Dr. Lisa Cassileth is a Board-certified Beverly Hills plastic surgeon. Her website can be found at www.drcassileth.com. The word "injectables" is generally used to mean two types of plastic surgery products: "fillers" and Botox®. Botox® is described in last season's newsletter. Here, we'll focus on the fillers. They are used to augment lips, improve nasolabial folds, hide small scars, and eradicate wrinkles, and are an exciting and constantly changing part of minimally invasive plastic surgery. There also so many different types of fillers, however, that it gets overwhelming at times. I'll go through my favorite injection sites and what fillers I prefer to use in each, and then explain what each filler is.
Injection Sites
The image below shows my favorite injection sites.
Glabellar lines (brow furrows): Ideally, the muscle is first relaxed with Botox®. If you still have a line after Botox® treatment in this area, you must be a lifetime frowner! A hyaluronic acid (HA) product like Restylane® can be injected to fill deep furrows. If you just have some shallow wrinkles, collagen may work well. Hollow cheeks: Even if you have few wrinkles, a thin face is a sign of old age. Sculptra™, injected throughout the face, plumps the cheeks and fills it out, avoiding the "Beverly Hills pull" look! Lip lines are difficult to treat. Most respond to a layered approach, with deep HA to plump up the area and CosmoDerm® superficially to erase the line. |  | Dark under-eye grooves may be helped by injectables. If you have a deep line here and can easily feel bone through it, then HA, injected deeply, may be able to fill out your line. Nasolabial folds extend from the corner of the mouth to the nose. As the face ages, this line may become extremely deep and give your age away. Filling deep folds with Perlane® or Radiance (Radiesse™), or less deep lines with an HA product Restylane®, will restore the youthful and flatter contour.
Lips can be augmented with HA, like Hylaform®, for plumpness. This area is very sensitive to injection. I usually recommend using a "block" - an injection that numbs the area thoroughly before injecting a filler into the lips.
Filling in the Details
Collagen Zyderm® is bovine (cow) collagen, which generally works well, with the following limitations: first, 3% of all patients are allergic; and second, it goes away fast - too fast for some - the claim is six months but in my experience, if you get three, you are lucky. The first time you use it, it needs to be tested by injecting a small amount into your arm. You need to come back in four weeks for the treatment, assuming that your arm does not develop a reaction. And the more times you have it done, the faster it seems to go away. The same company came up with Zyplast®, which is "cross-linked with glutaraldehyde," which is designed to last a little longer. It usually lasts only about 5 months, and it is thicker and sometimes a little lumpy. Zyderm® I, Zyderm® II, and Zyplast®: $200 - $400. May cause allergic reaction. Require two visits and four-week wait the first time. Last 4 - 5 months. FDA-approved. CosmoDerm® is another type of collagen. Unlike Zyderm®, allergies are rare, so you don't need the arm test. CosmoDerm® is lab-grown human skin. Despite how disgusting this sounds, it is absolutely safe and any potential dangerous agents are removed first. CosmoDerm® also has a thicker long lasting version called CosmoPlast®. It is a little more expensive but worth it. They both have lidocaine, which numbs as it fills, but the injection still hurts. I use the CosmoDerm® for very superficial lines, like around the eyes, and CosmoPlast® for slightly deeper lines, like those on the upper lip. They last between three and six months. CosmoDerm®/CosmoPlast®: $300 - $600. FDA-approved.
Restylane®, Captique™, & Hylaform® The newest FDA-approved fillers are made with hyluronic acid: Restylane®, Captique™ and Hylaform®. These are currently THE injectables. Hyaluronic acid(HA) is great stuff - it is found in very young skin. It absorbs water, so it plumps things up in a natural way. The HA in Restylane® and Captique™ is made by bacteria, which sounds gross, but it is thoroughly sterilized before being packaged. Hylaform®, by contrast, comes from processed rooster combs, so although theoretically there could be some reaction, I've noticed there is usually less sensitivity. Both types last 6 to 9 months and can be used on lips for augmentation, and on deep wrinkles and folds. The down side is that the injection stings, especially with the Restylane®. Rarely, the area injected gets very swollen for the first 24 hours - we're talking duck lips here - but this is usually a reaction to something in the Restylane® and can be prevented next time by using Hylaform® instead! Finally, there is also a "thick" version of Restylane® called Perlane®, which is super thick, works well for extremely deep folds, and tends to last a little longer than Restylane®. Restylane®: $500 - $1,000. FDA-approved. Hylaform®: $400 - $1,000. FDA-approved. Perlane®: $600 - $1,000. NOT approved by FDA.
