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We have so many fantastic filler products now that no single filler is the best for every site or for every intended application. The two major forms of filler FDA-approved for lines and folds are the hyaluronic acids (e.g. Restylane, Belotero, Juvederm) and calcium hydroxylapatite (Radiesse).

The most commonly used US hyaluronic acid (HA) filler families are Restylane (Galderma) and Juvederm (Allergan). Belotero is also FDA-approved in the US, but only one type “Belotero Balance” is available. In Europe, Belotero is much more popular and there are many variations that parallel the Restylane and Juvederm products available in the US. Despite minor technical differences in these products, they can provide long lasting results that are much longer than wrinkle blockers (e.g., Xeomin, Dysport, and Botox). When it comes to dermal fillers proper training, appreciation of anatomy, fundamental awareness of aesthetic hallmarks, understanding of the particular filler properties being used, communicative skills of the injector, and cumulative injection experience are all more important than the actual filler being used.

HA fillers provide immediate improvement for re-volumizing deflated areas of the face, filling in of fine lines, and effacement of deep folds. They can also be helpful to mask the under-eye bags and enhance and gently lift the brows. They are very popular to improve lip volume, shape, and symmetry.

Calcium hydroxylapatite works differently as the vehicle carrier provides an immediate volumizing effect that lasts about 3 months. The calcium spheres, however, also stimulate new collagen synthesis that then provides very long-lasting results up to 24 months. It has the highest G prime of all fillers, which in a sense measures its stiffness. It therefore provides a very robust filling and is fantastic for boosting the midface area and helping the nasolabial folds. It, however, is should not be placed in the body of the lips as granulomas can form. A disadvantage is that Radiesse is not reversible with an enzyme like the HA fillers can be.

Dr. Burroughs has a great deal of experience having used these products for over 13 years. For HA filling he prefers the Restylane family as he believes they are more predictable. Juvederm HA filler is fantastic and the HA filler he started out using, but it attracts fluid over several days following the injection which can cause some unpredictability and even unsightly results in certain areas of the face such as under the eyes. Some have claimed that Juvederm provides more “smoothness,” which Dr. Burroughs feels is more marketing hype than actually clinically meaningful.

However, Juvederm is less likely to form bumps because it readily diffuses in the tissues. This can make it a technically easier product to inject for those not comfortable with post-injection massage and molding of the product. It also may cause it to appear to last less long as it spreads more. This is also an issue with Belotero HA filler. Belotero is fantastic under the eyes as it causes negligible to no tyndall effect as compared to the other HA fillers. The Tyndall effect is a scattering of the light causing a bluish appearance similar to how our veins in our skin appear blue. Clients and patients don’t want to have their smooth skin also appear blue. Belotero is fantastic for fine lines as it can be intradermally (very superficially) injected.

Restylane HA fillers are more cohesive and tends to stay where they areas placed. It does, however, sometimes need to be carefully molded once injected. Dr. Burroughs doesn’t see this as a disadvantage, however, because much of facial aesthetics is understanding shapes, curves, lines, and projections. Dr. Burroughs finds dermal filler injecting to be very artistic, and the very best injectors understand facial aesthetics in 3-dimensions.

The advantage of more cohesive fillers is that they can be used to build up the face in a manner that is not impossible with less cohesive fillers and those with a lower G prime. This is especially evident in the lower eyelid/tear trough hollow under the eyes. Juvederm injected in this area in enough volume to make a difference can readily drift into the top of the cheek creating unwanted fullness. Also, the water-attracting properties that may be optimal in the lips are not desirable in the eyelids because they can be prone to swelling. In fact, Dr. Burroughs sees many patients for second opinions following that filler placement under their eyes that cause prolonged swelling issues or need reversal because of too much blue appearance. This does not happen with Belotero and only very rarely with Restylane.

On the other hand, one has to expect lumps with Restylane and actively work to smooth these if they occur. This can easily be done and it is my opinion that the results are worth the effort.

