“What we are able to accomplish nonsurgically is, to me, miraculous,” stated Audrey Rose, NP, the CEO and founder of Audrey Rose Institute (Boca Raton, Fla.). “I use injectables for full facial balancing and contouring. First, I might treat the temples, cheeks, undereye or nose, and then complete the full facial rejuvenation by augmenting and contouring the lower face with liquid frontoplasty, jawline rejuvenation and/or chin rejuvenation,” she shared. “It is quite amazing that someone can come in without a chin, for example, and with relatively low risk walk out with a chin.”
With today’s patients demanding injectables that are safe and proven effective, the bar continues to be raised with new products, new indications and improved results.
According to cosmetic surgeon Alexander Rivkin, MD, founder of Rivkin Westside Aesthetics (Beverly Hills, Calif.) “Allergan products, as a whole, are the best researched and studied injectables on the market. The company has invested an immense number of resources in pivotal clinical trials, expanding indications and post market research studies, establishing the safety and efficacy of their product line. To me, that translates into an assurance of reliability.
Allergan’s JUVÉDERM collection consists of six long-lasting fillers, allowing providers to treat specific areas of the face. The company’s most recent addition is JUVÉDERM VOLUX® XC, a HA filler for lasting definition in the jawline, for adults with moderate to severe loss of jawline definition. “I use JUVÉDERM VOLUX XC in the jawline and chin, as per the indication,” Dr. Rivkin noted. Being that it replaces volume and lifts tissue incredibly well, I can promise my patients a duration of effect longer than any other HA filler on the market.
Ms. Rose noted another Allergan Aesthetics product, the company’s skin booster – JUVÉDERM SkinVive – will soon be the first of its class available in the U.S. While not a dermal filler, she explained that SkinVive is considered a skin conditioning HA gel intended to improve the quality of the skin by being injected into the mid-dermal layers. It is anticipated to be approved in late 2023.
“Resilient hyaluronic acid (RHA) fillers are the most recent addition to injectables,” said Amelia Hausauer, MD, FAAD, director of dermatology at Aesthetx Plastic Surgery and Dermatology (Campbell, Calif.). “A Swiss company called Teoxane makes RHA® Redensity, which was first approved in the U.S. in December of 2021 for dynamic lines and wrinkles around the mouth. This is actually the first filler that got the FDA nod for that specific indication.”
Another interesting product that is still gaining traction is “Renuva® by MTF Biologics, which was added to the list of FDA-approved injectable products in January of 2021,” Dr. Hausauer added. “This adipose allograft is used to restore volume and contour. It is unique in that it does not actually contain fat cells, but once injected, the patient’s own fat cells grow to help restore volume. Although Renuva has FDA clearance in the U.S., as yet there are not many providers that perform the procedures.”
In the world of neurotoxins, “the rollout for Daxxify (daxibotulinumtoxinA) is happening now, which is a neuromodulator that was FDA approved in September 2022 for the treatment of frown lines,” Ms. Rose reported.
When providing injectables, precision is key for patient comfort and safety. For this reason, Air-Tite Aesthetics (Virginia Beach, Va.) is proud to be the U.S. importer of THE INViSIBLE NEEDLE™, the smallest TSK needle on the market today. At just 0.2 mm in diameter this new needle is 33% thinner than the popular TSK 30G needles. According to the manufacturer, this thinner size may provide a more comfortable injection experience, while potentially reducing the risk of bleeding and bruising for patients.
Another exciting advancement in needle technology has been the development of low dead space needle hubs, which helps to greatly reduce product waste. The low dead space (LDS) hub design with INViSIBLE NEEDLE reduces the excess hub space to nearly zero, which could result in a potential cost and product savings with each box. A conventional needle hub may retain a sizeable dead space, sacrificing unused medicine or product with every injection.
Facial Sculpting with Dermal Fillers
With the many fascinating new injectables in today’s market, Ms. Rose is extremely passionate about dermal fillers and feels they are an opportune way to integrate her love of medicine and her talent as an artist. “I use hyaluronic acid (HA) dermal fillers to augment, lift and bring harmony and balance between an individual’s facial features to create a more youthful and alluring appearance,” she explained. “We do a lot of hyperdilute calcium hydroxylapatite and Sculptra® , which is a biostimulator for the neck and décolleté.”
According to Dr. Hausauer, since HA fillers were first approved, they have remained significant in the injectables category. In her practice, she uses Sculptra along with HA fillers to help rebuild structural support in the face. “Sculptra not only acts as a filler, but also stimulates collagen production and restores volume to the face. Because it has a gradual onset over several weeks, the volume restoration can appear very natural. It is typically used along the frame of the face to restore volume along the temples, jawline, and lower half of the face.
For Dr. Rivkin, who specializes in delivering non-invasive cosmetic treatments, HA fillers play a key role in his practice. “I focus on facial sculpting in my practice, so HA fillers are important. I am very happy with the launch of JUVÉDERM VOLUX XC because I do a lot of noses, jawlines, chins and cheeks, so it is important to have a filler that is very robust and lasts a long time. For the jawline, I place the filler very deep into the tissue, pretty much on top of bone, since it works best with a lot of tissue overlaying it,” he shared.
Facial Rejuvenation with Neuromodulators
Neuromodulators have long reigned in the fa8gcial rejuvenation arena, with Botox® (Allergan Aesthetics) as one of the most recognizable brand names in this category, along with Dysport from Galderma Laboratories (Fort Worth, Texas) and Xeomin (Merz). Each of these uses slightly different formulations of botulinum toxin A and temporarily block the nerve signals that cause muscles to contract, resulting in smoother skin and softening of fine lines and wrinkles.
