10 Oct Which dermal filler should you choose for your patients?
There are so many dermal fillers on the market now and most have unique advantages, so you are missing out if you do not offer a wide variety in your dermatology practice. However, with so many fillers, it can be expensive to maintain inventory for all of them. Here is a basic guide of which fillers to choose for your practice.
What Type of Patients Do You See in Your Practice?
If your patient population is mostly adolescents with acne, then offering an injectable treatment for acne scars is a great addition (Journal of the American Academy of Dermatology). Bellafill is a collagen-based injectable that is FDA-approved for the treatment of acne scars. I did the research trials that led to approval for acne scar treatment, and people were thrilled with the results. This injectable provides a long-lasting solution–up to five years–for acne scars. It delivers instant results as well as continued improvement over time. This filler usually is injected once a month for 2 to 3 months. After each injection, the patient may experience swelling and bruising. It works by filling the space with collagen, but also by stimulating the skin cells to make more collagen to fill in the depression. The scars may actually look worse for a few weeks until the swelling subsides. In my practice, I wait four weeks after each treatment to give the skin time to make collagen to fill in the scars. This treatment works best on rolling and boxcar acne scars and does not work well on ice pick scars. This treatment is not reversible. I have found that the best candidates are those who no longer have acne but have acne scars, chicken pox scars, or depressed surgical scars. It is advisable to wait at least six months after isotretinoin therapy before using this product, because isotretinoin can affect the production of collagen which is an important part of this procedure’s mechanism of action. This can be combined with microneedling procedures.
If you see predominantly male patients, fillers offer a great aesthetic option for ages 20 to 100. The oldest male patient I’ve injected was 95 years old, and he had great results! More and more men are seeking cosmetic procedures. Men often benefit from facial fillers in the chin, and jaw are to give them a more rugged chiseled look. They often have fat loss in the mid face that gives them a gaunt aged look that is easily corrected with a dermal filler. I only use HA fillers to shape the angles of a man’s face and give volume in the cheeks. HA fillers feel soft, are reversible and give a natural look. I find that many men who want to retain their crow’s feet and forehead movement prefer dermal fillers over botulinum toxins to treat these areas.
In addition, patients who are actors prefer HA fillers over toxins because they retain their normal movement and facial expressions. Actors like HA fillers because they are reversible and can temporarily change their look for a film. For example, injecting HA fillers in the chin and jawline area will give male actors stronger facial contours and angles which has been shown in studies to increase perceptions of facial attractiveness (Nature). I prefer Voluma or Restylane Lyft injections for the chin and jaw areas, and Volbella for the fine lines on the forehead and crow’s feet. Since men cannot cover with makeup, they are much more averse to downtime, so use of Arnica and avoidance of ibuprofen, aspirin and omega 3 fatty acids 10 days prior to injections is important. I give my patient a list of things to be avoided prior to the appointment to lower their bruising risk.
If you see younger women, ages 20 to 30, you should definitely have a lip filler to your armamentarium. Fillers can be used to define the vermillion border of the lip, add volume to the body of the lip, or change the shape of the lip. My favorite lip fillers are Restylane Silk, Volbella, and Belotero. This image shows a variety of lip shapes that you can give your patients using HA fillers.
If your client base is composed of middle-aged women, ages 40 to 50, you will most likely be treating nasolabial folds, marionette lines, and under the eyes. I prefer Restylane and Juvéderm Ultra for these indications. Radiesse is also an option, but it is not an HA filler and is therefore not reversible. When you are learning to inject fillers, you must use a reversible product such as an HA filler until you perfect your skills. I have been doing fillers for over 20 years and I still prefer to use HA fillers because it gives me the flexibility to try fillers to enhance various facial features without the fear of long-term repercussions.
If you treat a lot of very athletic patients, especially runners, or vegetarians and vegans, who tend to have less facial fat, using a larger volume filler is the best option. I prefer Voluma for large areas such as the cheeks, chin, and temples in people with very thin faces such as marathon runners. Restylane Lyft can be used to pull back sagging skin and add volume in people who are not a candidate for skin tightening procedures such as Ulthera. Fillers can also be added after skin tightening procedures when both tightening and volume are needed.
If your practice has patients aged 50+, you will likely want to use a combination of three types of fillers: a thin formula, one with medium thickness, and a thick option. I will discuss the way to choose between these in the next section. Because I am a big believer in HA fillers for beginning injectors, I feel that you should choose from those. I am not going to discuss Belotero because it is not as multipurpose as other HA fillers, so it does not make sense to offer it if you are trying to keep your inventory down.
Types of Hyaluronic Acid (HA) Fillers
Hyaluronic acid is a naturally-occurring sugar found in the skin that helps attract water. It is broken down by aging and processes that occur naturally within the skin, and has a positive long-term effect on the skin by coaxing skin cells to produce youthful substances such as collagen and more HA. HA injections in the skin may help prevent some of the signs of skin aging by promoting the production of these substances. Injectable HA can be broken down with an injection of hyaluronidase, a naturally-occurring enzyme. Therefore, the results are completely reversible, making this my favorite type of dermal filler.
These are the two main brand companies (in alphabetical order, not personal preference). Each offers the three most important types of fillers you need to build your injectable practice.
1. Allergan (the maker of Botox and Juvéderm products): Juvéderm products are softer and more moldable than most of the other fillers. They are ideal for adding volume to various areas of the face. Juvéderm products are available in three “particle sizes” that are chosen based on the area to be treated.
- Volbella is the newest of the dermal fillers. It is ideal for subtly plumping the lips and filling in fine lines. Results last for up to a year.
- Juvéderm Ultra or Ultra Plus are ideal for the nasolabial folds, which are the parentheses lines between the nose and the mouth, and the marionette lines, which are the lines from the corner of the mouth down to the sides of the chin. Results last for up to a year. I prefer Juvéderm Ultra because the needle used to inject is smaller.
- Voluma is used to add soft, natural-looking volume to the midface. Results last for up to two years.
2. Galderma (the maker of Dysport botulinum toxin and Restylane products): Restylane products are stiffer and more cohesive than most of the other fillers. They are ideal for providing structural support to the face. Restylane products are divided into three “particle sizes” and are chosen based on the area to be treated.
- Restylane Silk is ideal for enhancing the outline of the lips, filling in fine lines around the mouth and augmenting lip volume. Results last for about nine months.
- The original Restylane is ideal for nasolabial folds and the marionette lines. Results last from nine to 12 months.
- Restylane Lyft is used to pull back sagging facial skin, add volume to the midface, and to define the chin and jawline. It is a great product for giving men a more defined or chiseled jaw. Results last from 12 to 18 months.
A Concluding Note
My suggestion is to analyze your patient population and pick one or two fillers at first. The medium-thickness fillers like Restylane and Juvéderm Ultra are the most versatile, so start with one of those. Stay tuned for more ideas on how to use injectables in your practice. Skin Type Solutions Franchise Systems can educate you and your staff about the various fillers and how to incorporate them into your practice. Visit STSFranchise.com for information about applying to be one of our Physician Partners.
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Based on Dr. Baumann’s patent-pending Baumann Skin Typing System, this first-of-its-kind retail model provides dermatologists with the scientific methodology, training, and education necessary to prescribe effective, customized skincare regimens utilizing multiple brands of products that have been independently tested and approved by Dr. Baumann. To learn more about what Skin Type Solutions can do for your dermatology practice, visit the STS site here.