review of long-lasting dermal fillers - atsh.co.ir gold artesense/dermal... · review of...

Supplement to theAesthetic Buyers Guide

Volume 2 • Number 1 • 2006

Review of Long-LastingDermal Fillers

Jean Carruthers, MD, FRCS(C),FRC(Ophth), Editor

A Continuing Medical Education ProgramPublished by Medical Insight, Inc.

www.cine-med.com

Target AudienceThis publication is intended for plastic surgeons, dermatologists,and other allied health professionals.

Learning ObjectivesAfter reviewing this CME publication, the physicianwill be able to:

• Identify the mechanism of action for CaHA, LIS,PLA & PMMA dermal fillers (volumizer vs. stimulator).

• Identify the difference between dislocation and migrationof filler material.

• Identify the characteristics of bovine collagen.

• Identify the outcomes for various injection planes.

• Define granulomas and their primary treatment option.

Obtaining CreditTo receive CME credit for the completion of this activity, mail or faxthe completed Registration, Post Test, and Evaluation Forms locatedat the back of this publication to: Ciné-Med, Inc., CME Department,127 Main Street North, Woodbury, CT 06798, Fax: 203-263-4839. Acertificate will be sent via regular mail.

AccreditationCiné-Med, Inc. is accredited by the Accreditation Council forContinuing Medical Education (ACCME) to provide continuingmedical education for physicians.

Ciné-Med, Inc. designates this educational activity for a maximum of1 AMA PRA Category 1 credit(s)™. Physician should only claim creditcommensurate with the extent of their participation in the activity.

The accreditation period for this material is:February 2006 – February 2008.

Commercial SupportThis activity is supported by an educational grant fromMedical Insight, Inc.

DisclosureIt is the policy of Ciné-Med to insure balance, independence, objectivity,and scientific rigor in all its educational programs. Faculty, course direc-tors, and planners participating in an accredited program are requiredto disclose to the program audience any real or apparent conflict(s) ofinterest. This pertains to relevant financial relationships within thepast 12 months with a commercial interest and the opportunity to affectprogram content relevant to products or services of that commercialinterest. The intent of this policy is to allow for a determination to bemade as to whether that relationship may constitute a conflict of inter-est that must be resolved. Information that a faculty member, coursedirector, or planner (including spouse/partner) has no relevant financialrelationships will be provided to the learners.

Faculty DisclosuresThe following contributors have indicated they do not have anyrelevant financial relationships to disclose:Jack Friedland, MDPierre Nicolau, MDKevin Smith, MD

The following contributors have indicated they do have relevantfinancial relationships to disclose:

Alastair Carruthers, MDAllergan, Inc. - Consultant, Honoraria, Investigator.Artes Medical, Inc. - Advisory Board, Warrant Holder.Bioform Medical, Inc. - Consultant, Investigator.Medicis, Inc. - Consultant, Honoraria, Investigator.Q-Med, Inc. - Investigator.

Jean Carruthers, MDAllergan, Inc. - Consultant, Honoraria, Investigator.Artes Medical, Inc. - Advisory Board, Warrant Holder.Bioform Medical, Inc. - Consultant, Investigator.Medicis, Inc. - Consultant, Honoraria, Investigator.Q-Med, Inc. - Investigator.

Steven Cohen, MDArtes Medical, Inc. - Stock Holder.Also engaged in off-label use of fillers on additional sites outsideof nasolabial folds.

Miles Graivier, MDArtes Medical, Inc. - Advisory Board.Bioform Medical, Inc. - Medical Advisory Board.Dermik Laboratories, Inc. - Medical Advisory Board.Also engaged in use of semi-permanent and permanent fillersfor soft tissue contouring.

John Joseph, MDAllergan, Inc. Advisory Board, Trainer.Artes Medical, Inc. - Advisory Board, Stock & Warrant Holder.Dermik Laboratories, Inc. - Injection Trainer, Advisory Board.Q-Med, Inc. - Advisory Board.Also engaged in off-label use of Sculptra and Botox.

Nicholas Lowe, MDMedicis, Inc. - Consultant, Research Grants.Sanofi Aventis - Consultant, Research Grants.

Rhoda Narins, MDArtes Medical, Inc. - Advisory Board, Warrant HolderColBar - Investigator, Stock Options.Dermik Laboratories, Inc. - Investigator.Medicis, Inc. - Medical Board, Investigator.Also engaged in off-label use of Sculptra, Radiesse and Silicone.

Mark Rubin, MDArtes Medical, Inc. - Advisory Board.Inamed, Inc. - Research Grant.Medicis, Inc. - Medical Advisory Board, Research Grant.

CME CONTENTReview of Long-Lasting Dermal Fillers

3www.miinews.com Review of Long-Lasting Dermal Fillers

Editorial Advisory Board . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-5

Introduction by Jean D. Carruthers, MD, Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

The History of Cosmetic Dermal Fillers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Long-Lasting Filler Comparison Chart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-13

Clinical Roundtable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

The Ideal Dermal Filler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Mechanism of Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Longevity of PMMA Fillers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Characteristics of Bovine Collagen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Allergenicity of Bovine Collagen Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Dislocation vs. Migration of Fillers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Injection Techniques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Outcomes of Injections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Corrective Measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Granulomas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Recommended Treatment for Granulomas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

The Future of Permanent Fillers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

CME Test. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

CME Registration Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

CME Evaluation Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Medical Insight, Inc.®

120 Vantis, Suite 470Aliso Viejo, California 92656www.miinews.com

Publishers of the Aesthetic Buyers Guide™

Telephone: (949) 830-5409Facsimile: (949) 830-8944Subscriptions: [email protected] Inquiries: [email protected]

Table of Contents

Correction of errors: Medical Insight, Inc. assumes no liability for the information contained in this publication. Every effort has been takento ensure the accuracy of this information by contacting sources believed to be reliable. Errors, when discovered, will be promptly correct-ed. Copyright: This publication is protected by U.S. Copyright Law; © 2006 Medical Insight, Inc. Unauthorized reproduction is strictlyforbidden by law.

Aesthetic Buyers Guide is a trademark of Medical Insight, Inc.

Publ isher Information

Michael [email protected]

4 Review of Long-Lasting Dermal Fillers www.miinews.com

Steven R. Cohen, MDClinical Professor,Plastic Surgery Training ProgramUniversity of California, San Diego

Dr. Cohen has served as the Chief of CraniofacialSurgery and Surgical Director of the CraniofacialCenter at Children's Hospital of San Diego since

1999. He founded FACESplus with Dr. Ralph E. Holmes, formerChairman of Plastic Surgery at the University of California, SanDiego. In 1990, Dr. Cohen was recruited to direct the CraniofacialProgram at the University of Michigan in Ann Arbor, where he builtthe infrastructure that is present to this day. He serves as a clinicalprofessor in the Plastic Surgical Training program at the Universityof California, San Diego. Dr. Cohen has written over 150 articles formedical literature and served on the editorial boards of PlasticReconstructive Surgery and Annals of Plastic Surgery. He was former-ly on the executive boards of the American Society of CraniofacialSurgery, the American Society of Maxillofacial Surgeons and theAmerican Cleft Palate-Craniofacial Association.

Editor ia l Advisory Board

Alastair Carruthers MD, FRCPCClinical Professor, Division of DermatologyUniversity of British Columbia

Dr. Alastair Carruthers is a cosmetic dermatologicsurgeon who operates his own clinical practice inVancouver, BC. He is also a clinical professor of der-matology with the Faculty of Medicine at the

University of British Columbia (UBC). Dr. Carruthers received his med-ical degree from Brasenose College, Oxford in 1969, did his dermatologyresidency at St. John's Hospital for diseases of the skin in London andcompleted his graduate studies in dermatologic surgery at theUniversity of California, San Francisco in 1977. During his 20 years ofpractice, Dr. Carruthers has made several major contributions to thefield of dermatology. Foremost among these was the use of the BOTOX®

procedure in cosmetic applications, a discovery he made with his wife,Dr. Jean Carruthers, in 1987. Since this time, they have been at theforefront of BOTOX® research, development and education, publishingnumerous articles with their data. Dr. Carruthers is a member of sever-al national and international associations, including the AmericanDermatology Association and the Canadian Dermatology Association,where he served as president from 1998 to 1999.

Jack A. Friedland, MD, FACSAssociate Professor of Plastic SurgeryMayo Medical SchoolPhoenix, AZ

After completing his undergraduate education atthe University of Wisconsin, Dr. Friedland gradu-ated from Northwestern University Medical

School in 1965 where he was elected to Alpha Omega Alpha, HonorMedical Society. He completed a straight surgical internship and gen-eral surgery residency at New York University-Bellevue MedicalCenter, followed by the completion of a plastic surgery residency at theInstitute of Reconstructive Plastic Surgery in New York City. Since1996, Dr. Friedland has practiced at Mayo Medical School in Phoenix,Arizona as Associate Professor of Plastic Surgery. He has performed asExaminer for the American Board of Plastic Surgery and is a memberof the American Association of Plastic Surgeons, American BurnAssociation, American Society of Plastic and Reconstructive Surgeonsand is past President and current member of the Board of Trustees onthe American Society for Aesthetic Plastic Surgery.

