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Injection technique varies from filler to filler Most physicians use either an anterograde, retrograde, or serial puncture technique Most collagen and HA fillers are injected at a 45-degree angle (Fig 23-19) It is important to be individually trained on the injection techniques of each filler Fillers can be used in combination with botulinum toxins and other cosmetic procedures (Fig 23-20) Although this chapter focused on facial use, fillers can also be injected in other areas of the body such as the hands (Fig 23-21) Many injection techniques can be used However, it is difficult to teach various techniques without video and live demonstrations In the future, instructional videos will be available at wwwdermnet and training courses will be offered at the University of Miami In addition, the American Academy of Dermatology and the American Society of Dermatologic Surgeons offer training courses for dermatologists
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Filling agents for soft issue augmentation procedures are now widely available, based on the long-standing successful track records of the earliest products Most agents in the soft tissue augmentation armamentarium can be safely used alone or in combination The
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FIGURE 23-19 Most collagen and HA llers are injected using a 45-degree angle Injecting over the thumb can help ensure this angle
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most frequently used agents are those that contain HA Given the widespread popularity of soft tissue augmentation and the ever-present need to develop safer fillers that last longer than the current products, new fillers frequently enter the market Soon to be made available in the US is an HA filler that contains lidocaine as well as more durable and safer synthetic agents In short, the demand for soft tissue augmentation procedures has steadily increased since their inception and research is ongoing to develop products that address the shortcomings of the earlier products while incorporating and expanding on their advantages Moreover, the coupling of fillers with other cosmetic interventions (eg, Botox injections) enhances their longevity and efficacy, and creates an overall realistically aesthetic appearance71 To keep astride with the rapidly changing cosmetic dermatology arena, it behooves the aesthetic practitioner to be aware of the current availability, application, and future potential of dermal fillers
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1 Neuber F Fettransplantation Chir Kongr Verhandl Dsch Gesellch Chir 1893;22:66 2 Klein A, Elson M The history of substances for soft tissue augmentation Dermatol Surg 2000;26:1096 3 Glaich AS, Cohen JL, Goldberg LH Injection necrosis of the glabella: protocol for prevention and treatment after use of dermal fillers Dermatol Surg 2006;32:276 4 Gniadecka M, Nielsen OF, Wessel S, et al Water and protein structure in photoaged and chronically aged skin J Invest Dermatol 1998;111:1129 5 Baumann L Soft tissue augmentation In: Baumann L, ed Cosmetic Dermatology: Principles and Practice New York, NY: McGraw-Hill; 2002:155-172 6 Eppley BL, Dadvand B Injectable softtissue fillers: clinical overview Plast Reconstr Surg 2006;118:98e 7 Stegman SJ, Chu S, Armstrong RC Adverse reactions to bovine collagen implant: clinical and histologic features J Dermatol Surg Oncol 1988;14:39 8 Castrow FF II, Krull EA Injectable collagen implant-Update J Am Acad Dermatol 1983;9:889 9 Siegle RJ, McCoy JP Jr, Schade W, et al Intradermal implantation of bovine collagen Humoral immune responses associated with clinical reactions Arch Dermatol 1984;120:183 10 Baumann LS, Kerdel F The treatment of bovine collagen allergy with cyclosporin Dermatol Surg 1999;25:247 11 Moody BR, Sengelmann RD Topical tacrolimus in the treatment of bovine collagen hypersensitivity Dermatol Surg 2001;27:789 12 Hanke CW, Higley HR, Jolivette DM, et al Abscess formation and local necro-
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FIGURE 23-20 (A and B) A patient treated with Radiesse to several facial areas and with Botox to the platysma (Photos courtesy of Lisa Grunebaum, MD)
