Speaking at the 2005 South Beach Symposium, Rhoda Narins, M.D., a clinical professor of dermatology at New York University, said dermatologists should feel free to combine various fillers to maximize results, whether or not the fillers are used in an off-label fashion.
"Sometimes we get the best results by combining different fillers," says Dr. Narins, director of the Dermatology, Surgery and Laser Center in New York. "A lot of agents are available, and more and more are becoming available, so that each patient gets the treatment that is best for them. We can now work with a palette of materials instead of just one color."Examples Dr. Narins gives the example of Restylane (Q-Med) being used for deeper lines and folds and lips, Sculptra (Dermik) being used for volume correction in the face, and collagen being used for fine lines.
The gold standard of treatment for rejuvenation is Botox (Allergan), or botulinum toxin type A, and Restylane, or hyaluronic acid, rather than Botox and collagen, she tells Cosmetic Surgery Times.
"Some patients are comfortable with collagen because they have used it for years," she says. "Because it lasts only three or four months, and bovine collagen requires a skin test, its use is diminishing."
Side effects associated with fillers include bruising, swelling and erythema. These are transient and for the most part expected, and occur in less than 12.5 percent of patients who use fillers for cosmetic enhancements, according to Dr. Narins.
"With longer-lasting, deeper fillers such as Sculptra, Radiance and Artecoll (Artes Medical), there have been reports of granulomas," Dr. Narins says. "Until the studies have been finished, we can't say how rarely they occur."
She added that with improved dilution and technique, fewer granulomas likely would develop.
Contraindications In terms of contraindications, it's best to avoid using the fillers in patients who are pregnant or are taking vitamin E or aspirin, Dr. Narins says.
"Clearly, if a patient is allergic to collagen, don't use it," she says. "If they don't have downtime, and have an event to attend right away, that's another consideration in terms of what to use."
Dr. Narins differentiated between collagen, hyaluronic acid and other fillers, noting that the products are fillers themselves. By contrast, other filling agents such as Sculptra, Radiance (BioForm) and silicone provide filling as the body produces collagen around them.
The choice of filler depends on the area, with collagen, silicone and hyaluronic acid being more appropriate for contouring of the lips, and Sculptra and Radiance being contraindicated in the lips, Dr. Narins says.
Sculptra, or injectable poly-L-lactic acid, was approved last summer to restore and/or correct facial volume loss in patients with HIV. One of the side effects of antiretroviral therapy for HIV is facial fat loss characterized by sunken cheeks and hollow eyes. One of the advantages of injectable poly-L-lactic acid is that it does not need to be tested for allergic reactions, Dr. Narins notes.
Autologous fat One of the trends in cosmetic fillers is the use of autologous fat for facial enhancement, which requires harvesting the patient's own fat and necessitates the use of local anesthesia. Using autologous fat can restore volume to areas, with the rest of the fat being frozen for future use. Using fat grafts does not require allergy testing. However, the effects are short-lived in the movement lines around the mouth because the body reabsorbs the fat. The fat can last for years in the cheeks.