Hello, Perlane; goodbye, bruising

Q. What is Perlane?

It is a higher-viscosity hyaluronic acid manufactured by Q-Med, the same company that manufacturers Restylane for Medicis. Medicis purchased the marketing rights for Restylane in the United States and invested the time and money to get the filler approved. At some point, Medicis undoubtedly will obtain approval for Perlane and add this to its offerings.

A third filler in the Restylane family is Restylane Fine Line. This filler has a lower viscosity and is used for facial areas where the skin is thin, such as around the eyes. Restylane Fine Line is excellent for the correction of crow's feet.

It is my hope that some day we will have the complete family of Restylane products approved for use in the United States. This would allow customization of the filler to the site and allow facial restoration to be a complete art. Just think how boring life would be if paint only came in the color blue. This is where we currently stand in filler material approvals in the United States.

Q. How do you prevent hyaluronic acid-induced bruising?

A. Bruising is the main side effect associated with the use of hyaluronic acid fillers.

Hyaluronic acid fillers bruise more than the older collagen fillers because hyaluronic acid attracts and absorbs liquids while collagen does not. This means that hyaluronic acid absorbs and holds water, accounting for its wrinkle-correction longevity, but it also absorbs and holds blood. Many of the lumps that are present after hyaluronic acid injection are not due to uneven placement, but rather due to small hematomas at the injection site. More pronounced bleeding can lead to bruising that can take at least a week to resolve.

Bruising can be reduced in filler patients by using some of the same ideas pertinent to dermatologic surgery.

I recommend that patients discontinue aspirin and nonsteroidal anti-inflammatory use for pain relief two weeks before their filler appointment. Acetaminophen should be used instead for headaches and joint pain; however, it may not be advisable to stop aspirin use in patients who require stroke prophylaxis. I also anesthetize the skin with 2 percent lidocaine plus epinephrine, waiting a few minutes for a good blanch to appear prior to injecting the hyaluronic acid. This means that the epinephrine has induced some vasoconstriction.

I also ask the patients to hold a plastic bag with ice on the injected site for five minutes before leaving the office. This encourages the patient to sit still with the head upright while the ice induces some vasoconstriction. It is also advisable for the patient to wait at least an hour prior to dropping the head below the waist or undertaking vigorous physical exercise. The prevention of bruising is important since it improves patient satisfaction with the injection process.

Zoe Diana Draelos, M.D., is a clinical associate professor of dermatology, Wake Forest University School of Medicine, Winston-Salem, N.C., and primary investigator, Dermatology Consulting Services, High Point, N.C. Questions may be submitted via e-mail to zdraelos@northstate.net