

the market

1999Restylane

LaunchNASHA

technology

Fillers classification

BIODEGRADABLEResorbable in months

PERMANENTFILLERS

SEMI PERMANENTFILLERS

Resorbable in 1-2 years

Traditional fillers are biodegradable (i.e.

they are metabolised and excreted by the

body)

They have a proven record, but the effects

of some can be relatively short-lived

Permanent fillers play an important role in

the treatment of patients with HIV-

related lipoatrophy.Traditionally, they have been associated with a

high incidence of granulomas.

Semi-permanent fillers (usually containing microspheres) offer

longer-lasting effects than traditional fillers

but some are associated with the

development of granulomas

Types of fillers

Biodegradable, resorbable in months

Resorbable in years(Microparticles)

Permanent or nonresorbable

Bovine collagen (zyderm I & II, zyplast)

Calcium hydroxylapatite (CaHA) (Radiesse)

Paraffin Liquid silicone

Human-derived collagen (cosmoderm, cosmoplast)

Poly-L-Lactic acid (PLLA) (Sculptra)

Polymethylmethacrylate (Artecoll)

Hyaluroic acid: -rooster combs HA (avian) (Hylaform)-NASHA HA ( bacterial) (Restylan, Perlane, Juvederm ultra & Juvederm ultra plus)

Polyacrylamide hydrogel (Aquamid)

Hydroxyethylmethacrylate (Dermalive)

BACTERIAL vs ANIMAL HA FILLER

• A Natural Polysaccharide Carbohydrate• Found in all living organisms (HA has no organ or species specificity, highly biocompatible, no risk

of allergic reaction)

In Humans, HA resides in many tissues of the body:– Dermis of the skin (forming part of the extracellular matrix)– Cartilage, bone & synovial fluid– Vitreous body– Blood vessels

HA – What is that?

HA – The main Property

• HA is highly hydrophilic (hygroscopic capacity)

• Can attract and bind water up to 1000 times its own weight

The hydrophilic quality is the most important characteristic of HA, conducive to maintaining adequate internal hydration, lubrication, and moisture retention in

the body.

HA – The functions in the skin– Traps a vast amount of moisture to keep

the skin hydrated– Provides viscoelastic properties,

acting as a shock absorber and lubricant

– Helps new skin cells grow and replace old cells (provide support for tissues)

– Helps skin cells produce collagen and other substances essential for maintaining skin structure

– Protects skin cells by preventing free radical activity (free radical scavenger)

HA in the Skin

• The largest amount of HA resides in skin tissue• about 7-8g per adult human (total 12gm)• about 56% of the total amount in the body (the rest in

eyes and joints)• the dermis has 2-4mg/ml• the epidermis has 0.5mg/ml

• The half-life of HA in the skin is usually less than one day• One third of the HA in the body is removed and replaced

every day

Filler General Knowledge (2)Effects of Aging on HA natural production

Thinning of the skin Loss of fullness of the lips Sunken eyes or cheeks

More prominent facial bones and blood vessels (as skin loses volume) Ptosis of the nose

Wrinkles around the eyes and mouth

Filler General Knowledge - Cross-linking process

Biological half-life of natural HA in the skin is only 1 – 2 days

To prevent such rapid degradation, HA molecules are bound together= CROSS LINKING PROCESS

More resistant to heat More resistant to degradation by enzymes and free radicals

More resistant to Mechanical Stress

MOST IMPORTANT – Cross Linking process does not prevent HA from binding large volumes of water

BDDE

• BDDE = Butandiol Diglycidyl Ether • BDDE stabilizes the HA and makes it last longer but still leaves its

hydrophilic property• BDDE is the least toxic cross-linking agent, but is still toxic when

unbound

• Reactions to HA fillers are caused by unbound BDDE

The lower the level of free BDDE, the better it is

Cross Linking Effect

As you increase the degree of cross-linking, a liquid will first become a gel and then a solid.

