Today's fillers: Carefully consider product choices for patients to achieve 'customized' outcomes

"Today, we have a wonderful armamentarium of fillers that allow us to really target various levels of the skin," he says. "This gives us the option of choosing filler X, Y or Z - or a combination of fillers - to treat a particular condition or defect."

Dr. Pinski, a dermatologist practicing in Chicago and associate clinical professor of dermatology at Northwestern University, gave an update on several state-of-the-art fillers at the American Academy of Dermatology's Academy '05.

For a patient with both fine lines and deep lines, a couple of different fillers may be used - something for superficial lines layered over something deeper, according to Dr. Pinski.

"That allows us as dermatologists, to be just a little more advanced than our surgical colleagues who don't have the background and knowledge of the skin that we do."

Fillers like the old gold standard Zyderm (Inamed) collagen are ideal for shallow wrinkles, fine lines and superficial distensible scars, and they are best used in patients who have gone through initial skin testing. But for people who are being treated for the first time without a skin test, it might not be the filler of choice because of the potential for allergenicity. In place of it, Dr. Pinski suggests using CosmoDerm (Inamed), which is human collagen perpetuated from an embryonic human cell line in a laboratory.

"No skin testing is required and that's a big advantage over Zyderm," he says. "And duration of the materials is virtually the same." In best case scenarios, these fillers will last up to six months.

A new form of Restylane is now being developed and tested. Called Restylane Fine Line (Q-Med Laboratories), the hyaluronic acid will likely join Zyderm and CosmoDerm on the list of superficial fine line fillers sometime next year, according to Dr. Pinski.

Deeper defects

Moving further into the skin where slightly deeper cosmetic defects cause creases, nasolabial folds and smile lines, Zyplast (Inamed) or its analogous counterpart, CosmoPlast (Inamed), work well. The main difference between the two collagen products is that CosmoPlast requires no skin test. Both products contain lidocaine, which helps prevent pain. The downside with these collagens is their longevity.

Newer products like Restylane and Hylaform (Inamed) tend to be of longer duration than collagen. And while no skin testing is needed, these products tend to be a bit more discomforting to the patient.

"I always use topical anesthesia before injecting these materials," Dr. Pinski says. "If a procedure is painful, the patient will be somewhat hesitant to come back for more, no matter how good they look."

Even deeper

Going still deeper into the skin is the last tissue plain, the sub-dermis. Traditionally, the most popular filler substance used here was fat transplants. While Dr. Pinski still uses this product, a newer treatment called Sculptra (Dermik) or poly-L-lactic acid, is worth a look. The advantage is that it is a bit more predictable in its response, but the downside might be the high cost. A vial costing $1,000 might augment a small amount of lipoatrophy of the cheeks, while severe atrophy may require two to three vials.

Another sub-dermal filler augmentation product, similar to Sculptra is Radiance (Bioform Inc.), a synthetic substance made up of calcium hydroxylapatite, or bone crystals. While some claim the filler lasts two to three years, the downside to this product is its potential to cause foreign body reactions for years to come.