“Neuromodulators stop the release of acetylcholine to disable muscle contraction. In my practice, we use neuromodulators to smooth glabella lines to rejuvenate the face," reported Ms. Rose. “We also use neurotoxins in the body, for example to slim the arms by decreasing the size of the deltoids, which is highly popular right now, and we can slim the calf by decreasing the size of the gastrocnemius muscle.”
Dr. Hausauer utilizes neuromodulators in combination with other treatments for facial rejuvenation. “I will often use neurotoxins to soften the crow’s feet, which are due to constant muscle contractions or squinting. Sometimes I may do a laser treatment around the eye first. I feel the combination of the laser and the neuromodulator not only softens crow’s feet, but also helps build new collagen to create a smooth layer over time, since the patient cannot contract the skin in the area as it is healing.”
“I have used botulinum toxin type A at my practice for over 19 years,” said Filippo Brighetti, MD, a specialist in plastic and reconstructive surgery and aesthetic medicine in Bologna, Italy. “It is a very safe molecule, and in my everyday practice I use it mainly for the upper third of the face, the periocular lines, glabella lines and forehead. But in some cases, we can use it to reduce wrinkles on the side of the nose for patients with very deep marionette lines, and for the depressor angularis oris, the muscle that lateralizes and lowers the angle of the mouth.”
The Wholistic Approach to Facial Rejuvenation
“I recommend procedures that are best suited for my patients’ concerns, and often use a combination of treatments to treat the whole face,” Dr. Brighetti continued. “Normally the inferior region is the first thing I approach by treating the nasolabial fold and the marionette lines, then the middle third of the face, including the cheek and tear troughs. Then more precision techniques like chin or nose will be considered within the context of the entire face. If I use high-energy devices like laser or radiofrequency (RF), I do it before injectables or the injectables will not last as long. One of my favorite combinations is the fractional laser for “barcode” lip lines followed by injectable filler for the vermillion border and the vermillion itself.”
Dr. Brighetti emphasized that the glabella region is a delicate area because of the poor thickness of soft tissues upon the bone and because of the presence of the super jugular neurovascular bundle. “I like to approach this area using HA filler and botulinum toxin,” he said. “The final outcome is similar to a fractional laser in the glabella region because normally the two vertical lines of the glabella have muscle memory, which may not respond well to botulinum neurotoxin. So, adding HA to treat the wrinkle subdermally provides a much better outcome.”
“I have learned over the years that I am not doing my patients justice by just doing one thing or fixing one symptom,” Ms. Rose agreed. “I think using multiple modalities is driven by providing patients with the best outcome and the best version of themselves. I really enjoy treating my patients fully by balancing the portion, size and shape to contour the individual face. My ideal treatment for tightening is a combination of fractional bipolar radiofrequency (RF) treatment and ultrasound therapy treatment with hyperdilute CaHA for patients who have a lot of laxity. I often reconstitute one to one and use a cannula to really get it into the soft tissue to help build and restore collagen. Sometimes I cycle hyperdilute CaHA and Sculptra for improved outcomes.”
“I try to get as much done for my patients as possible in a single visit, so I have used fillers and toxins in combination for 20 years,” Dr. Rivkin shared, but he added that his signature treatment is a nonsurgical rhinoplasty. “Many patients are aesthetically sensitive about their nose. With this treatment they can basically have a new nose shortly after they come in. People are very emotionally affected by the appearance of their nose, so it is very rewarding when they are thrilled with their results; it really makes a big difference in people’s self-confidence. I have never seen any other injectable procedures have that effect,” he emphasized.
“For nonsurgical rhinoplasty, I use HAs such as JUVÉDERM® VOLUMA® XC (Allergan Aesthetics) or Restylane® Lyft (Galderma) as temporary fillers and I will use Polymethylmethacrylate (PMMA) as a permanent filler,” Dr. Rivkin continued. “For most of the patients that come in I offer Voluma and Lyft for one session and I will switch over to PMMA for the second session. Because the filler settles after the procedure, I always do a touchup treatment one to three months after the first session, at which point I give patients a choice of another temporary filler or they can switch over to permanent filler. The majority of people choose permanent. Then about a year afterwards I give them another session of permanent filler and then we are usually done.
Training and Safety
With the rise of popularity in cosmetic injectables, training and safety are priorities for today’s aesthetic providers, resulting in a number of available training resources. According to Dr. Brighetti, training in facial anatomy and vasculature will provide the foundation for proficiency in providing injectables, as experience and artistry are the desired traits for providers and will ensure patient safety and satisfaction.
“There are many anatomical variants, so knowing the vascular architecture of the face is important but you have to develop confidence in your hand,” explained Dr. Brighetti. “Ultimately you have to feel the tip of the microcannula or needle in your hand, so you know which soft tissue you are dealing with, such as the superficial fat versus the deep fat compartments. Always take your time and do not hurry your training because while problems such as a vascular occlusion may be rare, if encountered can be very distressing for both the provider and the patient.”
Dr. Rivkin told us a relatively new group has formed that is very much devoted to injectable safety, called the International Society for Aesthetic Competence (ISAC), and is a collection of top injectors devoted to protocols, research and injectable safety. “I am part of the U.S. contingent, and we are going to be very active in researching and presenting information about injectables and injection safety and training,” he stated. He emphasized that new practitioners should take their time to train and gain experience with injectables and stick to the basics when starting.
Maintaining knowledge with updated injectable products and technologies may feel daunting, but Ms. Rose has some advice for practitioners: “Learn the fundamentals first; get comfortable injecting the basics, then move to advanced training and do not overwhelm yourself.
Keep yourself up to date with the latest technologies through publications, educational webinars, societies and conferences and you will have all you need to guide you on your journey as an aesthetic injectable provider.”