Miles H. Graivier, MD, FACSPrivate PracticeNorth Atlanta Plastic SurgeryRoswell, GA

Dr. Miles Graivier earned his medical degreefrom the University of Texas at Houston, graduat-ing with high honors. After finishing a five year

residency in General Surgery at Emory University, Dr. Graivier thencompleted a two year fellowship in Plastic and ReconstructiveSurgery at the University of California at Los Angeles (UCLA). Dr.Graivier is Board Certified in Plastic & Reconstructive Surgery andis a member of the American Society of Plastic & ReconstructiveSurgeons and the Georgia Society of Plastic & ReconstructiveSurgeons. He is a Fellow of the American College of Surgeons andnow works in private practice at the North Atlanta Plastic SurgeryCenter in Roswell, Georgia.

Jean D. Carruthers, MD,FRCS (C), FRC (Ophthalmology)Clinical Professor,Department of OphthalmologyUniversity of British Columbia

Jean D. Carruthers, MD, is a clinical professor in the Department of Ophthalmology at the University of British Columbia inVancouver, where she specializes in aesthetic facial ophthalmology. Dr. Carruthers is a diplomat of the American Board of Cosmetic Surgery andfellow of the American Society of Ophthalmic Plastic and Reconstructive Surgery. She has been invited to give more than 100 presentationsworldwide on topics in cosmetic surgery. Her clinical expertise comprises cosmetic and therapeutic use of botulinum A exotoxin, aesthetic fillers,aesthetic face lift, cosmetic laser-assisted upper and lower eyelid blepharoplasty, and a variety of resurfacing procedures and other soft tissueenhancement techniques. Dr. Carruthers is currently President of the Cosmetic Surgery Foundation for Education, Research and Patient Safetyand past President of the Canadian Laser Aesthetic Surgery Society. This year she is President of the Foundation of the American Academy ofCosmetic Surgery and Secretary of the same Academy.

M O D E R A T O R


Editor ia l Advisory Board

Nicholas J. Lowe, MD, FRCP, FACPConsultant Dermatologist, Cranley Clinicfor Dermatology, London, EnglandClinical Professor of Dermatology,UCLA School of Medicine, Los Angeles

Dr. Lowe graduated from the University ofLiverpool Medical School in England in 1968 and subsequentlycompleted his internship in Liverpool Teaching Hospitals. Heentered the Royal Navy as a Surgeon Lieutenant on a short servicecommission and completed an Internal Medicine residency at theRoyal Navy Hospital in Hampshire and in London, England. In 1989he founded and is the Medical Director of Southern CaliforniaDermatology, Psoriasis and Laser Center and Clinical ResearchSpecialists, Inc., in Santa Monica, California. Dr. Lowe remains atthe UCLA School of Medicine as Clinical Professor of Dermatologyand is Senior Lecturer and honorary consultant at UCL, London. In1994, Dr. Lowe founded the Cranley Clinic for Dermatology inLondon, England, which houses clinical and research facilities.

John H. Joseph, MDFacial Plastic & Reconstructive SurgeryBeverly Hills, CAAssistant Clinical ProfessorUCLA School of Medicine

Dr. John H. Joseph is a Facial Plastic Surgeon inprivate practice in Beverly Hills and is an Assistant ClinicalProfessor at UCLA. He specializes in aesthetic facial plastic surgerybut is also involved in congenital and traumatic facial reconstructivecases. Dr. Joseph received his undergraduate degree in Biology fromthe University of Illinois. His medical school training and GeneralSurgery Internship were obtained from the University of Illinois inChicago. He attended the top ranked residency in Head and Necksurgery at the University of Iowa. He completed a one year fellowshipwith Dr. Frank Kamer in Facial Plastic and Reconstructive Surgery,and continued to assist in that office until starting his own practicein Beverly Hills. Dr. Joseph is Board Certified by the AmericanAcademy of Facial Plastic and Reconstructive Surgery and by theAmerican Board of Otolaryngology.

Rhoda S. Narins, MDDirector,Dermatology Surgery and Laser CenterClinical Professor of Dermatology,NYU Medical SchoolImmediate Past-President ASDS

Dr. Rhoda S. Narins, one of the nation's top dermatologic surgeons,was selected by her peers as one of only 12 dermatologists in theUnited States listed in "Best Doctors in America" under AestheticSurgery. She is currently President of the American Society ofDermatologic Surgery and Clinical Professor of Dermatology at NewYork University Medical School where she teaches advanced derma-tologic surgery and is Chief of the Liposuction Surgery Unit. Dr.Narins has lectured extensively world wide on dermatologic surgeryincluding liposuction, fat transfer, collagen and other fillers, chemi-cal peels, Ultra-Pulse CO2 & other lasers, sclerotherapy, BOTOX®,and skin care. She is board certified by the American Board ofDermatology and Chief Emeritus of Dermatology at white PlainsHospital Medical Center.

Kevin C. Smith, MD, FRCPC, FACPDermatologist, Private PracticeNiagara Falls, Ontario, Canada

Dr. Kevin Smith graduated from the University ofAlberta in Edmonton, Candada in 1983. He becamea Diplomat of the United States National Board ofMedical Examiners in 1984 and the American Board

of Dermatology in 1988. In 1989 Dr. Smith achieved Fellowship at theRoyal College of Physicians (Canada) in Dermatology. He is now in pri-vate practice for Dermatology at the Niagra Falls Dermatology andSkin Care Centre in Niagra Falls, Ontario. Concurrently, Dr. Smithserves as Courtesy Staff for the Department of Internal Medicine atGreater Niagara General Hospital in Niagara Falls, Ontario, Canada.

Pierre J. Nicolau, MDBoard Certified Plastic Surgeon,Private Practice, Paris, FranceFormer Registrar and Senior Registrar (L.T.) Leeds General Infirmary, LEEDS, U.K.

Dr. Nicolau studied at the University of Montpellier—The oldest active medical school in the world—where he specializedin plastic surgery. In 1976, there were very few surgical services spe-cializing in aesthetic and reconstructive plastic surgery. In most of theuniversity hospitals, this specialty was taught in maxillofacial, cervico-facial or orthopedic departments. As a result, he traveled to England toperfect his surgical techniques, where reconstructive surgery was moredeveloped due to the treatment of WWII injuries, particularly severeburns. After returning to France in 1983, he performed hospital-basedprocedures in reconstructive surgery focusing on burn victims, skinand breast cancers and body contouring for weight loss patients, inaddition to opening his private practice. Dr. Nicolau has priviliges atl'Assistance Publique - Hôpitaux de Paris as Chirurgien Attaché and ison the staff at l'Hôpital Rothschild, l'Hôpital Saint Antoine. InColombes, he is also on staff at l'Hôpital Louis Mourier, a leading cen-ter for the surgical treatment of obesity.

Mark G. Rubin, MDAssistant Clinical Professor of DermatologyUniversity of California, San DiegoLasky ClinicBeverly Hills, CA

After obtaining his MD from Jefferson MedicalCollege in Philadelphia, PA, Dr. Rubin completed his medical residencyin dermatology at the Henry Ford Hospital in Detroit, MI, and his inter-nal medicine internship at Alton Ochsner Hospital in New Orleans, LA.Dr. Rubin has been lecturing on cosmetic dermatology and skin rejuve-nation for over 13 years and has personally trained over 700 doctorsfrom ten countries in his techniques for skin rejuvenation. In addition,he teaches and arranges Cosmetic Peel Workshops for physiciansaround the nation. Author of numerous medical journal articles, Dr.Rubin is Board Certified in Dermatology and is an associate Professorof Dermatology at UCSD. He is a Diplomat of the American Board ofDermatology and National Board of Medical Examiners, as well as amember of the American Academy of Dermatology and the AmericanSociety of Dermatologic Surgery among others.


The History of Cosmetic Dermal Fillers

By Jean Carruthers, MD, FRCS

To correct contour deficiencies of the face, a varietyof injectable soft tissue augmentation agents haveemerged. The first was bovine collagen, introducedapproximately 30 years ago1 and marketed asZyderm® I and II (Inamed, Santa Barbara, Calif.)for superficial lines and later as Zyplast® (Inamed),a glutaraldehyde cross-linked counterpart, fordeeper lines and folds.2 Both products require askin test for allergy before use and have a longsafety record. To reduce the allergenic limitationsof bovine collagen, human collagen fillers werelater developed and marketed as CosmoDerm™ Iand II (Inamed) and CosmoPlast™ (Inamed). Allfive products typically last three to five months intissue3 and all contain lidocaine to minimize painduring treatment.

Hyaluronic acid (HA) fillers such as Restylane®

(Q-Med AB, Uppsala, Sweden) and Hylaform®

(Inamed) have the advantage of reduced risk ofallergic reactions because HA is chemically thesame for all species.4-6 A transparent gel, Restylaneis produced from streptococci by biofermentation5

and typically remains in tissue for six to 12months after implantation.3 Hylaform is derivedfrom rooster combs6,7 and remains in tissue for sixto nine months.3 Both products are used fornasolabial folds and lips3 and neither contains lido-caine to reduce pain during treatment. Safety datafor non-animal stabilized HA gel for soft tissueaugmentation has been documented.8 NeitherRestylane nor Hylaform require an allergy skintest before use.

