NOV-DEC 2013

MedEsthetics—business education for medical practitioners—provides the latest noninvasive cosmetic procedures, treatment trends, product and equipment reviews, legal issues and medical aesthetics industry news.

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FILL HARMONICS in powder form and is mixed with water. Prior to application, the material needs to be reconstituted properly before it can be used effectively to volumize wide surface areas. A few days after the material is injected, the site of injection will resume its pre-treated shape as the water is absorbed, says Dr. Applebaum. Then, over the course of the next six to eight weeks, Sculptra will stimulate the tissue to make its own collagen. "So now your body is generating the collagen, the particles disappear, and you're not left with any foreign material," Dr. Applebaum notes. If patients need significant volume restoration, you may need to plan two to four injection sessions six to eight weeks apart, while young patients needing just a little volume restoration may get a great result with only one treatment. For best results, Dr. Applebaum suggests "undertreating" areas to monitor how much the individual's body will stimulate its own collagen before reapplying the material. "Results are going to be more gradual, and the patient will 30 NOVEMBER/DECEMBER 2013 | MedEsthetics have more longevity," he notes. Artefill (Suneva Medical, is another filler option for those looking for a truly permanent result. Derek Jones, MD, associate professor of dermatology at UCLA and founder and medical director of Skin Care & Laser Physicians of Beverly Hills, California, sometimes applies Artefill to deep nasolabial folds and acne scars, though due to its nonreversibility, he uses it only for specific indications. Dr. Applebaum also cautions practitioners to look at the long-term effects of this permanent product and carefully gauge how it will react with aging skin. Managing Complications The first commercially available collagen came from bovine sources, which required skin testing weeks prior to facial injection to avoid allergic reaction. With modern HA fillers, the potential for allergic reactions is very low, says Dr. Applebaum, and no skin testing is necessary. That said, injecting fillers can yield potentially significant complications if not managed properly. The most common complications are bruising and swelling at the injection site, which can last up to a week. To reduce bleeding and bruising, ask patients if they are taking any anticoagulant medications or supplements, including ibuprofen, aspirin, fish oil, omega-3, vitamin E and herbal supplements, including ginkgo biloba, as these may induce more bleeding, says Dr. Fitzgerald. Another common problem is injecting too much of a product or injecting into the wrong plane. HA fillers are somewhat forgiving in that you can use the enzyme hyaluronidase to dissolve the HA when patients are not pleased with the results. This not true with non-HA fillers, such as Radiesse, Artefill and Sculptra. Heavy-breasted patients are often good candidates for fillers in the decollete. Dr. Applebaum also cautions against applying products too superficially, which can create a Tyndall effect—a grayish or purplish hue under the skin—especially on fair-skinned patients. According to Dr. Jones, one exception to this rule is Belotero Balance, which can be injected superficially without causing this discoloration. The most important concern with filler injections is the rare, yet possible, issue of vascular compromise that can be manifested by pain, blanching or a purple reticulated pattern on the skin, says Dr. Cohen. This complication results from injecting a filler directly into a blood vessel, causing occlusion © ISTOCKPHOTO.COM Dr. Cohen likes to use Perlane and sometimes Juvederm Ultra Plus in the décolleté area. He'll often combine treatments, such as an IPL for photodamage and lentigines, an er:YAG laser for textural irregularities and fine lines, and fillers for volume restoration. Heavy-breasted patients are often good candidates for fillers in the décolleté, he says, due to the gravimetric forces pulling down and contributing to volume loss over time. Often an HA filler with 2ccs or more will help recontour that area. "I'll wait six to eight weeks and then repeat with a little more filler and another laser session," he says. Both Radiesse and Sculptra consist of biodegradable microspheres that metabolize slowly over time. Radiesse metabolizes over the course of about a year, while the results of Sculptra can last for two years or longer before breaking down, says Dr. Fitzgerald. Unlike HA fillers that come in gel form, Sculptra comes

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