In our practice, we prefer the many synthetic fillers (Restylane (Q-Med), Captique (Inamed) and Radiesse (BioForm).
Skin and allergy testing is not required and there is no risk of disease (hepatitis, HIV) transmission. Patients have a higher acceptance for the synthetic over animal-based or human-based products.Both the patient and physician can immediately enjoy the rejuvenative effect following injection. We recommend patients avoid any blood-thinning agents for approximately two weeks prior to injections and immediate massage of the hyaluronic acid agents is avoided due to their heparin-like effect on the tissues.
Eyelids, glabellar region
Necrosis of tissue and even blindness is a risk of injections in the eyelid and glabellar region.
Intravascular injection must therefore be carefully avoided. Caution must also be exercised that the needle is securely attached to the syringe when using non-luer lock syringes. Eye injuries have occurred from accidental needle expulsion during injections under pressure.
For the deep glabellar and nasolabial folds our preferred filler is Radiesse. Radiesse is calcium hydroxyapatite, and has been used for years for vocal cord and bladder dysfunction. It is critical to obtain off-label consent for cosmetic uses.
Radiesse is an excellent subdermal filler for severe folds, wrinkles that require large volumes and respond well to deep placement, which is critical with Radiesse. We recommend injecting Radiesse below the dermis to avoid visibly noticeable lumps and irregularities. We have also used Radiesse for post-traumatic cranio-facial volume deficits, and are presently using it for enophthalmos in anophthalmic patients. It can also be placed in the preperiosteal plane for cheek and chin augmentation.
For the nasolabial folds, we inject slightly medial to each nasolabial fold as the more lateral tissue laxity and natural muscular action of the facial muscles will tend to lateralize the effect and may worsen the fullness lateral to the fold if not placed medially.
We place topical anesthetic gel (e.g., Hurricaine (Beutlich) in the gingival sulcus prior to the injections. We generally use 1 percent to 2 percent lidocaine with epinephrine with 1 ml to 2 ml at each injection site. Generally a single syringe (1.3 ml) of Radiesse is adequate for most nasolabial folds. Some patients desire or require a second syringe at a later time. In the glabellar areas only 0.2 ml to 0.4 ml is required. Patients should be cautioned and placement must be precise in the glabellar region. Tissue necrosis and vision loss havebeen reported with inadvertent intravascular injections in the periocular areas. Glabellar fold injections seldom require injecting local anesthetic, which can distort the target area and lessen the chance of obtaining the desired result.
Because patients often complain of lumps and irregularities, we discourage Radiesse injections for lip augmentation. Caution must be exercised to avoid injecting Radiesse too superficially. We have found Radiesse gives some improvement for at least two years in most patients. Following injection, patients may massage the areas immediately and for several weeks if required.
Lips, eyelids, brow
In the lips, eyelids and brow we prefer hyaluronic acids.