With all soft tissue fillers, injection technique is akey component to successful augmentation. ZydermI, for example, is placed in the superficial dermis byserial punctures that barely penetrate the skin. Thematerial is “flowed” into the superficial dermis by

positioning each injection volume at the advancingedge of the preceding injected volume. The contin-uous flow smoothly fills the superficial defects.5

Overcorrection is necessary because the salinedilutent is reabsorbed during the first 24 hours.

Placing the filler at the appropriate depth is par-ticularly important to achieve the desired cosmeticresult. If Zyderm is placed too superficially, theskin looks flat and yellow.3 If Zyplast (injected intothe mid dermal region) is placed too superficially,long-lasting overcorrection and beading mayresult. If injected into the subdermal region, theduration of correction is reduced.5

The Restylane products include fillers with HAparticles sized according to the depth of depositioninto skin. The most commonly used injection tech-nique for these products is linear threading.3 Thephysician holds the syringe parallel to the fold,pierces the skin, and moves the needle forward.While withdrawing the needle, the physicianpresses the plunger to expel the filler into the tis-sue. Visual and tactile responses to the injectionguide the treatment. Injections placed too deeplyprovide reduced benefits, whereas injectionsplaced too superficially may result in a ridge or anuneven skin surface. The epidermis may appeartransparent at first, then spotty red or gray.

Restylane Hyaluronic Acid(HA) filler, by Q-Med.


The fillers discussed so far have limited duration intissue, requiring patients to return for retreatmentevery four to six months to maintain cosmetic ben-efit. Others, such as liquid injectable silicone (LIS),last for years or may be permanent.

Liquid silicone has a long and controversial his-tory as a filler. Developed in 1945 by Dow CorningCorp. for military purposes, silicone was intro-duced to cosmetic medicine in the 1960s as a fillergel for breast implants9 and later for soft tissueaugmentation.10 Although silicone produces cos-metic benefits, silicone granulomas have beenreported11 and injection of impure silicones hasresulted in serious complications,12 some appear-ing many years after implantation.13

A comprehensive review of possible causes and treat-ment options for granulomas associated with allinjectable dermal fillers will be available in 2006.14

Adverse reactions and complications (includinggranulomas) of fillers have been reviewed recently.15,16

Two medical-grade silicones (both LIS) are cur-rently available: (1) Silskin™ ( Richard-James, Inc.Peabody, Mass.), which has received anInvestigational Device Exemption for a clinicaltrial on facial wrinkles, and (2) Silikon® 1000 (AlconLaboratories, Inc., Forth Worth, Texas), which isFDA cleared as an injectable tamponade for retinaldetachments. The FDA Modernization Act of 1997permits FDA-cleared devices to be used “off-label”for any condition within the doctor-patient rela-tionship, such as soft tissue augmentation.

The risks and benefits of using liquid silicone forsoft tissue augmentation have been the subject ofconsiderable debate. Experts agree, however, thatthe quality of results depends on technique, minorcomplications may occur even with good technique,serious complications are rare when small volumesof sterile pure liquid are used, and serious compli-cations can occur years after treatment. They alsoagree that dislocation—in this case, movement ofsilicone from the site of injection to another bodysite—may result if large volumes are injected.When this occurs, the silicone is not contained bytissues into which it is injected, causing the filler tomove due to muscle contraction or gravity.17

As with temporary fillers, injection technique iscritical to success with LIS. The microdropletserial puncture technique has been used exten-sively for silicone injections. With this technique,migration is eliminated because the microdropletsstimulate fibroplasia and the formation of acollagen capsule that holds them at the implanta-tion site. Silicone microdroplets displace dermalconnective tissue and new collagen is depositedaround the microdroplets, resulting in augmenta-tion. The amount of new collagen synthesized ispredictable and self-limiting. Injections are madeover several time intervals to assure slow but pro-gressive collagen formation. Since augmentation isgradual, undercorrection (rather than overcorrec-tion) is appropriate.18 The microdroplet techniquerequires several repeat treatments, and the timeinterval to visible improvement is longer than withother fillers.19

Optimal results are obtained when silicone is inject-ed beneath the layer in which the defect originates.For example, injecting LIS just below the dermis isappropriate for correcting contour depressions inwhich dermal and epidermal layers of normal thick-ness lie above a subdermal layer of insufficientdepth. If LIS is injected into the dermal or epider-mal layer, beading and granulomas may result.Beading and overcorrection can be treated with

Lips augmented withliquid silicone.


intralesional anti-inflammatory corticosteroids.18 Acomprehensive update on the use of LIS for softtissue augmentation has been published recently.20

Radiesse™ (formerly Radiance, BioForm MedicalInc., San Mateo, Calif.) is a biocompatible implantof calcium hydroxylapatite (CaHA) micros-pheres of 25 to 45 microns in diameter, suspendedin a cellulose gel. It has been FDA cleared for thetreatment of oral and maxillofacial defects, vocalcord augmentation, and radiographic tissue mark-

ing. Although approved in Europe as a soft tissuefiller, Radiesse has not been FDA cleared for facialcosmetic use in the United States.19 Clinical trialsfor FDA clearance in the correction of nasolabialfolds and HIV lipoatrophy are in progress.

Radiesse has been used in orthopedic and recon-structive surgery, dentistry,21 treatment of bonedeficiencies,21,22 and as a bulking agent for stressurinary incontinence.23 Its safety profile21,24 hasbeen established and longevity of the injectableagent appears to be up to nine months,19,25 but maybe longer.

As a constituent of bone, CaHA is biocompatible. Itshould not stimulate an immune reaction21,23,26 anddoes not require an allergy skin test.3,19 SinceCaHA microspheres do not appear to migrate,calcify, or ossify when injected into soft tissue,Radiesse has potential as a soft tissue filler.23,27

Cosmetic uses of CaHA in the skin have beenreported.21,27,28 Comite and colleagues19 have evalu-ated the product for the treatment of HIV-associated lipoatrophy in three patients. Facialimprovement after treatment ranged from 75% to90% and significant improvement remained for upto nine months. Tzikas28 treated the lips, nasolabi-al folds, glabellar rhytides, prejowl depressions,marionette lines, acne scars, and surgical soft tis-sue defects of 90 patients. Six months after CaHAtreatment, patients reported good to excellent

results in appearance (74% of patients), softness(80%), and overall satisfaction (88%). Adverseeffects were temporary and included moderate tosevere pain during injection as well as post-treat-ment erythema, edema, and ecchymosis. Mucosallip nodules appeared and persisted in sevenpatients; four nodules required intervention. Lipnodules were reported in another study as well.27

Radiesse nodules are hard and white and consistmainly of clumped calcium microspheres.25

As to the mechanism of action, CaHA microspheresare believed to form a framework for soft tissueingrowth as the gel carrier dissolves.29 Fibroblasts,which accumulate on the microsphere surface at thesite of injection, hold the microspheres in place as thenew tissue develops.19 In some patients, a layer of fib-rin develops around the microspheres until the beadsare broken down enzymatically into calcium andphosphate.25 Radiesse works well for deep folds andwrinkles; soft tissue contouring, including cheek andbrow enhancement; for scars; for nasal contouring,29

but not for lip enhancement and superficial lines.3

Radiance at 4 months. Packed calcium microspheres, interstitum filledwith fibrin and scattered fibroblasts and macrophages (100x).

Nodules in lip after injection ofcalcium hydroxylapatite (CaHA)microspheres.


Like other longer-lasting fillers, Radiesse is injected(threaded) into the dermal-subdermal junction orlower as the needle is withdrawn. In HIV-infectedpatients, the cheeks may require massaging to dis-tribute the filler evenly. Overcorrection is notrecommended and patients may require a touch-upsession two to four weeks later.19

Polymers of poly-L-lactic acid (PLA) have beenused for years in absorbable sutures, soft tissueanchors, surgical sealant meshes and solidimplants (plates, screws, and pins), and drug deliv-ery devices. Marketed in Europe as New-Fill®,injectable PLA microspheres of 1 to 50 microns indiameter have been used to enhance wrinkles andto correct folds and volume losses and scars.3,30

Sculptra™ (Dermik Laboratories, Berwyn, Pa.) PLAwas recently cleared by the FDA for restorationand/or correction of the signs of facial fat loss(lipoatrophy) in people with HIV.30

In a 100-patient clinical study, Laglenne and col-leagues19,31 showed that PLA corrected vertical facialwrinkles with high patient and physician satisfac-tion. Immediate or delayed granulomatous orallergic reactions were not observed for upto one year. (Laglenne had developed theseresorbable injectable PLA microspheres in the mid-1990s). Several years later, Valantin and colleagues32

treated 50 HIV-infected patients with PLA in anattempt to correct severe facial lipoatrophy. Totalcutaneous thickness increased steadily for up to oneyear and remained significantly above baseline for

nearly two years. Palpable but non-visible subcuta-neous nodules appeared in 22 patients and resolvedwithout intervention in six patients. A randomizedclinical trial33 in which PLA was injected into thedeep dermis of HIV-infected patients showed thatpatient self-perception, anxiety, and depressiondecreased with facial lipoatrophy correction.