Radiance Radiance is an injectable made from hydroxylapetite microspheres in a carboxymethylcellulose gel carrier. (Its new name is Radiesse™, but it is still commonly known by its former name, Radiance.) Hydroxyapetite is so tough it has been used to replace bone! Not surprisingly, this can make the injection a touch firm, so it needs to be injected deeper, where it cannot be felt or seen. It's good for deep folds (like nasolabial), and it lasts for months to years. I never use it on lips because it can make them bumpy and they feel unnatural. Granuloma (hard lump) formation is possible. More commonly, especially in lips, a small bump can develop a few weeks after injection that must be "snapped" -- external pressure is placed on the bump and the scar tissue forming around the bump will break, evening out the filler again. The good news is that I've seen patients who had Radiance injected into their deep wrinkles nine to twelve months earlier, and the Radiance is still present. Also interesting is that this stuff will show up on an xray - so warn your dentist! Radiance: $600 - $1,500. FDA Off-label use.
Sculptra™ Sculptra™ (marketed as NuFill in Europe), is now FDA approved for lipodystrophy (fat-wasting). It works best when more facial volume is needed. It is composed of polylactic acid crystals, which cause your body to create collagen, creating a fuller, more youthful look. Unlike other products, it is watery in consistency and you cannot judge the result immediately. Sculptra™ is generally injected in three sessions over three months, so that the product can be layered to fill out the areas that need the most contouring. The product lasts for about two or more years, and touch-ups are needed every year or two. Sculptra™: $300 per cc. Expect around 8cc to be used in the first session. FDA-approved.
Fat Autologous fat means fat from your own butt or elsewhere can be used to fill up your wrinkles. This can work beautifully when done by a surgeon who is experienced and skilled with fat injections, but even so, one can expect to need a second injection for the lips about 40% of the time. Many doctors will freeze your fat and use it for a secondary injection. Let me tell you now that this does not work. Freezing kills the fat and although it may cause some temporary inflammation that looks like it's working, the fat will not last, and any apparent benefit will soon disappear! Th treatment is more involved, since a small area of your fat is numbed and suctioned up, in addition to the facial injection. Fat: Highly variable cost, $300 - $1,200 per site. Not controlled by FDA.
Silicone Historically, silicone was one of the first fillers. It is still very much in use, mostly by plastic surgeons who have been using it for years and years. Most say that there are no problems with silicone injection, but patients sometimes develop tough areas around the free silicone, called granulomas, that need to be cut out. Most problems that occur happen when low-grade, cheap silicone is used. If you do choose to use this, know that it is NOT approved by the FDA, and not recommended by this doctor either! Silikon: $350 - $1,500. NOT approved by FDA, NOT used by Dr. Cassileth.
Others Of the various other injectables, many are similar to existing products, like collagen that comes from a sheep instead of a cow, or hyaluronic acid from a different source. So now that you are an expert, you can ask your doctor the nature of the injectable, how long it lasts, and what areas it is used for. Perhaps the only other type I am often asked about is Artecol. This is made with collagen-wrapped microspheres; it's like Radiance wrapped with Zyderm. If you understand that, you can go to the advanced class. This is another injectable which can form granulomas (rarely) and make lumps, but it lasts for about a year or more. If it's injected deeply it can be used for nasolabial folds or cheek plumping, and it is safe for most people. It is not yet approved by the FDA, but since the microspheres and the collagen are both separately approved, it should have few barriers to future approval. Artecoll: $1,000. Not approved by FDA.
Please note that the prices listed above are intended to give you a rough approximation of market prices.
Coming soon...
Part three in this series on injectables covers sclerotherapy -- treatments meant to get rid of those pesky spider veins. But do they work? Coming soon to your email inbox!
BOTOX is a registered trademark of Allergan, Inc. RESTYLANE and PERLANE are registered trademarks of Q-Med AB COSMODERM, COSMOPLAST, ZYDERM, and ZYPLAST are registered trademarks of INAMED Corporation RADIESSE is a trademark of BioForm Medical, Inc HYLAFORM is a registered trademark of Genzyme Corporation CAPTIQUE is a trademark of Genzyme Corporation SCULPTRA is a trademark of Dermik Laboratories Copyright © 2005 Lisa B. Cassileth, MD, Inc. All rights reserved. Privacy Policy & Disclaimer Click here to unsubscribe from Dr. Cassileth's newsletter.