Some injectors feel that Juvederm HA filler doesn’t last as long, but the Juvederm family has Voluma that can last up to 24 months. The other variations of Juvederm, however, may give a shorter clinical improvement even though the filler is still in the tissues because of how it spreads out across the areas of injection. This can also occur with Belotero do to its dispersive properties.

For potential increase of patient safety and because the injections are more comfortable he advises cannulas. Cannulas also cause less tissue trauma and bruising. Many injectors don’t use cannulas as they are more technically challenging and add to the cost of injecting, but Dr. Burroughs thinks the advantages outweigh the disadvantages. For fine-tuning, he will use needles but typically starts most injections with cannulas.

Dr. Burroughs is nationally known as an eyelid expert, and his “filler blepharoplasties” have become a very popular treatment in his practice drawing patients from as far away as New York. His techniques for under eye filling have evolved from managing complications from outside practices as well as learning over time what works best. Also, because he is an eyelid surgeon, he understands not only the anatomy but how the tissues interact with one another and with different fillers. He advises most under eye dermal filling to start with Belotero as it is the most forgiving HA filler in this location. It has the least risk of causing the skin to appear blue and injects very smoothly. However, because it diffuses easily, patients need to be warned not to rub their eyes and it won’t last as long as Restylane. He has seen Belotero to last as long as 1-2 years under the eyes and Restylane even longer. For patients with deep hollows and thicker eyelid skin they do very well and usually better with Restylane-L. The other variations of Restylane with the exception of Silk are not as well suited for under eye injections.

Dr. Burroughs believes Juvederm has too high of a risk of causing unsightly swelling under the eyes, so he does not recommend it for under eye filling. Dr. Burroughs has had patients referred for lower eyelid Radiesse problems that have required surgical and steroid injections to improve the issues. For these reasons, he, does not advise it for lower eyelid placement. Radiesse, however, works great along the orbital rim and upper cheek area and is fantastic at optimizing the cheek bone areas and “Ogee” curve of beauty. The great thing about a filler blepharoplasty is that results are instant, and many patients can put off surgery by filling in the hollows and masking their fat bags. Also, some surgical patients obtain the best results by having HA filler placement following surgery to optimally smooth and fill the under-eye hollows and transition with the upper cheek. Lastly, because HA fillers can be reversed with an enzyme, hyaluronidase, any unwanted issues can be reversed or optimized with titrated injections of hyaluronidase. Under the right circumstances, Dr. Burroughs has been referred unhappy patients that he has been able to “sculpt” the HA filler that wasn’t smooth or otherwise aesthetically pleasing and salvage the investment that patients had made in their under-eye filler. Other times, all of the HA filler needed to be completely removed and a “filler blepharoplasty” or surgery done to optimize the lower eyelid cosmetic appearance.

As discussed earlier, Dr. Burroughs was an early adopter of cannulas and he especially advocates their use around the eyes. Because they aren’t sharp they cause less bruising and won’t injure the eye if a patient suddenly moves. There is also less theoretic risk of injection into a blood vessel that can lead to skin necrosis or even blindness. Dr. Burroughs strongly recommends that all injectors know an ophthalmologist that can inject hyaluronidase behind the eye if the fortunately very rare but very detrimental stroke to eye occurs from filler getting into the blood stream of the eye. This can be sight-saving, but most injectors and even most physicians and surgeons are not comfortable with retrobulbar injections behind the eye. Dr. Burroughs was first trained as an eye surgeon, and has had extensive experience injecting safely all around and even behind the eye.

Dr. Burroughs is a strong advocate of dermal fillers as they not only provide outstanding cosmetic results but they complement and even rival and replace surgical outcomes sometimes. He oftentimes performs filler injections with or following his surgeries because surgery can’t re-volumize deflated areas and to smooth deep folds that surgery can sometimes lead to an unnatural appearing result. Wrinkle blockers (e.g., Xeomin, Dysport, and Botox) are often used in conjunction with fillers as they enhance and complement the results or fillers. They also help fillers last longer by decreasing the mechanical breakdown caused by muscle action around the fillers.

