Experts share insight to maximize filler results

Las Vegas – Injectors' opinions often differed regarding the use of various fillers during discussions at Cosmetic Surgery Forum here this week; perhaps most notably, Belotero balance (hyaluronic acid/HA, Merz). During the panel discussion, several experts shared their tips for maximizing results.

Vivian Bucay, M.D., said that although injectable filler strategies have largely shifted toward replacing lost volume, "Sometimes it really is about the line – that's all the patient wants. And we're obligated to be able to do those treatments as well."

For superficial etched lines, "You have to have superficial placement. If you inject from below, you're still not going to sweep that out" because the problem does necessarily lie subcutaneously. With Belotero Balance, she said, "It's nice to be able to polish things up and have that finishing touch to treat the lines." She is a San Antonio-based dermatologist in private practice.

Chicago-based facial plastic surgeon Steven Dayan, M.D., said he sometimes thins hyaluronic acid (HA) products for use in thin-skinned areas such as under the eyes by adding lidocaine, often with epinephrine.

However, Dr. Bucay respectfully disagreed with this approach. "That's fine for changing some of the rheological properties. But if you have a particulate-based filler that forms dermal aggregates, you're not going to produce a different kind of filler by simply mixing it with saline or lidocaine. You still have a diluted version of the same thing. I haven't seen a study yet, to see if there's better dermal integration or not" with diluted products. But based on her observation, she said that once the filler absorbs, "I believe there's some weightiness and unevenness. That's just a personal opinion."

Joel Schlessinger, M.D., said, "The area that troubles me quite often is very thin rhytids on the lip. I use Belotero for them predominantly. But I often have more bruising." Based in Omaha Nebraska, he is board-certified in dermatology, cosmetic dermatologic surgery and pediatrics and the founder of Cosmetic Surgery Forum.

Heidi Waldorf, M.D., added that filler injections in and around the lips tend to create a "purple mustache" of post-treatment bruising that's virtually unavoidable with superficial injections. Moreover, said Dr. Waldorf, collagen, which dermatologists previously used for the lips, is hemostatic. "HA is not – it opens up the vessels." She is director of laser and cosmetic dermatology and associate clinical professor of dermatology, Mount Sinai School of Medicine, New York.

Conversely, Dr. Bucay said that in her experience, it's possible to avoid bruising. "It's a matter of how adherent those lines are – do you have to do a lot of subcision?" Using a limited number of injection points can reduce bruising, added Dr. Waldorf, but superficial lip injections naturally tend to involve more – not fewer – injection points than do deeper injections.