Creative combinations, techniques expand filler possibilities

Las Vegas - As filler options expand and dermatologists' skill with them improves, creative combinations and injection techniques can optimize soft tissue augmentation results.

This is according to Joel L. Cohen, M.D., speaking at the American Society of Cosmetic Dermatology and Aesthetic Surgery (ASCDAS)5^th Annual Meeting and Exhibition, here.

Dr. Cohen is a clinical assistant professor of dermatology at the University of Colorado and director of AboutSkin Dermatology and DermSurgery in metropolitan Denver.

The lower cross-linking improves biocompatibility, allowing for a longer tissue residence time, he tells Dermatology Times. Dermatologists can boost Restylane's results in some areas of the face, however, with techniques such as combining the treatment with Botox (Allergan). He cited research from Alastair Carruthers, M.D., indicating that Restylane, in fact, lasted up to 44 percent longer in the glabella when combined with Botox, with an average longevity of 18 weeks on its own and 32 weeks in combination with Botox.

The filler combination with Botox can also be ideal for areas such as oral commissures, and Dr. Cohen described a case in which fillers were used first and the lips massaged. Then, on the same visit, Botox was used in the depressor anguli oris muscle in order to turn a downward-turning "horseshoe" smile to a more horizontal, neutral smile.

In addition to the glabella and oral commissure, the combination of toxin and filler in some cases can be helpful for etched-in horizontal forehead lines, evolving vertical lip lines or prominent nasolabial folds with a bit of a "gummy" smile, Dr. Cohen says.

Right filler, right location

Choosing the right filler for the right location is another issue.

Whereas Restylane can be ideal for many areas such as nasolabial folds, one issue that might suggest an alternative filler is the possibility of swelling that can occur when used in the lips, and studies have, in fact, shown more swelling with Restylane than with the bovine collagen-based filler Zyplast (Inamed).

The swelling problem may lead some to instead choose other hyaluronic acid or collagen fillers, and Dr. Cohen shows an example of one case in which he combined Restylane in the nasolabial folds and the human collagen-based filler CosmoDerm (Inamed) for the upper lip line.

Among collagen fillers, CosmoDerm and CosmoPlast (Inamed) have become desirable choices for many dermatologists over bovine collagens Zyderm (Inamed) and Zyplast because these human fillers do not require skin tests, whereas the longevity is the same.

"CosmoDerm has replaced Zyderm for me," Dr. Cohen says. "Patients don't want to have a skin test and it takes up the doctor's time, as well."

In the pipeline

New products in the pipeline, such as Restylane Fine Line, Hylaform Fine Line and several Juvederm (Inamed) products, will add more versatility to fillers, but until they arrive, Dr. Cohen suggests alternatives such as using a 32-gauge needle to fill in etched-in lines in the nasolabial folds and vertical lip lines.

"If you have a Restylane syringe and have a little left over, for instance, you're not committed to that 30-gauge needle that comes with the package," he says. "You can pop on a 32-gauge needle and try to tuck that into some very fine lines."

Cautionary measures should be taken with all filler use, however, and Dr. Cohen advises keeping current on news of adverse cases. He indicates that there have been reports of necrosis in the glabella with various fillers, and explains that this is due to either placement of too much filler exceeding the arterial pressure in the area or frank intravascular injection.