FIGURE 23-21 The hand on the left is before Radiesse treatment The image with the dark nail is after Radiesse (Photos courtesy of Lisa Grunebaum, MD)
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sis after treatment with Zyderm or Zyplast collagen implant J Am Acad Dermatol 1991;25:319 Cooperman LS, Mackinnon V, Bechler G, et al Injectable collagen: a six-year clinical investigation Aesthetic Plast Surg 1985;9:145 Cukier J, Beauchamp RA, Spindler JS, et al Association between bovine collagen dermal implants and a dermatomyositis or a polymyositis-like syndrome Ann Intern Med 1993;118:920 Rosenberg MJ, Reichlin M Is there an association between injectable collagen and polymyositis/dermatomyositis Arthritis Rheum 1994;37:747 Elson ML Injectable collagen and autoimmune disease J Dermatol Surg Oncol 1993; 19:165 Klein AW Bonfire of the wrinkles J Dermatol Surg Oncol 1991;17:543 Hanke CW, Thomas JA, Lee WT, et al Risk assessment of polymyositis/dermatomyositis after treatment with injectable bovine collagen implants J Am Acad Dermatol 1996;34:450 Baumann L CosmoDerm/CosmoPlast (human bioengineered collagen) for the aging face Facial Plast Surg 2004;20:125 Okada S, Hagan JB, Kato M, et al Lidocaine and its analogues inhibit IL-5mediated survival and activation of human eosinophils J Immunol 1998; 160:4010 Cosmetic Surgery National Data Bank 2005 Statistics (American Society of Aesthetic Plastic Surgery website) http://wwwsurgeryorg/download/ 2005statspdf Accessed June 7, 2006 Lemperle G, Rullan PP, Gauthier-Hazan N Avoiding and treating dermal filler complications Plast Reconstr Surg 2006;118:92S Baumann LS, Shamban AT, Lupo MP, et al Comparison of smooth-gel hyaluronic acid dermal fillers with crosslinked bovine collagen: a multicenter, double-masked, randomized, within-subject study Dermatol Surg 2007;33:S128 Balazs EA, Bland PA, Denlinger JL, et al Matrix engineering Blood Coagul Fibrinolysis 1991;2:173 Hylaform [package insert] Genzyme Biosurgery, Ridgefield, NJ 2004 Bergeret-Galley C Comparison of resorbable soft tissue fillers Aesthetic Surg J 2004;24:33 Monheit GD, Prather CL Juv derm: a hyaluronic acid dermal filler J Drugs Dermatol 2007;6:1091 McCracken MS, Khan JA, Wulc AE, et al Hyaluronic acid gel (Restylane) filler for facial rhytids: lessons learned from American Society of Ophthalmic Plastic and Reconstructive Surgery member treatment of 286 patients Ophthal Plast Reconstr Surg 2006;22:188 Narins RS, Brandt F, Leyden J, et al A randomized, double-blind multicenter comparison of the efficacy and tolerability of Restylane versus Zyplast for the correction of nasolabial folds Dermatol Surg 2003;29:588 Tezel A, Walker P P2906 The influence of formulations on persistence with hyaluronic acid dermal fillers [Abstract] J Am Acad Dermatol 2007;56(2):AB198
31 Kinney BM Injecting Puragen Plus into nasolabial folds: preliminary observations of FDA trial Aesthetic Surg J 2006;26:741 32 Hirsch RJ, Lupo M, Cohen JL, et al Delayed presentation of impending necrosis following soft tissue augmentation with hyaluronic acid and successful management with hyaluronidase J Drugs Dermatol 2007;6:325 33 Hirsch RJ, Cohen JL, Carruthers JD Successful management of an unusual presentation of impending necrosis following a hyaluronic acid injection embolus and a proposed algorithm for management with hyaluronidase Dermatol Surg 2007;33:357 34 Goldberg RA, Fiaschetti D Filling the periorbital hollows with hyaluronic acid gel: initial experience with 244 injections Ophthal Plast Reconstr Surg 2006;22:335 35 Lambros V The use of hyaluronidase to reverse the effects of hyaluronic acid filler Plast Reconstr Surg 2004;114:277 36 Pierre A, Levy PM Hyaluronidase offers an efficacious treatment for inaesthetic hyaluronic acid overcorrection J Cosmet Dermatol 2007;6:159 37 Hirsch RJ, Brody HJ, Carruthers JD Hyaluronidase in the office: a necessity for every dermasurgeon that injects hyaluronic acid J Cosmet Laser Ther 2007;9:182 38 Amphastar com http://wwwamphastar com/amphadasewhatishtm Accessed, February 29, 