Sculptra is provided in a vial that must be recon-stituted with 5 mL sterile water and incubated forat least two hours before use. Serial injectionsspaced 0.5 to 1 cm apart are directed to the deepdermal-subdermal junction. A crisscross and tun-neling (threading) technique with massagingevery three to four injections is recommended for aface with mild to moderate lipoatrophy. Physiciansshould avoid overcorrection and strive to distrib-ute the dissolved product evenly in the tissue.Injections into the orbit and perioral regions arerecommended only for physicians with adequate

experience in the technique. Three to five sessionsspaced four to six weeks apart comprise a typicalcourse of treatment.30 The injection technique hasbeen further described for on-label and off-labeluses.34 An update on the use of Sculptra has recent-ly been published.35

Sculptra is biocompatible, biodegradable, andimmunologically inert. The reconstituted product isstable for 72 hours. Local anesthesia is recommend-ed to reduce pain during treatment.3 Injections maytrigger sufficient collagen production to prolong

Non HIV-Infected patient before treatment with Sculptra. Non HIV-Infected patient after three treatments with Sculptra.

Ph

otos

cou

rtes

y of

Nic

hol

as J

.Low

e,M

D,F

RC

P,F

AC

P


benefit for 12 to 18 months in HIV-infectedpatients.32,33 Three cases of adverse events (giantcell granulomas) occurring 12 months after skinaugmentation with New-Fill have been reported.36

Polymethylmethacrylate (PMMA) was synthe-sized initially by Roehm in 1902, patented in 1928as Plexiglas, and has since been used as bonecement, in dentures, in prosthetic devices, inintraocular lenses and as a carrier for antibiotics.37

Since 1985, PMMA has been studied as a soft tis-sue augmentation device.38,39

The goal was to develop an augmentation devicethat would provide long-lasting augmentation.One way was to insert a nonresorbable syntheticmaterial in powder form that would act as amatrix to stimulate collagen deposition over a longperiod of time.25 The search for the appropriatematerial led to PMMA, the most widely used arti-ficial material in medicine.

The first step in developing PMMA for soft tissueaugmentation was to isolate microspheres largeenough to avoid phagocytosis but small enough toallow injection into the deep dermis through a 26-gauge needle. Microspheres between 30 and 50 µmmet these requirements and were shown to promote78% connective tissue encapsulation.25 Animalexperiments38 in which PMMA microparticles sus-pended in Tween 80 or gelatin medium wereinjected into the dermis and subdermis showed that(1) fibrous capsules had formed around each micros-phere within two weeks, (2) microspheres hadremained intact for seven months, and (3) theTween 80 or gelatin had not elicited a tissue reac-tion. However, foreign body giant cells were seen in1.5% of all invading cells. The next step was to injectthe microspheres (Arteplast®) into human patientswith scars and wrinkles.39

Between 1989 and 1994, 587 patients were givenArteplast subdermally. By 1994, granulomas haddeveloped in 15 patients (2.5%) 6 to 18 months

after treatment. To reduce the rate of granulomaformation, the microspheres were washed by acomplex procedure and coated with high-viscositybovine collagen rather than gelatin or Tween 80.The result was wider spaces between the micros-pheres, which facilitates tissue ingrowth muchbetter than the smaller spaces between clumpedbeads. In the improved product (Artecoll®, RofilMedical International, Breda, The Netherlands),the granuloma formation rate was less than 0.02%in 400,000 patients worldwide.40 Formation andtreatment of Artecoll-associated granulomas overa five-year period have recently been reported.41

In 2003, the FDA advisory panel recommendedthat Artecoll receive U.S. marketing approval. Afterfinal FDA approval for marketing in the U.S., theproduct will be manufactured and marketed in theUnited States by Artes Medical, Inc. (San Diego,Calif.) as ArteFill®.39,42

Clinical trial results of Artecoll were reported in2004.42 In the multicenter study, 251 patientsreceived injections of Artecoll or collagen (ZydermII or Zyplast) in wrinkles of the nasolabial area,glabella, radial lip lines, and corners-of-the-mouth.Improvement in nasolabial folds was significantlygreater in the Artecoll group six months after treat-ment and significant augmentation persisted for12 months. Adverse events and immunoglobulin

Polymethylmethacrylate (PMMA) microspheres (200x).

Ph

otos

cou

rtes

y of

Got

tfri

ed L

empe

rle,

MD


Brand Active Carrier Mechanism Biodegradable? FDA Status Persistence Allergy Test ? AnestheticName Ingredient of Action For Wrinkles In Tissue

Silikon 1000 PDMS None Volumizer No Off-label Permanent No None

Radiesse* CaHA Cellulose Stimulator Yes Off-label 1- 2 years No Nonecarboxymethyl

cellulose

Sculptra† PLA Cellulose Stimulator Yes Off-label 1 year No Nonecarboxymethyl

cellulose

ArteFilI PMMA Bovine Stimulator No Approval Permanent Yes Lidocainecollagen collagen expected in 2006

Table 1: Primary long-lasting fillers used for soft tissue augmentation

PDMS= polydimethylsiloxane; CaHA = calcium hydroxylapatite; PLA = poly-L-lactic acid; PMMA = polymethylmethacrylate* Formerly Radiance† New-Fill in Europe

G levels were similar in both groups and no granu-lomas were reported after one year. Artecoll wasinjected as the needle was moved back and forthbeneath the wrinkle (tunneling technique). Artecollwas placed in the reticular dermis just above thejunction between the dermis and the subcutaneousfat. If the needle was inserted into the papillarydermis (resulting in a blanching effect), the injec-tion was halted until the needle was moved deeper.Complete five-year follow-up results of clinical trialpatients will be available in 2006.43 A recentreport44 provides additional details of efficacy, safe-ty, and injection technique for Artecoll.

Soft tissue fillers are currently classified on the basisof biodegradability or mechanism of action.45

Collagen, HA gels, PLA microspheres, CaHA, andhydroxyethyl methacrylate (HEMA) particles arebiodegradeable whereas LIS, certain polyacrylamide(PAAG) gels, and PMMA microspheres are not.

Regarding mechanism of action, fillers either addvolume and cause little foreign body reaction(volumizers) or they stimulate tissue and cause aforeign body reaction (stimulators).45 Volumizers

include silicone, certain polyacrylamides, collagen,and HA; stimulators include PLA, dextrans,CaHA, HEMA, and PMMA.

PLA and dextrans cause a foreign body reactionfor a limited time period before they are absorbed,whereas PMMA microspheres stimulate collagendeposition indefinitely and are never absorbed.The primary long-lasting fillers are compared inTable 1 below.

Demonstration of PMMA microsphere (ArteFill)with natural collagen formation.

Ph

otos

cou

rtes

y of

Got

tfri

ed L

empe

rle,

MD


1. Knapp TR, Kaplan EN, Daniels JR.Injectable collagen for soft tissue augmentation.Plast Reconstr Surg. 1977;60:398-405.

2. Narins RS, Brandt F, Leyden J, Lorenc ZP, Rubin M, SmithS. A randomized, double-blind, multicenter comparison ofthe efficacy and tolerability of Restylane versus Zyplastfor the correction of nasolabial folds. Dermatol Surg.2003;29:588-595.

3. Narins RS, Bowman PH. Injectable skin fillers.Clin Plast Surg. 2005;32:151-162.

4. Larsen NE, Pollak CT, Reiner K, Leshchiner E, Balazs EA.Hylan gel biomaterial: dermal and immunologiccompatibility. J Biomed Mater Res. 1993;27:1129-1134.

5. Klein AW. Skin filling. Collagen and other injectables ofthe skin. Dermatol Clin. 2001;19:491-508.

6. Manna F, Dentini M, Desideri P, De Pita O, Mortilla E,Maras B. Comparative chemical evaluation of twocommercially available derivatives of hyaluronic acid(Hylaform from rooster combs and Restylane fromstreptococcus) used for soft tissue augmentation.J Eur Acad Dermatol Venereol. 1999;13:183-192.

7. Monheit GD. Hylaform: a new hyaluronic acid filler.Facial Plast Surg. 2004;20:153-155.

8. Friedman PM, Mafong EA, Kauvar AN, Geronemus RG.Safety data of injectable nonanimal stabilized hyaluronicacid gel for soft tissue augmentation.Dermatol Surg. 2002;28:491-494.

9. Cronin TD, Gerow FJ: Augmentation mammaplasty:a new "natural feel" prosthesis. In: Transactions of theThird International Congress of Plastic andReconstructive Surgery, Series No. 66. Amsterdam,Excerpta Medica, 1964:41-49.

10. Ashley FL, Braley S, Rees TD, Goulian D, BallantyneDL Jr. The present status of silicone fluid in soft tissueaugmentation. Plast Reconstr Surg.1967;39:411-420.

11. Nosanchuk JS. Silicone granuloma in breast.Arch Surg. 1968;97:583-585.

12. Ellenbogen R, Rubin L. Injectable fluid silicone therapy.Human morbidity and mortality.JAMA. 1975;234:308-309.

13. Achauer BM.A Serious complication following medical-grade silicone injection of the face. Plast Reconstr Surg.1983;71:251-254.

