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FILL HARMONICS While today's HA fillers are all non-animal sourced and stabilized, they do have some important differences, including the manner in which the molecules are cross-linked, the particle size and their affinity to bind water (hydrophilic properties). These distinctions determine a filler's G prime, its hardness or resistance to deformation. Picture squirting out the contents of a tube of toothpaste. If the paste retains its shape without flattening, the material reflects a high G prime; a runny liquid that rapidly loses its peak formation has a low G prime. Restylane and Perlane (Medicis, restylaneusa.com) demonstrate stiffer qualities than other currently available HA fillers in the United States, which translates to a higher lift capacity, according to Joel L. Cohen, MD, medical director of AboutSkin Dermatology and DermSurgery, Englewood, Colorado, and a published author on fillers and complications. The stiffer quality of these fillers provides not only lift but also structural support. They are, therefore, more suited for creating a cheekbone, increasing chin projection or temple lifting. Other fillers, like Belotero Balance (Merz Aesthetics, belotero.com) and Juvederm (Allergen, juvederm.com), are softer materials that are ideal for filling lips, nasolaboial folds and finer lines. Juvederm, one of the more hydrophilic fillers, is a popular tool for imparting a soft shape around the lips but is not as well suited for treatment around the eyes, where Dr. Cohen notes that swelling and edema could occur as a result of the filler's hydrophilic properties. He suggests that Restylane, which is not quite as hydrophilic, might work better for treating the tear troughs and the nasojugal folds. Each physician has his or her own favorites. Dr. Cohen will often use Juvederm Ultra Plus in nasolabial folds to create a "nice, natural correction that doesn't tend to ridge" like some of the stiffer fillers. For the lips, he likes Juvederm Ultra with Restylane along the vermillion border if a bit more projection is desired. Rebecca Fitzgerald, MD, a Los Angeles-based dermatologist specializing in fillers, compares choosing fillers to a chef selecting ingredients for a particular recipe. "But, really, all of the hyaluronic acid fillers can be used anywhere," she says. David Applebaum, MD, FACS, a plastic surgeon based in Boca Raton, Florida, likes Juvederm Ultra Plus and Perlane for creating lift in the cheek area or to soften a nasolabial fold. He often uses a layering technique, drawing on the subtleties of each filler's nuances. For instance, he'll inject Perlane deeper in the fold and Restylane, a better choice for the superficial layers, in the crease of the fold. Dr. Applebaum also uses Perlane for the cheek hollows, marionette lines and the corners of the mouth. For defining the vermillion border around the lips or filling 28 NOVEMBER/DECEMBER 2013 | MedEsthetics fine lines, Dr. Applebaum says both Restylane and Juvederm are good choices. While many physicians prefer the softness of Juvederm for filling the lip, he prefers the "crispness" of Restylane. Typically, HA fillers can last anywhere from six to 12 months. Expect fillers to dissipate more quickly in areas subject to more motion, such as the lips, where they generally last five to eight months. In more stationary areas, such as cheekbones, effects can last up to 12 months. In the periorbital area, treatments with HA fillers have been reported to last as long as two to three years. Collagen-Stimulating Volumizers While HA fillers are a top choice for specific indications, such as fine lines and icepick acne scars, collagen-stimulating fillers, such as Radiesse (Merz Aesthetics, radiesse.com) and Sculptra (Valeant Aesthetics, sculptraaesthetic.com), can help create volume across a larger region with results extending to 24 months or longer. Another key difference between volume fillers and HA fillers is the plane of injection. "When you talk about volume filling in the infraorbital area, it should be done deep and along the periosteum. When we're injecting the temples, it is similarly done deep onto the periosteum," says Dr. Cohen. The stiffer quality of these fillers provides not only lift but also structural support. Volumizing products work well for restoring structure in areas where skeletal shifts take place, such as the midface and the cheekbones. "If I want to put a little volume everywhere in the face, I use Sculptra," says Dr. Fitzgerald. "If I want to place a 'liquid injectable implant' in the cheek or chin, I use Radiesse." Radiesse diluted to a thinner consistency with lidocaine is also a favorite for filling the backs of the hands, where tendons and blood vessels are often visible through thinned skin. © THINKSTOCK Choosing Your Tools