2008 39 Goldman MP Optimizing the use of fillers for facial rejuvenation: the right tools for the right job Cosmetic Dermatology 2007;20(7S):14 40 Broder KW, Cohen SR An overview of permanent and semipermanent fillers Plast Reconstr Surg 2007;118:7S 41 Bucky LP, Kanchwala SK The role of autologous fat and alternative fillers in the aging face Plast Reconstr Surg 2007; 120:89S 42 Stashower M, Smith K, Williams J, et al Stromal progenitor cells present within liposuction and reduction abdominoplasty fat for autologous transfer to aged skin Dermatol Surg 1999;25: 945 43 Baumann L, Narins R, Werschler P Dermal filling agents: evaluating more choices for your patients Part 2 Skin Aging 2007;15(6):50 44 Majola A, Vainionp S, Vihtonen K, et al Absorption, biocompatibility, and fixation properties of polylactic acid in bone tissue: an experimental study in rats Clin Orthop Relat Res 1991; 268:260 45 Gogolewski S, Jovanovic M, Perren SM, et al Tissue response and in vivo degradation of selected polyhydroxyacids: polylactides (PLA), poly(3-hydroxybutyrate) (PHB), and poly(3-hydroxybutyrate-co-3-hydroxyvalerate) (PHB/VA) J Biomed Mater Res 1993;27:1135 46 Viljanen JT, Pihlajam ki HK, T rm l PO, et al Comparison of the tissue response to absorbable self-reinforced polylactide screws and metallic screws in the fixation of cancellous bone osteotomies: an experimental study on the rabbit distal femur J Orthop Res 1997;15:398
47 Burgess CM, Lowe NJ NewFill for skin augmentation: a new filler or failure Dermatol Surg 2006;32:1530 48 Sherman RN Sculptra: the new threedimensional filler Clin Past Surg 2006;33:539 49 Thioly-Bensoussan D A new option for volumetric restoration: poly-L-lactic acid J Eur Acad Dermatol Venereol 2006;20(Suppl 1):12 50 Vleggaar D, Bauer U Facial enhancement and the European experience with poly-L-lactic acid J Drugs Dermatol 2004;3:526 51 Keni Sp, Sidle DM Sculptra (injectable poly-L-lactic acid) Facial Plast Surg Clin North Am 2007;15:91 52 Vleggaar D Facial volumetric correction with injectable poly-L-lactic acid Dermatol Surg 2005;31:1511 53 Lowe NJ Dispelling the myth: appropriate use of poly-L-lactic acid and clinical considerations J Eur Acad Dermatol Venereol 2006;20(Suppl 1):2 54 Vleggaar D Poly-L-lactic acid: consultation on the injection techniques J Eur Acad Dermatol Venereol 2006;20(Suppl 1):17 55 Borelli C, Kunte C, Weisenseel P, et al Deep subcutaneous application of polyL-lactic acid as a filler for facial lipoatrophy in HIV-infected patients Skin Pharmacol Physiol 2005;18:273 56 El-Beyrouty C, Huang V, Darnold CJ, et al Poly-L-lactic acid for facial lipoatrophy in HIV Ann Pharmacother 2006;40:1602 57 Cohen SR, Berner CF, Busso M, et al Fiveyear safety and efficacy of a novel polymethylmethacrylate aesthetic soft tissue filler for the correction of nasolabial folds Dermatol Surg 2007;33:S222 58 Narins RS, Beer K Liquid injectable silicone: a review of its history, immunology, technical considerations, complications, and potential Plast Reconstr Surg 2006;118:77S 59 Jones DH, Carruthers A, Orentreich D, et al Highly purified 1000-cSt silicone oil for treatment of human immunodeficiency virus-associated facial lipoatrophy: an open pilot trial Dermatol Surg 2004;30:1279 60 Zappi E, Barnett JG, Zappi M, et al The long-term host response to liquid silicone injected during soft tissue augmentation procedures: a microscopic appraisal Dermatol Surg 2007;33:S186 61 Hevia O, Cazzaniga A, Brandt F, et al Liquid injectable silicone (polydimethylsiloxane): four years of clinical experience [Abstract] J Am Acad Dermatol 2007;56(2):AB1 62 Hanke W A new ePTFE soft tissue implant for natural-looking augmentation of lips and wrinkles Dermatol Surg 2002;28:901 63 Cox SE Who is still using expanded polytetrafluoroethylene Dermatol Surg 2005;31:1613 64 Duffy DM Complications of fillers: overview Dermatol Surg 2005;31:1626 65 Beer K Evolence: the thing of shapes to come Skin Aging 2007;15:22 66 Smith KC New fillers for the new man Dermatol Ther 2007;20:388 67 Narins RS, Brandt FS, Lorenc ZP, et al A randomized, multicenter study of the
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