14. Lemperle G , Gauthier-Hazan N, Wolters M, Eisemann-Klein M, Zimmermann U. Foreign body granuloma afterall injectable dermal fillers: Their possible causes andtreatment options. Plast Reconstr Surg. 118 (Suppl.):2006

15. Duffy, DM. Complications of fillers: overview.Dermatol Surg. 2005;31 (Part 2):1626-1633.

16. Lowe NJ, Maxwell CA, Patnaik R.Adverse reactions to dermal fillers: review.Dermatol Surg. 2005;31(Part 2):1616-1625.

17. Duffy DM. The silicone conundrum: a battle of anecdotes.Dermatol Surg. 2002 ;28:590-594.

18. Orentreich D. Liquid injectable silicone: techniques forsoft tissue augmentation. Clin Plast Surg.2000;27:595-612.

19. Comite SL, Liu JF, Balasubramanian S, Christian MA.Treatment of HIV-associated facial lipoatrophy withRadiance FN (Radiesse). Dermatol Online J. 2004;10:2-15.

20. Duffy, DM. Liquid silicone for soft tissue augmentation.Dermatol Surg. 2005;31:1530-1541.

21. Hobar PC, Pantaloni M, Byrd HS. Porous hydroxyapatitegranules for alloplastic enhancement of the facial region.Clin Plast Surg. 2000;27:557-569.

22. Costantino PD, Friedman CD, Jones K, Chow LC, PelzerHJ, Sisson GA Sr. Hydroxyapatite cement. I. Basicchemistry and histologic properties. Arch OtolaryngolHead Neck Surg. 1991 ;117:379-384.

23. Mayer R, Lightfoot M, Jung I. Preliminary evaluation ofcalcium hydroxylapatite as a transurethral bulking agentfor stress urinary incontinence. Urology. 2001;57:434-438.

24. Havlik RJ; PSEF DATA Committee. Hydroxyapatite.Plast Reconstr Surg. 2002;110:1176-1179.

25. Lemperle G, Morhenn V, Charrier U.Human histology and persistence of various injectablefiller substances for soft tissue augmentation.Aesthetic Plast Surg. 2003;27:354-366.

References


26. Stein J, Eliachar I, Myles J, Munoz-Ramirez H, StromeM. Histopathologic study of alternative substances forvocal fold medialization. Ann Otol Rhinol Laryngol.2000;109:221-226.

27. Sklar JA, White SM. Radiance FN: a new soft tissuefiller. Dermatol Surg. 2004;30:764-768.

28. Tzikas TL. Evaluation of the Radiance FN soft tissuefiller for facial soft tissue augmentation. Arch FacialPlast Surg. 2004;6:234-239.

29. Graivier MH, Jansen DA. The role of Radiesse in facialshaping. Plast Reconstr Surg. In press.

30. Vleggaar D, Bauer U. Facial enhancement and theEuropean experience with Sculptra (poly-l-lactic acid).J Drugs Dermatol. 2004;3:542-547.

31. Laglenne et al. Un nouveau produit de comblement desrides, entirement resorbable. Dermatologie 2000;54:30-33.

32. Valantin MA, Aubron-Olivier C, Ghosn J, Laglenne E,Pauchard M, Schoen H, Bousquet R, Katz P, CostagliolaD, Katlama C. Polylactic acid implants (New-Fill) tocorrect facial lipoatrophy in HIV-infected patients: resultsof the open-label study VEGA. AIDS. 2003;17:2471-2477.

33. Moyle GJ, Lysakova L, Brown S, Sibtain N, Healy J,Priest C, Mandalia S, Barton SE. A randomized open-label study of immediate versus delayed polylactic acidinjections for the cosmetic management of faciallipoatrophy in persons with HIV infection. HIV Med.2004;5:82-87.

34. Humble G, Mest D. Soft tissue augmentation usingSculptra. Facial Plast Surg. 2004;20:157-163.

35. Vleggaar, D. Facial volume correction with injectablePoly-L-Lactic Acid. Dermatol Surg. 2005;31:1511-1518.

36. Beljaards RC, de Roos KP, Bruins FG. NewFill for skinaugmentation: a new filler or failure? Dermatol Surg.2005;31:772-776.

37. Lemperle G, Hazan-Gauthier N, Lemperle M. PMMAmicrospheres (Artecoll) for skin and soft tissueaugmentation. Part II: Clinical investigations.Plast Reconstr Surg. 1995;96:627-634.

38. Lemperle G, Ott H, Charrier U, Hecker J,Lemperle M. PMMA microspheres for intradermalimplantation: Part I. Animal research.Ann Plast Surg. 1991;26:57-63.

39. Lemperle G, Romano JJ, Busso M. Soft tissueaugmentation with Artecoll: 10-year history, indications,techniques, and complications.Dermatol Surg. 2003;29:573-587.

40. Artecoll Physicians Brochure 2005, Rofil MedicalInternational NV, Breda, The Netherlands.

41. Carruthers A, Carruthers JDA. Polymethylmethacrylatemicrospheres/collagen as a tissue augmenting agent:personal experience over five years.Dermatol Surg. 2005;31:1561-1565.

42. Cohen SR, Holmes RE. Artecoll: a long-lasting injectablewrinkle filler material: Report of a controlled,randomized, multicenter clinical trial of 251 subjects.Plast Reconstr Surg. 2004;114:964-976.

43. Cohen SR, Berner CF, Busso M, et al.ArteFill®/Artecoll®: A long-lasting injectable wrinkle fillermaterial. Plast Reconstr Surg. 118 (Suppl.):2006

44. Thaler MP, Ubogi ZI. Artecoll: The Arizona experienceand lessons learned. Dermatol Surg. 2005;31:1566-1576.

45. Nicolau, PJ. Long lasting and permanent fillers:Biomaterial influence over host tissue response.Plast. Reconstr. Surg. In press.

References


What do you and your patients considerto be the ideal dermal filler?

Steven R. Cohen, MD: Patients want somethingthat is effective, is reasonably priced, lasts forever,and is complication-free. The ideal filler, to me, ispermanent, effective, and very safe.

Mark Rubin, MD: People are looking for afiller with some persistence. Some believe that apermanent filler is what everybody is looking for,but in reality a lot of patients don’t want some-thing permanent.

Jack Friedland, MD: A patient would say, “Iwant something permanent at a good price.” That’sunderstandable, but I think fillers are ancillaryrather than primary methods of treatment. If it’spermanent, it has to be perfectly done from a tech-nical standpoint because if there’s a problem, ittakes surgery to change it.

Pierre J. Nicolau, MD: I am a plastic surgeonso most of my patients come to me for a long-lastingresult. That’s different with patients going to seedermatologists, where they don’t mind going backevery three, four, or six months. So for me, the idealfiller is easy to use off the shelf, not too expensive,and fairly long-lasting with no side effects.

Miles H. Graivier, MD: Most people wantsomething that lasts 10 months to two years. Forme, the ideal filler would be easy to handle andeasy to inject, with minimal potential side effects— one that allows patients to leave the office witha change in their appearance.

Rhoda S. Narins, MD: I like something you cankeep at room temperature, has a syringe designthat makes it easy for me to inject, and lasts ninemonths to a year.

How does the mechanism of action differ betweentemporary and permanent fillers?

Dr. Nicolau: The right question should be, whatis the difference in action between a volumizer(volume filler) and a stimulator? A volumizer isneutral in the human body, doesn’t create a foreignbody reaction, and stays as a bulk. Examples arecollagens, hyaluronic acid, silicone, and certainpolyacrylamide gels (PAAGs). The other fillers,including polymethylmethacrylate (PMMA)microspheres, poly-L-lactic acid (PLA), dextrans,calcium hydroxylapatite, and hydroxyethyl-methacrylate (HEMA), are stimulators thatpromote a foreign body reaction to create newcollagen and new tissue.

Dr. Graivier: Hyaluronic acid fillers (Restylane)bind water and form a gel; as you lose volume, thebond becomes stronger. The fillers maintain anaugmentation effect only while the gel is present.Particulate products with microspheres (Radiesseand ArteFill) have a gel or collagen carrier that isdissipated and replaced by the patient’s own con-nective tissue; the microspheres form a scaffold forthe patient’s own tissue ingrowth. Poly-L-lacticacid (Sculptra) microspheres work differently.They are a volumizing agent that also stimulatesthe patient’s own collagen production.

Clinical Roundtable Discussion

Editor’s Note: The following Clinical Roundtable discussion was moderated by Jean D. Carruthers, MD,FRCS, who has extensive experience in the research and use of dermal fillers. Dr. J. Carruthers and hercolleagues share their expert knowledge and experience with several types of long-lasting dermal fillers.


Alastair Carruthers, MD: With most temporaryfillers, the correction you get will go away over aperiod of time. Permanent fillers typically inducefibroplasia, the laying down of collagen around thefiller. These fillers have a “period of disappoint-ment”; you start off with the initial result with someswelling, the swelling goes away, the carrier goesaway, and then you get your own collagen as fibro-plasia kicks in. It’s very important to warn patientsof this period of disappointment. Otherwise, theyexpect that what they see in the mirror before theywalk out will be permanent, which it’s not.