CROSS-LINKING PROCESS

Liquid Gel Solid

No crosslinking Some crosslinking More crosslinking

Liquid Gel Solid

No crosslinkingNo crosslinking Some crosslinkingSome crosslinking More crosslinkingMore crosslinking

Liquid Gel Solid


Liquid Gel Solid


Liquid Gel Solid


Liquid Gel Solid


Liquid Gel Solid


Liquid Gel Solid


Liquid Gel Solid


Liquid Gel Solid


Liquid Gel Solid


Liquid Gel Solid


Liquid Gel Solid

How does cross-linking affect stability?

Add more cross-links

Easily damaged fence

More stable fence

Concentration of cross-linker

Hyaluronic acid molecule

Cross-linker

Too little

Just right

Number of cross-linking molecules that bind to HA

Too many cross-links in the molecule

Excess cross-linker in solution

Efficacy of cross-linking

Low efficacy cross-linking

Efficacious cross-linking

Homogeneity of cross-linking

Cross-linking notequal - heterogenous

Cross-linking isequal - homologous

Parameters that influence dermal filler performance

• Hyaluronic acid cross-linking is essential in influencing a dermal filler’s characteristics (vicosity & longivity). But, cross-linking is governed by four parameters:–the concentration of cross-linker–the number of cross-linking molecules that bind to hyaluronic acid –the homogeneity of cross-linking density–the efficacy of cross-linking.

• Different sizes of particles, thus products vary in their clinical applications (used for fine lines to deep folds)

The ideal filler

Safety of fillers

• Biocompatible, with low immunogenicity• Stable at implantation and no risk of migration• No risk of infectious contamination• No risk of carcinogenic potential • No risk of teratogenicity• FDA approved for its safety and target indication

Longivity of Filler

• Injection technique and depth of deposition• Amount injected• Location or area treated (mechanical stress at site of Rx)• Individual response and charachteristics• The injected material itself : Degree of crosslinking (the higher the longer) Concentration of crosslinking 3D molecule Gel hardness

Calcuim hydroxylapatite(Radiesse)

Product description

• Radiesse contains biomaterials with well established and understood safety and performance characteristics

• Components

– CaHA Particles (30% by volume)• Standard biomaterial• Used in orthopedics, ENT, dentistry• Extensive studies on safe use as

biomaterial• Natural - same composition as mineral in

bone and teeth

– Gel Carrier (70% by volume)• Cellulose based gel with glycerin and

sterile water• GRAS Classified by FDA (“Generally

Recognized as Safe”)

Product characteristics• Radiesse microspheres are formed from pure,

synthetic CaHA particles composed of Ca2+ and PO4

3- & hydroxide ions

• Ca2+ and PO43- ions are a natural component of

teeth and bone, making them inherently safe and biocompatible

• The CaHA microspheres are uniform in shape and range in size from 25 – 45µm in diameter

• The gel carrier holds the microspheres together and is fully resorbeable

Gel carrier performs as a passive filler initially, resulting in immediate 1:1 correction

Radiesse; mode of action

Macrophages dissolve gel carrier


Macrophages dissolve gel carrier & fibroblasts form new collagen


New resident tissue (collagen) anchors microspherules of CaHA


CaHA particles degrade and macrophages metabolize microspheres (enzymatic rather than phagocytosis)


Soft tissue behavior

• Gel carrier with CaHA provides the initial correction (0-4 months)

• Macrophages dissolve gel carrier• Fibroblasts form new collagen• New resident tissue anchors particles: collagen formation• Combined matrix (CaHA & natural tissue) results in

increased longevity (12+ months)

• Soft tissue histology

– no antigenic or major inflammatory response

– new dermal extracellular matrix

• No migration• No calcification or ossification

16 week human histology

X-ray & CT-scan & CaHA

• Conclusions X-ray: – CaHA is not consistently visible; depending on volume present– CaHA does not obscure underlying structures– Dental work is always visible

• Conclusions CT-scan:– Consistently visible– CaHA does not obscure underlying structures– No evidence of CaHA migration

• 2 physical characteristics of dermal fillers that dictate their ability to volumize and lift:

Radiesse has a– High viscosity (ability to resist a force that is applied

to it) so remains in place with increase bulking

– High elasticity (ability to push backagainst a force applied to it (as gravity) ).

