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Hyaluronic Acid (HA) Dermal Fillers (Restylane, Perlane, Juvederm, Belotero)

What are Hyaluronic Acid (HA) Dermal Fillers?

Typical areas most commonly injected with fillers.

Dermal Fillers” in general are sterile injectable substances that are used by Plastic Surgeons, Facial Plastic Surgeons, and Dermatologists to add volume to areas of the face, and occasionally to the body.

Most common uses for injection of Dermal Fillers are to:

  • Reduce wrinkles or lines on the face (laugh lines, smile lines, Nasolabial folds, Smoker’s lines, etc)
  • Add volume to the lips,
  • Replace lost volume to the cheeks, or around the eyes
  • Re-shape the nose, jaw-line, chin, cheek bones, etc.
  • Improve depressed scars or acne scars
  • Dermal Fillers are also used by Body Plastic Surgeons to add volume to the hands or even the heels in order patients; and occasionally to the Clitoris or G-spot in women.

Dermal Fillers come in a variety of materials and by numerous companies. The oldest Dermal Fillers were Collagen based (Cosmoderm, Cosmoplast, Zyderm, Zyplast, Evolence, etc). Cow collagen (bovine), pig collagen (porcine), as well as human collagen were widely used in the 1980s and 1990s. After 2000, Hyaluronic Acid also known as “HA fillers” (Captique, Hylaform, Restylane, Perlane, Juvederm, Belotero) became more popular.

HA fillers are the most commonly used dermal fillers in the U.S. today. There are other types of fillers as well such as Radiesse (calcium hydroxylapatite or “Bone Cement”), Artefill (Polymethylmethacrylate “PMMA” microspheres in bovine collagen), Silicone, Sculptra (Poly-L-Lactic Acid) and even fat.

Hyaluronic Acid fillers are some of the most natural feeling and looking substances and these fillers are amongst the safest of all fillers. Hyaluronic Acid is naturally a part of our skin, similar to collagen. Hyaluronic Acid fillers usually do not require allergy testing while collagen fillers often did require allergy testing. Hyaluronic Acid fillers are also mostly dissolvable and can be removed with an injectable enzyme known as Hyaluronidase (Wydase, Hydase, Vitrase).

The most commonly used FDA approved Hyaluronic Acid dermal fillers at The Naderi Center are: Restylane, Perlane, Juvederm, Belotero. Captique and Hylaform are no longer used by Dr. Naderi or Dr. Kulak.

 

 

How do Restylane, Perlane, Juvederm, Belotero work?

Similar to fat or any other material, Restylane, Perlane, Juvederm, Belotero simply add volume to “fill” or augment. These fillers can plump up, or smooth out areas on the face.

How long do the effects of Restylane, Perlane, Juvederm, Belotero last?

Hyaluronic acid filler molecules can last up to 18 months in certain areas of the face. However the visible effects of the fillers, to the naked eye, can last a shorter period. HA fillers last a shorter time in more dynamic and mobile areas such as lips but last longer in less mobile areas such as the lower eyelid tear troughs or the nose.

FULL CORRECTION is an important concept in longevity of the filler results. Full correction refers to fully correcting the problem with the necessary amount of filler. For example, for deep nasolabial folds or smile lines, 2 to 3 syringes of Restylane may be required for the best results or “full correction.”

However, if a patient chooses to only use 1 syringe, optimal results will not be reached. While the filler material injected may be present for up to a year or more, the “visible results” may not be appreciated for more than just a few days! This phenomenon occurs because immediately after the injection, the patient visibly notices the “improvement” but after a few days when the initial swelling settles down, the patient will rightly think he or she needs more volume, and wrongly think “the Restylane must have all been absorbed.” Patients often forgot the starting point and how deep the lines were in the first place.

The problem all along was that the full amount of necessary volume was not injected in the first place. This is why “full correction” is so important. At The Naderi Center, we often provide a significant discount when multiple syringes of Filler are required for a single area just so that our patients can attain the full correction and get the best results and not have to compromise results for cost.