Why does a PMMA injectable filler providea long-lasting result?

Kevin Smith, MD: Some of the correction iscreated by the PMMA bulk itself. About 20% of theinjected volume is PMMA and the rest is liquidcollagen. The liquid collagen is not cross-linked soit doesn’t hang around long. And because the

N- and C-terminal ends have been clipped off, thecollagen is not very allergenic. (When the immunesystem attacks collagen, it recognizes the C-termi-nal and the N-terminal ends.) The body gets rid ofthe liquid collagen fast, then reacts to the PMMAparticles by producing its own natural collagenand this provides additional correction.

Dr. Rubin: It’s well-documented that once injected,PMMA remains in place and the body doesn’tdestroy it. The collagen response to the injectiongives a significant amount of the permanent volume.

John H. Joseph, MD: PMMA has been used inthe body since the 1930s, so we know the body isunable to dissolve it. It’s both a passive and anactive filler. As a microsphere is injected underthe dermis, PMMA stimulates the skin to makecollagen, elastin, and fibroblasts.

PMMA filler 3 weeks after implantation. Natural collagen begins toform and is continuously remodeled.

PMMA filler 3 months after implantation. Ingrowth of vessels isobvious and collagen encapsulates each single microsphere.

Ph

otos

cou

rtes

y of

Got

tfri

ed L

empe

rle,

MD


What are the advantages of using a bovine collagencarrier gel for a particulate filler?

Dr. Nicolau: Bovine collagen is fairly viscous so itprevents the clustering of microparticles. It alsoprevents their displacement.

Dr. A. Carruthers: You don’t want the particles tosettle in the carrier, so collagen helps to hold themapart. In other words, you don’t have to shake itbecause the particles have settled to the bottom ofthe syringe. It’s very easy to inject.

Dr. Rubin: It’s a material that everybody’s used tousing. We are comfortable with its flow character-istics and behavior. The other benefit is that it’sslowly degradable. With some products that cameout with beads and gel bases, they found that ifthe base dissolves too rapidly, the beads clumptogether. You need something that takes severalmonths to degrade to decrease clumping.

Dr. Smith: Other carriers such as hyaluronic acidhave been tried, but the electrical properties of col-lagen help to maintain the product in dispersion.

Dr. Graivier: Once approved by the FDA, ArteFillwill be the only filler on the U.S. market with a col-lagen carrier. Dr. Gottfried Lemperle found thatthe collagen carrier in ArteFill is different from thecollagen in Zyderm and Zyplast which is 90%native. Zyderm and Zyplast last three to sixmonths, but the collagen carrier in ArteFill lastsonly a few weeks. Dr. Lemperle chose that particu-lar collagen because it kept the microspheresseparated better than the other gel carriers and itis fairly hypoallergenic.

In your experience, do all bovine collagenproducts have the same allergenicity?

Dr. Graivier: No, because the composition of thecollagen in ArteFill is different, the likelihood ofthis collagen stimulating an allergic reactionshould be lower.

Dr. A. Carruthers: No. My experience withArtecoll is that it’s less likely to produce a positiveskin test than Zyderm. I had two individuals whowere skin-test positive to Artecoll and were alsopositive to Zyderm.

Dr. Narins: No. The collagen in Artecoll has muchlower allergenicity than the collagen in Zydermand Zyplast.

Dr. Lowe: They have varied allergenicity, but ifyou are allergic to bovine collagen you must beskin tested before you have another one injected.When you are starting off with any animalcollagen product, it’s very important to “double-skin-test” before the first injection of filler. Youhave to remember that with the first injection, youmay see no problem at the forearm, but that’s thesensitizing injection so you don’t actually see thereaction until the second injection. If the secondinjection is in the face, you’ve got trouble.

What is the difference between dislocation andmigration of fillers?

Dr. Nicolau: Dislocation is a mechanical phenome-non; weight or muscular action may move theimplant from where it was placed. For instance, inthe lips (which are always moving), particulateimplants may move along the white line. Fillers inthe breast may move because they’re too heavy.

Temporary allergic reaction 6 weeks after a hyaluronic acid filler.May be treated by a physician with intralesional corticosteroid.

Ph

oto

cou

rtes

y of

Nic

hol

as J

.Low

e,M

D,F

RC

P,F

AC

P


Migration is a physiologic phenomenon by which thefiller is carried away by macrophages or other cells.

Dr. Cohen: Dislocation implies that somethinghas been moved from its primary site by physicalmeans, but migration implies that a material isable to get into a lymphatic or blood vessel and betransported elsewhere.

Dr. Smith: Dislocation might happen after youinject the filler. The filler can be nicely distributedabout the lips, and then the patient gets home andtries to reshape the lips by massaging and rubbingthem. But she can wind up moving the filler, likesqueezing the toothpaste inside a tube.

Dr. Joseph: Often, if fillers end up where youdidn’t want them it’s because you didn’t put it inthe right place to begin with. Most doctors don’twant to say that, but technically they didn’t putthe filler where it was supposed to be. I don’t thinkI’ve ever seen migration.

Are you concerned about dislocation or migrationwith these fillers?

Dr. Nicolau: The product I use the most isArtecoll, strictly a permanent filler. Dislocationhas been reported with the polyacrylamide gels,but in my experience there are no migration ordislocation problems with Artecoll.

Dr. A. Carruthers: For permanent fillers, I havenever seen movement of properly injected micro-droplets of silicone oil. On the other hand, ArteFill(or Artecoll) is typically injected outside the mus-cle of the lip and seems to get pushed through andshows up on the mucosal surface. That’s presum-ably due to the action of the orbicularis oris.

Dr. Cohen: The specific material in ArteFill hasbeen studied very extensively in animals. The par-ticles are not prone to migration because they arenot able to be phagocytized.

Dr. Friedland: I have had no problems withcollagen and hyaluronic acid.

Dr. Smith: Dislocation of the implant is always anissue, especially if the patient is manipulating thefiller afterward. The important thing is to tell thepatient not to manipulate the filler.

Which technique do you use to inject fillers intonasolabial folds, glabellar frown lines, andmarionette lines?

Dr. Graivier: The hyaluronic acid fillers(Restylane, Captique, and Hylaform) are good forthe mid to deep dermis. For fine lines, I injectHylaform Fine Line with a 30-gauge needle anduse a serial puncture technique. For the nasolabialfolds, marionette lines, and corner of the mouth,ArteFill will be a nice product and give permanentaugmentation. For that I will use a 26- or 27-gaugeneedle with a linear threading technique when Ineed to be very precise.

Dr. Cohen: For the nasolabial folds I use a thread-ing technique and with something like ArteFill,you have to be in the dermal-subdermal junction.For other ones such as Restylane, you occasionallywant to be more superficial in the fine wrinkles.For the marionette lines you might use a combina-tion of threading and a cross-hatching techniqueor radial fanning.

Dr. A. Carruthers: With ArteFill, the techniqueis very specific. You move the tip of the needlebackward and forward, change the angle slightly,and lay microstrands in place to gently augment.It’s always better to undercorrect and come back.With Artecoll, I always plan on at least two, some-times three or four injection sessions. You can put atemporary filler over the top and then as the tem-porary filler goes away, you can add more Artecoll.

18

Dr. Smith: The main thing is controlling pain andbruising. I’ve learned to use ice or ice plus vibra-tion. We ice the intended injection point and thesurrounding tissue for five or 10 seconds. Theassistant usually holds the ice cube within a cen-timeter or two of the injection site. Patients areamazed. This technique has revolutionized myapproach to fillers because I haven’t had to use aninjectable or topical anesthetic since August 2005.

Dr. Joseph: Artecoll had initial problems becauseof poor injection technique. It was injected into thepapillary dermis, which you never should do. Thematerial itself wasn’t as refined as ArteFill is goingto be, so they had some problems with granulomasand inflammation from too superficial placement.

Which injection technique do you use for lipenhancement?

Dr. A. Carruthers: I use a similar technique,bearing in mind that the FDA panel recommendedthat lips were a contraindication to the use ofArteFill. I would caution people against usingArteFill in the lips until they cultivate sufficientexpertise in its use in other areas.

Dr. Nicolau: I do it the way I would for any kindof microsphere implant, including ArteFill. It isvery important to prevent lip muscular move-ments, so right after the injection I use smallamounts of botulinum toxin to weaken the lips fora few weeks. That way, patients won’t move theirlips much, which prevents dislocation.

Dr. Rubin: Lip border enhancement calls for aserial puncture technique. The (filler) materialflows on its own down the tunnel. So even thoughthe technique is not linear threading, it produces asimilar effect. And in the meat or vermillion of thelip, I use serial puncture and then a lot of aggres-sive massaging in the lip, particularly when Iinject hyaluronic acid.

Dr. Graivier: I’ve done a lot of lip augmenta-tions with Radiesse and I still have a 12% rate ofnodule formation. I usually use Restylane orCaptique because patients want to see how theylike their augmented lip, especially when theyare having their lip augmented for the firsttime. I don’t recommend lip augmentation withRadiesse unless you are very experienced andcomfortable treating the nodules that can resultin 12% of patients. The edge of the lip, or thewhite roll, and philtrum column are nice areas forthe longer-lasting or possibly even the permanent

Injection too deep. Injection too superficial. Correct plane for injection. (Lifted needledemonstrates the thickness of the dermis).