Viscosity and Elasticity :providing volumizing and lifting capacity

Preoperative evaluation

• Consult with patient• Define the patient’s expectations• Assess globally then identify area(s) to be injected• Consent • Document and discuss preexisting scars, subcut. volume

differences between facial sides and any asymmetry. (photo prior to procedure)

• Avoidence of elective blood thinning medicine• Disinfect skin • Provide anaesthesia (topical, nerve block)• Disinfect again and mark areas to be treated

Postprocedures instructions

• Cold packs (intermittently)• Supplements that reduce bruising (vitamin K

cream)• Review after 2 weeks to assess satisfaction, as

well as photographs and potential touch up.

Indications for using HA-based dermal fillers

HA-based dermal fillers are indicated for use in several different aesthetic procedures. These procedures include:–glabellar (vertical frown) lines–nasolabial folds–oral commissures–vermillion borders (lip definition)–marionette lines–lip augmentation–cheekbones.

INJECTIONS LOCATIONS

Glabellar lines (frown lines) Periorbital lines (crow’s feet) Ocular Sulcus (tear troughs) Nasolabial lines (smile lines) Perioral lines (smoker’s lines)

Oral commissures Marionette lines

Vermilion border lip enhancement Acne scarring

Injection techniques

Injection techniques used for delivering dermal fillers:

• linear threading•serial puncture• layering•Fanning•Bolus

Injection Techniques

Most common

Linear threading technique

Serial puncture technique

Layering technique

Fanning technique

1

2

3

5

4

1

23

Guidelines for using HA-based dermal fillers• Glabellar lines

Step 3

Step 1 Step 2

10–15°

10–15°

Guidelines for using HA-based dermal fillers

• Nasolabial folds

Step 3

Step 1 Step 2

45°

Guidelines for using HA-based dermal fillers

• Oral commissures

30°

A30°

Step 3

Step 1 Step 2

A

10°

Step 4

B

C

B

C

A

Potential adverse events associated with dermal fillers

Acute injection site reactions (most commonly seen) mild to moderate swelling or bruising.

Superficial or inappropriate placement ( lumpiness, nodularity or visibility) (Rx hyaluronidase for HA, for CaHA if shallow nick the skin with blade & express nodule or dilute it out by saline inection)

Sensitivity (Rx topical &IL steroids) (later development of painful, erythematous, inflammatory nodules)

Infection (Rx antibiotics) (rare, reactivation of HSV or contamination of non FDA products)

Necrosis (occluding or compressing an artery) (Rx hyaluronidase)

(glabella supratrochlear a., NLF angular a., lips labial a.)

Precautions to reduce risk of necrosis at glabella

Inject medially and superficially

Using low volumes

Rx spread over multiple sessions

Aspirating before injecting

Algorithm for management of angry red bumps

• Lesion fluctuant-----------needle aspiration or incision & drainage, gram/acid fast stain, culture & sensitivity, antibiotics (14 days).

Worse----------may need chronic antibiotic suppression & IL steroids.

• Lesion non-fluctuant---------antibiotics (7days), then IL steroids?

Still---------------consider a calcineurin inhibitor & consider a biopsy for confirmation.

NB: Histopathology remains the criterion standard for identification of the responsible filler. The variation in microscopic morphology of the implanted particles and hydrogel allows to classify most cases

THANK YOU

filler.pptx

Documents

facial skin droopiness

drooping of skin loss

creaseas skin

ha animal based fillers

yearstraditional fillers

shadows of facial concavities

semipermanent fillers

shortlivedpermanent