Fillers: Tips and Tools for Beginning and Honing Your Practice

One of the gateway paths to a cosmetic dermatology practice is the integration and use of injectables, such as Juvederm (Allergan), Restylane (Medicis) and others. While this can be an easy introduction and generally is done with or around the addition of botulinum toxin to the practice, generally the introduction of more fillers is thought to be more complex than the use of botulinum toxins. There are several reasons for this, most having to do with complications and their treatment. Additionally, one can make the case that there is more ‘art' to the correct use of these products than is the case for botulinum toxins, which may be true.

It should be noted that there are many facets of filler usage that can be tweaked and learned over time, but these don't always lend themselves to a quick explanation during a weekend course or even longer periods of instruction. For this reason, filler usage, as with many dermatologic procedures, requires an evolving course of study. This article is intended to augment the knowledge base about fillers for the dermatologist in practice, thereby leading to better patient outcomes and satisfaction. Ahead, experts in the field of cosmetic dermatology lend their insights on the use of fillers and specifically what they would recommend for new (and advanced) users of fillers.

Entering the field of fillers

While there are many cosmetic dermatology procedures to choose from when starting or adding to a cosmetic practice, few offer such a low cost entry point as fillers. Generally speaking, the cost of adding fillers to a practice is significantly less than the cost of adding a laser or machines such as those for microdermabrasion or other devices. Additionally, the desire for fillers is ubiquitous, making their use more attractive.

When adding a procedure, the most important decisions revolve around its utility and the popular desire for the procedure, balanced against cost and downtime from its use. While these elements aren't equally balanced, they form a basis to gauge each new procedure before determining whether you want to bring it into your practice.

Fillers easily pass the tests noted above if they are done well and administered with care by the dermatologist. While other staff in the dermatologists' office can perform these and other procedures, it is my feeling that when starting out (and even now in my practice) it is best for the dermatologist to be the caregiver for fillers and botulinum toxins. This represents a point of distinction when comparing your services with the medispa or pharmacy down the street that has Botox for $8 a unit (or less!) or as the latest offering on Groupon.

Observation of others performing the procedure is the most important of all tools when it comes to the use of fillers. Method of injection can vary greatly from practitioner to practitioner and some dermatologists find one way is better for them than another. Nevertheless, it is important to see others in practice if you can in order to determine what is right for you.

Tips for starting out

Dr. Benjamin Barankin, Medical Director & Founder of Toronto Dermatology Centre, recommends that new users start out only with well-established hyaluronic acid fillers like Juvederm and Restylane for three main reasons:

• Great efficacy and longer safety data
• Great service and education by the provider companies to you and your staff
• Availability of an antidote (hyaluronidase) in case you make a mistake (e.g., overfill), or if a nodule forms

Dr. Barankin also recommends starting with injecting in safe and simple areas, like the nasolabial folds (laugh lines). With more experience and a better understanding of beauty and proportions, Dr. Barankin observes that new practitioners can slowly move to lips, tear troughs, cheeks, jawline and nasal contouring. It is valuable to start attending cosmetic meetings with live injections, and watch a few videos on injecting which can be found online, on DermTube.com, or added to many books.

Dr. Schlessinger's Tip: I feel that the most overdone and dangerous area is the area under the eyes. This is not an area I recommend for beginners and it can even perplex advanced users. The benefits often don't outweigh the risks, so it is important to gain considerable experience before moving on to treat this area.

Dr. Barankin prefers Juvederm in the lips because it is softer than most other fillers. He recommends Perlane (Medicis) and Radiesse (Merz) in the cheekbones and jawline, as well as for nose contouring.

According to Dr. Lawrence Finkel, who is in private practice in Warrenton, VA, most faces/wrinkles/folds are slightly asymmetric, so it is important to adjust accordingly. Many first-time users expect the syringe to be divided up exactly equally, which can lead to problems if one nasolabial fold is significantly different from another.

Dr. Finkel also recommends giving the patient a handheld mirror and having the patient check the results while there is still filler left in your syringe. Since it is their face, make sure they are happy and their expectations have been met. He points out that their monetary expectations are often not ours.

Dr. Schlessinger's Tip: Always write in your chart what you recommend as far as the numbers and types of fillers. Oftentimes, patients will need more fillers than they choose to receive and it is important to remember this on the follow-up visit and document it in the chart should they be upset with the results or lack of improvement. Many times, noting something like “We had recommended three syringes of filler at the consultation and you did only one, so it may be a good idea to do those other two in order to achieve a full correction” will result in the patient agreeing to the recommended treatment amount at a later date.

Dr. Barry Ginsburg, in private practice in Birmingham, AL, categorizes a patient's needs based on whether they require field therapy or spot therapy. If they require field, then he decides whether they need fuller cheeks and cheekbones or whether they could benefit from just cheekbone augmentation. For fuller cheeks or cheekbones he prefers Sculptra (Sanofi Aventis). If just cheekbones are needed, he chooses Radiesse. He finds Radiesse easy to spread and uses it in a fanning manner on the cheeks, instead of Sculptra, if patients want an immediate effect. For spot treatments, he prefers Restylane or Perlane and uses them for nasolabial folds, lips, corners of the mouth, and marionette lines.