Nasolabial folds and radial liplines 4 years after Artecoll(PMMA) injection.

Before Treatment.

Review of Long-Lasting Dermal Fillers www.miinews.com


products, because it doesn’t take a large volumeof material. I do a nice linear threading techniqueprecisely under the white roll and mold it withmy fingers.

What is the potential outcome when injectionsare too superficial?

Dr. Cohen: If they’re too superficial, you can getridges or bumps.

Dr. Narins: It depends on the filler substance. Ifyou inject Restylane too superficially, you can get abluish color. If you inject Sculptra too superficially,you can get bumps that are impossible to get rid of.With Silicone or ArteFill you can get bumps aswell. You want to go into the deep dermis withArtefill, but it’s probably okay to inject into theupper dermis.

Dr. A. Carruthers: Too superficial typicallymeans the injection is in the mid-dermis, inducingfibroplasia. You end up with a little bump that isoften a little red. Histologically it may appear tobe a granuloma. But when we’re talking aboutArtecoll, the granulomas have a very specific clini-cal appearance. They are the result of an abnormalreaction to the filler material rather than a natu-ral reaction to a foreign body.

Dr. Nicolau: With a permanent implant theremay be palpability, and then nodular formation.There is also a risk of infection from contact withsuperficial bacteria through the hair follicle orsweat glands.

Dr. Friedland: If it’s too superficial, you may seeit. If the filler has PMMA you may get a granuloma.I’ve never seen a granuloma from collagen orhyaluronic acid in all the years I’ve been doing this.

What corrective measures should be used wheninjections are too superficial?

Dr. Smith: You should be able to identify mistakesimmediately, and then massage the product downinto the deeper tissues right away. You can useyour thumbnail.

Dr. Rubin: With some fillers you can just nick thespot with the tip of a needle and express the inject-ed material out. With hyaluronic acid gels you caninject hyaluronase to dissolve the hyaluronic acid.

Dr. Narins: It’s very difficult to treat Sculptranodules. Sometimes you have to physically removethem. Artecoll nodules are easy to treat with injec-tions of cortical steroid. It’s easy to get rid ofRestylane by injecting Vitrase (hyaluronidase).

Dr. Graivier: In longer-lasting and semi-perma-nent products, you can start with a conservativesteroid injection (Kenalog 10%, 0.1 mL) and askthe patient to return in a month for a repeat injec-tion if necessary. If the problem is very superficial,dermabrasion will dissipate the product.

Dr. Cohen: The best measure is to avoid beingtoo superficial with permanent fillers. They aremore technique-sensitive than a temporary fillerwhere if it doesn’t work out, the filler is gone in afew months. With permanent fillers, technique hasto be much better.

What is the potential outcome when injectionsare too deep?

Dr. Smith: Disappointment. If you go too deep,you’re just wasting product because you’re notgoing to get much correction. You just need to adda lot more product if you put it in too deep. I justapologize to the patient and do it again for free. Bydisciplining myself that way, I tend not to makethat mistake very often.


Dr. A. Carruthers: Mainly, lack of efficacy. Theidea is that if you inject just under the dermis,then you will get correction relatively easily. If youinject a bit further away from the dermis, the lift-ing effect is transmitted over a wider area so youdon’t get as much lifting specifically where youwant it, but you’re still getting exactly the samevolume correction as you were going to get anyway,just that it’s a little bit deeper.

Dr. Narins: With some substances such ascollagen (not the new collagen Evolence fromColbar), if the injection is too deep, it just disap-pears. With hyaluronic acid, Sculptra, fat, andArteFill, there is no such thing as too deep interms of serious problems.

Dr. J. Carruthers Commentary: The aestheticbenefit the patient achieves with temporary fillersis 90% technique and 10% substance. With perma-nent fillers, it’s 99% technique. The more permanentthe filler is, the more important the technique is.

Have you seen complications with these productsin your patients?

Dr. Graivier: It’s important to avoid over-correc-tion and to bring the patient back in four to sixweeks for follow-up, then add more filler if neces-sary. It’s always easier to add than to remove. Themain complication early on is formation of nod-ules or firmness and clumping, especially withsemi-permanent and permanent fillers. If youinject Sculptra and get clumping very early in thefirst week, you can try to break up the area by

hydrodissection. With Radiesse and ArteFill, Iwould treat early nodules with aggressive massageand a conservative Kenalog injection.

Dr. Joseph: Skin slough, lumps, granuloma, andinflammation.

Dr. Friedland: I was one of either the first or sec-ond group to use collagen and I have seen a fewreactions to bovine collagen. Some last a year ormore. I’ve never seen a reaction to human collagen.

Dr. Narins: When done correctly, you see very fewproblems. I have seen other people’s complications,because I am very careful and also that’s what I domost of the time. I have seen lumps from fat thatare very easy to treat, and nodules from overlysuperficial injections of Scupltra that are very dif-ficult to treat. In Canada I’ve melted away Artecollgranulomas with intralesional cortisone.

Dr. Nicolau: I’ve had one nodule that I had toremove surgically from a wrinkle on the lower lip.I injected a little too much filler. It was very easyto fix.

Dr. Rubin: In the early stages of using any newfiller there’s a learning curve. Some people weinjected too deeply and some too superficially. Allresolved on their own. I’ve seen small percentagesof allergic reactions, but they’ve been uncommonwith all the fillers we’ve used.

What is a granuloma?

Dr. Graivier: A granuloma, by definition, is ahyperinflammatory reaction that occurs in everyarea that the product was injected at a perioddistant from when the initial injection was per-formed. This is distinct from a nodule. A nodule isearlier clumping of the product and not an inflam-matory reaction. Treatment of a nodule is differentfrom treatment of a granuloma. Every injectableproduct has documentation of late granulomas.

Correct plane and depth for injection of long-lasting dermal fillers.


Dr. Lowe: A chronic inflammatory reaction withinthe skin. It has a mixture of chronic inflammatorycells, often surrounding a foreign body (i.e., the filler).

Dr. A. Carruthers: A granuloma has a specifichistological appearance. With permanent fillers,granulomas are related to the size and nature ofthe material injected. Small particles are more like-ly to be ingested by macrophages and to producethis kind of a reaction. There do seem to be otherfactors involved, one of which may be foci of infec-tion elsewhere in the body, such as chronic dentaldisease, although that’s not as well established.

Dr. Nicolau: A foreign body reaction is a normalreaction; a granuloma is an overreaction. Thesheer injection of anything will induce a foreignbody reaction. Any product, including collagen,hyaluronic acid, and so on can induce a granulomaor inflammatory reaction.

Dr. Friedland: In essence it is the result of aninjected substance setting up an antigen-antibodyreaction. We call it a granuloma because it has agranular kind of a texture. It usually appearswhere the material was injected.

Dr. Smith: It’s very rare to have a true granuloma.Nodules are most often technique-dependent andare not granulomas. Particularly with Artecoll, thecommon mistake that doctors make is being tooambitious; they inject too much filler in one visit orthe visits were too close together. If you do that,sometimes you can feel it under the skin, and it’sjust excess fullness and not a granuloma or nodule.

Dr. Joseph: Most people will never form a granu-loma to bovine collagen, but I’ve seen probably fiveof them. Why one person’s body reacts and anoth-er’s doesn’t, you never know.

Dr. J. Carruthers Commentary: Complications,including granulomas, can occur with any filler—not just permanent fillers. In a study of anunselected sequential group of patients with

granulomas, Alastair and I found that with conser-vative management, all the granulomas resolvedwithin two years. The practice management prob-lem is that patients with granulomas tend tooscillate from doctor to doctor, so it is difficult for asingle physician to obtain long-term experience. Tomy knowledge, ours is the only recent long-termevaluation of a cohort of patients with granulomas.We have thus found that permanent fillers cancause transient problems, but not necessarily per-manent problems.

How do you recommend treating granulomas?

Dr. Graivier: The main thing is not to excise agranuloma. Treatment has to be very aggressiveby using both injectable steroids and oral steroids,and sometimes a mixture of 5-fluorouracil (5-FU)and triamcinolone. You can even resort tomethotrexate if the granuloma does not respond toanything else.

Dr. A. Carruthers: I inject triamcinolone ace-tonide in amounts sufficient to suppress thelumpiness. It is important to avoid injecting toomuch and producing steroid atrophy.

Dr. Smith: Most likely I’d inject Kenalog with aBecton-Dickinson 31-gauge diabetic needle. Welike Kenalog because it’s a medium-potency, anti-inflammatory steroid with a sustained effect.

Lips with granuloma 3 yearsafter Artecoll Injection.

Same patient 1 year later. Granulomaresolved from triamcinolone injections.

Ph

otos

cou

rtes

y of

Ala

stai

r C

arru

ther

s,M

D,F

RC

P


You can use this with areas of excess fullness too.Just don’t put in too much and don’t inject high-strength steroid. With 10 or 40 mg/mL you will gofrom a bump to a depression. The 3 mg/mLstrength does a nice job. It’s better to treat lightlytwo or three times than to try to blow them awayin one shot.