Lastly, skincare should never be neglected. Just like a nicely made bed, if the sheets are not smoothly pulled tight the top cover may not look smooth or if they bedcover is wrinkled or stained it doesn’t matter how tight the under sheets are pulled. A face with poor skin quality in terms of texture, fine lines, thickness, and uneven pigment may still not be optimally rejuvenated even if it is perfectly re-draped surgically, folds smoothed with filler, and deflated areas re-filled. Dr. Burroughs strongly advises all aesthetically minded patients be on a medical grade skin care regimen, so he has partnered with SkinCeuticals because their cosmeceutical products are formulated and backed by science to provide real results. Specific to HA fillers, the H.A. intensifier by SkinCeuticals bolsters hyaluronic acid levels up to 30%, which can enhance not only filler treated areas, but untreated locations. It amplifies the skin’s own HA levels by 30% within the first 12 weeks, and clinical data has shown 50% more collagen in the same 12-week study. This improves skin texture and can help with the fine lines around the crow’s feet and lips. There is also safe pigment correcting products called Advanced Pigment Corrector for at home use and Advanced Corrective peel that is safe for all skin types. These SkinCeuticals products help even pigment coloration and can improve the skin’s radiance. These are just a few examples of products that are easy and safe to use and that provide real benefit. There are many other SkinCeuticals products for reversing oxidative and ultraviolet light damage that can be further discussed with one of our skincare trained experts at Springs Aesthetics.

A critical hallmark of facial beauty is the quality and youthfulness of the skin, which besides the underlying facial anatomy is the first impression of what others notice on our faces. It therefore behooves any person interested in their appearance to be on a professional grade skin care regimen like that from SkinCeuticals. Dr. Burroughs is proud to be the first Colorado retail partner of SkinCeuticals. We that practice aesthetic medicine are excited by all the tools we have now from skincare to fillers and wrinkle blockers to minimally invasive to surgery for restoring and enhancing beauty. Likewise, filler products and techniques continue to evolve, and this is great for “aesthetic artists” like Dr. Burroughs as we can provide ever improving outcomes for our patients.

 

 

 

Summary of Dermal Filler Injection Recommendations By Dr. John Burroughs:

  1. Under the eyes: Start with Belotero in most circumstances but for very deep hollows with thicker skin then Restylane-L may be preferable. He does not advise Juvederm under the eyes because of the potential for unsightly swelling.
  2. Lips: Restylane. Although Juvederm can be fantastic, the water attracting properties can sometimes cause lips to look too full. He strongly believes lips are best enhanced by understanding the well-defined ratios and proportions of lip beauty and injecting them with this in mind. Indiscriminate injection of lips without understanding what constitutes a beautiful lip for each individual patient will lead to big unnatural appearing lips.
  3. “Parentheses” Around the Mouth (Nasolabial and Melolabial Folds): Radiesse or Restylane. For superficial lines then Belotero and Restylane silk are great choices.
  4. Midface Lifting and Contouring: Restylane Lyft or Radiesse.
  5. Brows: Restylane
  6. Forehead Lines: Restylane Silk or Belotero
  7. Prejowl Sulci: Radiesse or Restylane
  8. Perioral Lip Lines: Restylane Silk or Belotero
  9. Back of Hands: Radiesse
  10. Re-Volumizing Facial Hollows from Fat Atrophy and Deflation: Radiesse or Restylane
  11. Dynamic Lines Around Mouth: Restylane Define or Refine, which are formulated to flex and hold up to areas of higher pressure stress during facial movements.
  12. Temporal Hollows: Radiesse or Restylane
  13. Brows: Restylane-L
  14. Glabellar Frown Lines: Radiesse or Restylane only using a cannula.
  15. Traumatic or Congenital Bony Deformities and Depressions: Radiesse
  16. Chin & Nose Augmentation: Radiesse

John R. Burroughs, M.D.

Oculofacial Plastic Surgeon

Medical Director Springs Aesthetics