How often do I need Restylane, Perlane, Juvederm, Belotero?

Repeat injections of dermal fillers are needed to maintain or improve results. The frequency of repeat injections depends on the filler, the volume previously injected and the area on the face being injected.

Juvederm Ultra Plus and Perlane tend to last longer than Restylane or Juvederm Ultra. Belotero lasts less than the other HA fillers. These effects are due to the actual Hyaluronic acid concentration in each syringe of dermal filler as well as their “cross linking” or “bonding pattern.” The more concentrated and the more cross-linked, the longer they last. However there are distinct differences and advantages as well as disadvantages with each of these fillers and that is why at The Naderi Center, Dr. Naderi and Dr. Kulak offer and use all of the available FDA approved Hyaluronic acid fillers.

For instance, Restylane injected to the lower eyelid tear troughs (to improve under eye dark circles) may need to be repeated about once a year. However, for best results, Dr. Naderi or Dr. Kulak may do a lower volume injection to the tear troughs to maintain the great results at about 6 months instead of waiting 12 months until all of the filler has dissolved away.

Juvederm Ultra Plus or Perlane injections to the cheeks may need repetition about twice per year to maintain the fantastic results. Alternatively, lower volume injections can be done every few weeks to months in order to slowly and naturally augment the cheeks and create the ultimate desired results.

Juvederm Ultra or Restylane injections to the lips may need repetition 2 to 3 times per year on average. Belotero injections to the upper lip “smoker’s lines” or to acne scars may need repetition once or twice per year or more.

The fact is dermal fillers simply add volume. That’s it. Some people need less volume and some need much more.

The proper amount of volume injected as frequently as necessary is the best approach but even a little volume injected less frequently still can help improve wrinkles and lines in many occasions.

The limiting issue for many patients is cost. Companies like Allergan (makers of Juvederm) and Medicis (makers of Restylane & Perlane) make millions of dollars from selling these expensive substances to doctors. Doctors would love to have less expensive fillers available so their patients can get the “full correction” without hesitation. Some doctors order their filler syringes from Canada or use generic non-FDA-approved fillers. At The Naderi Center, we only use FDA approved authentic products directly from Allergan and Medicis. The cost is higher but safety is our primary concern.

What are the limitations of Fillers such as Restylane, Perlane, Juvederm, Belotero?

Fillers simply “fill” or add volume. If addition of volume fixes the problem then Fillers are the answer. But in some cases “dynamic wrinkles,” or wrinkles that get worse with expression or movement, need to be treated with Botox or Dysport. The wrinkles that are already present at rest known as “static wrinkles” can be improved with Restylane, Perlane, Juvederm, Belotero as long as the wrinkles or lines are not extremely superficial.

Lines or wrinkles that are extremely superficial need additional procedures such as CO2 laser chemical peels or dermabrasion. Addition of Fillers to very superficial lines may create a lump in the area. Also some lines may not be present at rest but show up with expression. Addition of Fillers to these lines in order to improve their appearance during expressions or movement may result in lumps appearing at rest.

Fern Technique injection pattern shown. Injections are done right under the skin in multiple directions with a cross hatching pattern

Occasionally the “Fern Technique” can be used to improve dynamic wrinkles that show up with expression or movement. Using the “Fern Technique,” Dr. Naderi or Dr. Kulak will cross hatch and fill the area with micro droplets of Filler in order to add more thickness and resilience to the skin. Dynamic wrinkles are usually seen in people with very chiseled or thin faces and athletes.

How are Fillers injected?

Fillers come in sterile single use syringes with a needle to inject. Many of the HA fillers at The Naderi Center have Lidocaine premixed for comfort. Dr. Naderi or Dr. Kulak occasionally add lidocaine to the fillers that do not have numbing medicine pre-mixed in the syringe. Fillers come in a variety of syringe sizes.