Dr. Lowe: I use intralesional dexamethasone ortriamcinolone, or NSAIDs. I will also use long-termantibiotics (tetracyclines).

Dr. Nicolau: It depends on the kind of filler.Granulomas are not treated in the same wayaccording to the injected product. Some need corti-coid, some need in situ-injected corticoid, and someneed an antimitotic drug (5-FU).

What does the future hold for permanent fillers?

Dr. Rubin: It’s certainly exciting. The main issuewill be the degree of patient acceptance. A lot ofpatient satisfaction or dissatisfaction will comefrom injection technique. If we have access to FDA-approved permanent fillers, it’s going to beimportant that everybody learns how to injectthem because these fillers are not so forgiving.

Dr. Smith: The next frontier will be volumizers,which can do things you don’t do with a focal filler.A classic one would be Sculptra. It just adds

volume diffusely and that will be particularlyuseful in old people for rejuvenating the dorsa ofthe hands. Sculptra also improves the handsfunctionally by making the skin a little thickerand acting like a little bit of padding so people areless likely to injure their hands. Also rejuvena-tion of the neck.

Dr. Friedland: If we can come up with a perma-nent filler that causes no reaction, is easy to put in,stays where it’s put, has a reasonable cost, has rea-sonable or no discomfort, and would be like bodytissue, that’s the future. Its use can be purely cos-metic or in reconstruction; these two applicationsgo hand-in-hand.

Dr. Graivier: Permanent fillers would be good inthick spots with fixation of skin and dermis downto the bone and muscle, such as the nasolabialfolds. These areas only deepen with age.Marionette lines and prejowl areas will also begood for a permanent filler. The nose (with scarsfrom skin cancers, depressions, post-rhinoplasticproblems) and scars with thick, rigid attachmentsites are also good sites for permanent fillers. Forsoft tissue contouring such as cheek augmenta-tion, or chin augmentation, I lean toward an agentin the semi-permanent range (1-5 years) becausethis soft tissue falls and changes with age.

Neck lines of 45 year old woman before treatment.

Neck lines after Hyaluronic Acid filler(Restylane) injections.

Ph

otos

cou

rtes

y of

Kev

in C

.Sm

ith

,MD

,FR

CP

C

NewFill Granuloma. Granuloma resolved afterKenalog injection.

Ph

otos

cou

rtes

y of

Nel

ly G

auth

ier,

MD


Dr. Cohen: From a patient care perspective, thequest for permanent or semi-permanent fillers isto provide patients with something that hasmarkedly longer duration. And that is the reasonArteFill was designed, to have an enduring, effec-tive, and safe outcome, because that’s whatpatients have asked for. Temporary fillers are veryuseful, and there are many patients, in whom Ithink a temporary filler may be better to use untilthe patient has a sense of how they like the effectof the filler. Ultimately, the best permanent fillerwould be something from an autogenous sourcethat would be long-lasting. Perhaps the addition ofstem cells or some type of factor that could stimu-late angiogenesis and permit the body’s own cells(whether fat or other type) to survive, will one daycome into play. For now, the quest continues.

Dr. Joseph: Pricing will be important. I’ll try any-thing if it’s FDA approved, but if it comes in at$1,000/mL people are going to say “forget it.” Ithink the consumer has been tapped out as far asthe money they spend on fillers; they are not will-ing to pay the price every time a novel filler comesout. Even a revolutionary product like Sculptra isfairly expensive, and Radiesse, when it came out,was way too expensive. Companies may shootthemselves in the foot.

Dr. Nicolau: When fillers can be used as theequivalent of a permanent prosthesis, that wouldbe ideal—correction of deep defects like nose defor-mities after surgery or deformities of the eyelid,where you need a deep volume.

Dr. Narins: Eventually someone will distributeSilicone. ArteFill is expected to come on the mar-ket sometime in 2006, and I don’t think anythingelse that’s permanent is close to coming on the U.S.market right now. Physicians should have expert-ise in using all these fillers because one or acombination of them may be better suited, depend-ing on the patient and situation. Skill is muchmore important with permanent products becausethe other products disappear.

Dr. J. Carruthers Commentary: The idea of apermanent filler is a highly alluring concept to thegeneral public. Some individuals, however, assumethat when the filler is injected, the effect is perma-nent and will somehow halt the aging process.Unfortunately the injected filler does not do this. Itdoes give a more permanent fill, but if the facialskin thins and sags a little because of the loss ofcollagen and elastin (as a natural part of aging),the aesthetic effect initially given by the filler maychange over time. Further treatments may berequired in subsequent months and years (as agingoccurs) to maintain the initial aesthetic benefits.

10 year PMMA histology.Pre-treatment. 1 year after PMMA(Artecoll) injection.

5 years after PMMA(Artecoll) injection.

Ph

otos

cou

rtes

y of

Ste

ven

Coh

en,M

D

Ph

otos

cou

rtes

y of

Got

tfri

ed L

empe

rle,

MD


CME Test Assessment

1. What classifies a dermal filler as a volumizer?

a. it causes a strong foreign body reactionb. it always contains collagenc. it causes little foreign body reactiond. it always contains microspheres

2. What classifies a dermal filler as a stimulator?

a. it stimulates tissue ingrowth through aforeign body reaction

b. it always contains a cellulose or bovinecollagen carrier gel

c. it always contains microspheresd. all of the above

3. What is dislocation?

a. movement of filler by macrophagesb. mechanical movement of filler materialc. dissipation of filler through dermisd. a chemical reaction

4. What is migration?

a. movement of filler by manipulationb. only related to silicone fillersc. mechanical movement of filler materiald. movement of filler by macrophages

5. Which of the following is trueabout bovine collagen?

a. it prevents clustering of microparticlesb. allergenicity rates vary by productc. skin testing is requiredd. all of the above

6. What is a possible result from an injectionthat is too superficial?

a. can cause granulomasb. allergic reactionc. can cause ridges or bumpsd. painful for patient

7. What is a possible result from an injectionthat is too deep?

a. always causes lumpsb. lack of efficacyc. causes bluish discolorationd. it will migrate

8. What is the correct dermal plane forlong-lasting fillers ?

a. the epidermal-dermal junctionb. the papillary dermisc. the dermal-subdermal junctiond. the subcutaneous fat

9. What is a granuloma?

a. clumping of the fillerb. same thing as a nodulec. reaction caused only by hyaluronic acidd. a late, chronic inflammatory reaction of all

injected sites

10. What is the primary treatment optionfor granulomas?

a. surgical excisionb. treatment with steroid creamsc. injection of intralesional corticosteroidsd. observation


Review of Long-Lasting Dermal Fillers

CME Registrat ion

Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

City________________________________________________________ State / Zip _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Phone ________________________________________________________________________ Fax _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

E-Mail_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Specialty __________________________________________________ Degree _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

CME Test Assessment Answer Sheet

1. a b c d

2. a b c d

3. a b c d

4. a b c d

5. a b c d

6. a b c d

7. a b c d

8. a b c d

9. a b c d

10. a b c d

Please complete the post-test by circling the correct answer on the answer sheet. You must achievea score of 70% or greater in order to have demonstrated understanding of the content.

To receive CME credit for the completion of this activity, mail or fax the completed Registration, Post Test,

and Evaluation Forms located at the back of this publication to: Ciné-Med, Inc., CME Department, 127 Main

Street North, Woodbury, CT 06798, Fax: 203-263-4839. A certificate will be sent via regular mail.


Review of Long-Lasting Dermal Fillers

Please rate each question on a scale of 5 to 1, with 5 being the highest and 1 being the lowest.

1. Objectives: To what extent were the objectives achieved? Excellent Poor

A. Identify the mechanism of action for CaHA, LIS,PLA & PMMA dermal fillers (volumizer vs. stimulator). 5 4 3 2 1

B. Identify the difference between dislocation and migration 5 4 3 2 1of filler material.

C. Identify the characteristics of bovine collagen. 5 4 3 2 1

D. Identify the outcomes for various injection planes. 5 4 3 2 1

E. Define granulomas and their primary treatment option. 5 4 3 2 1

2. Content: To what extent did the program: Excellent Poor

A. Increase your knowledge of the topic. 5 4 3 2 1

B. Present clear and organized content. 5 4 3 2 1

C. Meet your personal / educational objectives. 5 4 3 2 1

D. Help to improve patient care. 5 4 3 2 1

E. Cause you to make changes in your practice. 5 4 3 2 1

If you felt the content was not free of commercial bias, please explain: ___________________________

__________________________________________________________________________________________________

3. Overall Activity: 5 4 3 2 1

4. How long did it take you to complete this program? ________

Are there any educational topics that are not being sufficiently addressed?

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

To receive CME credit, please mail or fax completed registration, post-test, and evaluation forms to:Cine-Med, Inc., CME Department, 127 Main Street North, Woodbury, CT 06798 Fax: 203-263-4839

Evaluat ion

PRESORT STD

U.S. POSTAGE PAID

PERMIT NO. 1269

LONG BEACH, CA

review of long-lasting dermal fillers - atsh.co.ir gold artesense/dermal... · review of...

Documents