For some facial rejuvenation needs, hyaluronic acid may not be the top choice

Las Vegas - Although hyaluronic acid (HA) has proven to be a versatile dermal filler in a variety of formulations, special circumstances may require other materials, says an expert who spoke at the Cosmetic Surgery Forum.

In particular, says Murad Alam, M.D., professor of dermatology at Northwestern University, Chicago, “Sometimes we need longer-lasting products, or patients need significant amounts of volume.” For example, he says it would require “tremendous amounts” of HA to provide the volume needed by a 70-year-old female with significant atrophy and wrinkles, and she would need treatments repeated every two or three months.

Conversely, “With calcium hydroxylapatite (CaHa) or poly-L-lactic acid (PLLA), you might be able to use slightly fewer syringes and re-treat somewhat less often.” Alternatively, “You could combine products - CaHa or PLLA for underneath the eye, and HAs on top.”

Moreover, Dr. Alam says, some locations - such as a notch on the chin - may need stiffer products. In such areas, “I like to use CaHa, which is somewhat stiffer when undiluted. Filling that notch almost creates the illusion of a facelift, because there’s no longer a ‘double bubble’ where the jowl is lower than the chin. But to fill that notch, you need something firm - otherwise it will dissipate and the notch will reappear.” Of course, he says, “Some of the firmer, more viscous hyaluronic acid filler formulations may also be used effectively for these indications.”

Preparing for complications

Regarding complications, he says that in recent years, “I’ve seen two refractory cases of PLLA nodules in patients who did everything right - massage for five minutes five times daily - and were injected by very reliable physicians.”

For such cases, he suggests repeated injections with very dilute concentrations of triamcinolone acetonide, although some patients may require such injections for a prolonged period. “In general,” Dr. Alam says, “nodules, while uncommon, can develop after any type of filler placement. They can be an idiosyncratic, unpredictable result of filler injections, and usually can be easily managed.”

Regarding large-volume lipoatrophy, Dr. Alam says this is the only instance in which he would use silicone. “These patients are usually HIV-positive and willing to accept the risks. I tell them it’s an off-label treatment” that could cause granulomas and potentially long-term inflammatory changes.

Picking the right product

Conversely, Dr. Alam says, fine-line fillers also have their place. In this regard, he notes, “Belotero (Merz) is a specially formulated HA. It’s not as soft and easy to inject as CosmoDerm 1 (human-based collagen, Inamed) and ZyDerm 1 (bovine collagen, Allergan) used to be for fine lines, but it’s effective for all but the finest lines.”

As for which filler he prefers in which locations and indications, Dr. Alam says, “This topic is very open to interpretation.” Generally, he says, there are some areas where he would only use HAs. Examples include lip augmentation. “In augmenting the body of the lip, I prefer Juvéderm Ultra (Allergan) because it’s very soft.”

Conversely, he says that under the eyes or in the tear trough, “I’d use Restylane-L (Medicis). That’s because Restylane comes mixed with a certain amount of water - it’s a slurry. So it’s less prone to absorb additional water and create translucent bumps several days or weeks after injection. It won’t keep growing; it will stay corrected appropriately.”

Dr. Alam says he also sticks to HAs for the glabella. Here, “I’d use gentle injections, done slowly and superficially, because a variety of substances - such as autologous fat and collagen - injected here have resulted in retinal artery occlusion and blindness.”

For cheek augmentation, “You could use virtually whatever you want. I like diluted CaHa.” Likewise, Dr. Alam says that to raise a scar or brow, he’d likely use a firmer product such as CaHa or PLLA. “For slow, soft facial augmentation where the patient doesn’t want to feel any lumpiness, you might choose PLLA. However, keep in mind that sometimes this causes some bumps of its own.”

The only type of filler Dr. Alam says he avoids is permanent fillers such as ArteFill (polymethylmethacrylate/PMMA, Suneva). Because this filler contains PMMA beads, he says, “Based on Canadian and European data, patients can get a delayed adverse response; for instance, persistent redness over the site, ulceration or abscesses. If the filler is permanent - and not inside some sort of container, like a breast implant - it’s impossible to get out in its entirety. These patients have a risk of being disfigured and unhappy for a long time, and I’d rather avoid this.”

The right tools

As for injection equipment, he says, “I’ve never used any auto-injector devices. I do like cannulas very much, though. They have dramatically changed my practice.”

With the wide variety of cannulas available, it took him a while to find the cannula that works best for him - a medium-length, semi-rigid cannula.

“You’ll sometimes hear people say, ‘A cannula is so awkward. Injection takes forever, and I can’t make it work right.’ Usually, that’s not the right cannula for that person. When you find the right one for you, treatment takes no longer - and in fact it takes me less time - because I’m not worried about bruising.”

He uses cannulas to inject in the mid-fat in areas where bruising is likely, such as under the eyes, and in the nasolabial folds or at the lateral oral commissure. “Through one little stick with a 25-gauge needle, I can insert the cannula and move it all around as needed.” This allows him to treat large areas through just one or two apertures that will not need closing, he says.

“When you want precise localization,” Dr. Alam says, “some cannulas are 1 inch or longer, and their tips are a little flexible. So you can’t tell exactly where the tip is.” Accordingly, he says, such areas may require needles.

He also advises against using cannulas in areas that require fine, superficial filling, such as “hairline” wrinkles in younger patients. “For that, you need a needle inserted into the dermis. A cannula won’t work because cannulas are injected into the subcutis.”

Regarding injection technique, says Dr. Alam, “The smartest piece of advice I ever got was: inject slowly, less than 0.3 cc per minute. This might sound pretty fast, but it means one syringe takes three minutes to inject. If you do this, even if you’re not that skilled, you’ll have low risk of asymmetry or bumps because you can rectify areas and make sure the right and left sides are about equal. You can also avoid injecting into vessels because your forward pressure is less than the back pressure coming out of the vessel.”

Additionally, he says, injecting slowly allows modification of your strategy midstream if the patient so desires. Overall, “It’s less stressful for you and the patient.” DT

Disclosures: Dr. Alam has received grant/research support from Medicis, Valeant and OptMed.