  • Restylane and Perlane do not have lidocaine mixed in.
  • Restylane-L and Perlane-L have lidocaine mixed in. The Naderi Center only carries Restylane & Perlane with Lidocaine for comfort.
  • Restylane comes in a 0.5cc, 1cc and 2cc syringe
  • Perlane comes in a 1cc and 2cc syringe
  • Juvederm Ultra and Juvederm Ultra Plus do not have lidocaine mixed in
  • Juvederm Ultra XC and Juvederm Ultra Plus XC have lidocaine mixed in. The Naderi Center only carries Juvederm with Lidocaine for comfort.
  • Juvederm syringes used to be 0.8cc but have switched to 1cc sizes
  • Belotero comes in a 1cc syringe without lidocaine
  • Small 27g, 29g or 30g needles can be used to inject most HA fillers

The HA fillers can be injected right under the skin or all the way down on the facial bones or anywhere in between. The injections can be horizontal, vertical, or cross hatched (Fern). The injections take just a few minutes when done by skilled injectors like Dr. Naderi and Dr. Kulak. Sometimes, topical numbing creams are applied 20-40 minutes prior to the injections for additional comfort. Dental block to numb peri-oral nerves can also be done for additional comfort during lip injections. Mild discomfort, swelling and bruising can occur but the vast majority of patients tolerate the filler injections without any issues due to Dr. Naderi and Dr. Kulak’s gentle experienced techniques. No markings of the skin are necessary when injected by experienced injectors like Dr. Naderi or Dr. Kulak.

What are risks of Hyaluronic Acid (HA) Fillers?

Most fillers have the same risks and side effects. Bruising and swelling can often occur from small hidden blood vessels that often get in the path of the needle penetrating the skin. Pain and discomfort can occur from the injections. Infection or allergic reactions are extremely rare but possible. Scar tissue, discoloration, lumps or asymmetry can occur. Blood vessel occlusion and skin loss are extremely rare but a handful of cases have been reported in the world as is blindness. But for the vast majority of patients, the only issue is temporary bruising and swelling.

What are alternatives to Restylane, Perlane, Juvederm, Belotero?

Other types of fillers such as Collagen, Artefill, Radiesse, or Sculptra are alternatives to fillers. Fat from the patient is also a good alternative in certain cases where the patient has an adequate fat source (Belly, flanks, thigh). Implants can be used in place of fillers in some situations such as for lips or cheeks.

Restylane, Perlane, Juvederm, Belotero for Men:

More men are coming in for facial cosmetic procedures than ever before. The key in treating men is thorough understanding of the facial anatomy so that fillers are added to the proper locations to maintain a masculine and natural appearance. While feminization procedures are possible especially for transgender patients, the vast majority of men want to maintain a natural masculine appearance.

For example, while Juvederm Ultra Plus or Perlane is added to women to create sexy high cheekbones, in men the same fillers are added in a different location of the cheeks to create youthful volume and not a high feminine cheekbone. For men, the biggest obstacle is bruising and the inability to cover the bruises the way women would with makeup. But despite this, men typically bruise less and recover faster due to their thicker skin.

Dermal Fillers for Prevention of Wrinkles (Best age for Fillers):

Fillers are typically not preventive the way Botox and Dysport are. However, by maintaining facial volume, larger surgeries such as facelifts or mid-face lifts can be delayed or avoided. We all lose fat, muscle, even bone volume from our faces with age and it is important to maintain and replace this volume. Twenty years ago, facial plastic surgeons relied exclusively on extreme surgeries such as facelifts or mid-face lifts. Today, facial Plastic surgeons use fillers to replenish lost volume instead of, or in addition to more invasive surgeries.

Additionally, fillers injected to lines or wrinkles can help prevent the lines or wrinkles from getting deeper and this is often seen in the early 30’s. Fuller lips and higher cheek bones can be created for young women in their late teens or early 20’s.

Effects of Fillers in older patients:

Upside-down triangle of youth versus a more rectangular face with aging

Dermal fillers are often used in older patients to smooth out wrinkles or lines. For example, use of Botox to the forehead at a younger age can prevent lines from forming. But if a person has not been using Botox and shows up to a Plastic Surgeon in her 60’s, she may have developed deep wrinkles in that area from years of scowling or frowning. Botox will still be needed to relax the muscles responsible for the wrinkles but additionally Dermal Fillers like Restylane or Juvederm may also be needed to plump up and smooth out the deep wrinkles.

Aging is also a process where volume is lost from the face including the fat, muscle and bones and gravity pulls down the deflated area creating sagging. This aging process ends up creating a more rectangular face whereas a youthful face is characterized by an upside-down triangle shape. Using fat, facial implants or more commonly today, Dermal Fillers, lost volume can be added to the face to create a more natural rejuvenated look without surgery. Dr. Naderi prefers Juvederm Ultra Plus or Perlane for this type of “liquid facelift” or a “liquid mid-face lift” whereas Dr. Kulak prefers Radiesse for the same rejuvenation.

It is important to note that due to the volume loss with age and due to the skin elasticity being worse with age, much more volume is needed to plump or re-inflate the face of an older patient than a younger patient. For example, 2cc of Perlane may create nice full cheekbones in a 28 year old but at age 58, it may take 4-6cc of Perlane to get the same results.

How much do Fillers cost?

The actual cost per syringe that cosmetic surgeons pay is quite high. The price that a patient pays reflects the cost of the syringe that each Cosmetic Surgeon has to pay in addition to the skill and effort of the surgeon doing the injection. As such, there is a large variability in cost.

For example, is a spa purchases Restylane from Canada and has a nurse do the injections at the spa the cost to the patient will be much lower than if a cosmetic surgeon purchases Restylane directly from the company in the United States and injects it himself or herself. At The Naderi Center, we purchase all of our fillers directly from the companies and we insist on authentic FDA approved fillers. Furthermore, the injections at The Naderi Center are done by Board Certified experienced and artistic surgeons and as such the cost is slightly higher. Dr. Naderi is actually a clinical trainer for Allergan and teaches other doctors how to best inject Juvederm. Dr. Naderi is also a clinical trainer for Medicis and teaches other doctors how to best inject Restylane and Perlane. His videos are a source of education and instruction for doctors around the world who email him and thank him for having the videos on our websites and on You Tube.

Finally, each Filler has a slightly different cost and cost to the patient ultimately also depends on the volume needed. One syringe of Restylane is going to cost less than 4 syringes of Restylane but in an effort to compassionately care for our loyal patients and allow them to get the best “full correction” possible, we offer significant discounts when multiple syringes of a filler are required for the same area. Please ask us about our promotions and specials.

Why go to The Naderi Center for Dermal Fillers?

Dr. Naderi is a Board Certified Facial Plastic Surgeon and a National Clinical Trainer for Allergan and Medicis. He teaches other doctors how to inject Juvederm and Restylane and Perlane properly. Patients who want to get the best results will be going directly to the actual teacher for their injections by choosing Dr. Naderi.

Dr. Kulak is a Facial Plastic Surgeon with a gentle, artistic female touch and her patient love her nearly-pain-free techniques. She focuses on facial rejuvenation with advanced minimally invasive techniques as well as more invasive face lift and eyelid lift surgeries.

Other doctors from all over the world refer to Dr. Naderi’s instructional videos on YouTube to fine tune and improve their own Filler injection Techniques.

Dr. Naderi and Dr. Kulak spend a long time with each patient analyzing their anatomy and explaining their options honestly, ethically and compassionately.

Dr. Naderi’s gentle yet fast “no down time” injection technique minimizes swelling because the longer a doctor takes to inject, the more trauma is often caused and more pain and swelling results.

No rush, no sales pitch, no pressure to buy anything at The Naderi Center for Rhinoplasty and Cosmetic Surgery.

 

Specialization Matters!SM

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