If there is a residual frown after botulinum toxin usage, Dr. Ginsburg may choose to fill it superficially with Restylane or the newer Belotero (Merz), which he also uses for upper and lower lips. He also generally uses Restylane for tear troughs, since it is easy to massage into the area where it is most needed, while for chin augmentation he prefers Radiesse. He uses Perlane for deeper areas, but avoids using it in superficial lines.

Antoinette Notaro, MD from Mattituck, NY, also likes Radiesse for the cheeks, as it can be used deeply, while rebuilding the natural contour of the zygoma, giving a subtle improvement and not looking as if it were “done.” She also uses Juvederm Ultra XC for the lips and marionette lines more superficially and finds this combination gives a very smooth rejuvenation. She feels that Juvederm is less painful than other fillers for the lips.

Dr. Schlessinger's Tip: While Radiesse and Sculptra are used by many dermatologists, these have a somewhat steeper learning curve than other fillers, making it best to start out with hyaluronic acid fillers such as Restylane, Juvederm, Perlane and Belotero.

Dr. Brenda Dintiman, of Fairfax, VA, likes to use Juvederm in the lips if someone (especially patients in their 30s) wants a very soft effect. Otherwise, she uses mainly Restylane and Perlane for the lips and nasolabial folds. Likewise for Dr. Gail Drayton, of Los Angeles, who likes Restylane and Perlane for nasolabial and marionette lines, uses mostly Restylane above the lips.

Radiesse can also creates a pleasant upward lift of the cheeks and adds volume, Dr. Dintiman notes. This results in a more youthful triangle appearance of the face with the base of the triangle created by the high cheekbones. She also layers Restylane in the fine lines after adding volume with Perlane or Radiesse. Lastly, she notes the benefits that adequate filling of the malar area can achieve with respect to the nasolabial folds. This is often not understood by patients, but with adequate explanation can be helpful and illuminating for them.

Dr. Mark Hutchin, of Ashville, NC, tells his patients that wrinkles and lines on the face indicate a substantial loss of volume, which in the absence of supporting structure, allows gravity to take over, producing furrows, lines and wrinkles. He likes Sculptra to help rebuild volume, which, along with tretinoin and sunscreen, addresses the underlying problem of volume loss. He uses Juvederm Ultra XC for direct filling of lines and applies ice prior to the procedure to supplement the lidocaine in the Juvederm, making the injections tolerable even in areas such as the vertical lip rhytids, which tend to be painful when injected.

Jo Herzog, of Birmingham, AL prefers Restylane over Juvederm for the lips and tear troughs and prefers the firmer consistency in the lips that Restylane provides, feeling it is no more painful than Juvederm. She also notes that Restylane goes in smoothly in tear troughs and she has not experienced a Tyndall Effect (bluish discoloration from superficial placement) with its use.

Dr. Schlessinger's Tip: The Tyndall effect can be seen with any and all hyaluronic acid fillers, but it does seem to be more obvious with some. The most important thing to remember is to place the filler deep, especially in areas like the eyes and nasolabial folds. Some practitioners have advised the ‘fern' technique, which sometimes results in placing small droplets superficially. While this is a valid technique, it can occasionally lead to this effect, which can persist for up to years in certain individuals.

Dr. Herzog prefers to correct volume rather than lines when possible, but states that patients often have budgets that preclude this. For deep creases, she uses Radiesse or Perlane and also uses these to add volume to cheeks (which will pull out the nasolabial folds, much as with Dr. Dintiman's approach) and temples but prefers Sculptra for adding large amounts of volume in a cost effective manner. Dr. Herzog recommends starting slowly with Scuptra (one bottle) to avoid an unintended overuse of it, as it can be overcorrected if too much is used.

Overall, Dr. Herzog recommends starting with the hyaluronic acid fillers, choosing patients wisely and trying fillers initially on friends and family who are more forgiving.

Dr. Diane Thaler, of Sturgeon Bay, WI, recommends inserting the needle of the filler slowly rather than jabbing and quickly injecting, as this leads to less bruising. She also recommends pressure rather than ice for prevention of bruising and feels that up to five minutes of pressure can sometimes be helpful.

Dr. Schlessinger's Tip: I feel that ice usage is the most overrated aspect of fillers and botulinum toxin treatments. I almost never use ice pre- or post-procedure, as it won't prevent a bruise and can allow a bruise to become huge while an ice bag covers the expanding bruise and allows it to accumulate. Pressure is the best way to prevent a bruise.

Dr. Robert Lamberts, of Grand Rapids, MI, dilutes his Restylane and Perlane with a 50/50 mixture of lidocaine for the lateral commissures of the mouth. This allows him to spread the filler more evenly, avoid lumps, and have a greater margin of error should future correction be necessary. He notes that this area needs to be injected superficially and this sometimes needs to be treated again in two to three weeks, but the results are superior with this method of correction.

Additionally, he enjoys using Sculptra for volume replacement, Artefill as a long-term filler (up to 10 years), and Restylane and Perlane for site-specific areas (nasolabial fold, tear troughs, marionette lines, acne scars and vertical lip lines). He also uses Restylane for lips, employing a technique of individual vertical punctures.

Future Directions

Each dermatologist who introduces fillers into practice or adds new fillers will learn to fine-tune the ‘art' of fillers over time. The tips included herein give some ideas as to how experts in the field view fillers and utilize them. In the future, there will be even more choices of fillers and neurotoxins, and thus the integration of multiple platforms will become even more confusing. But the most important thing to remember is to start out small and add new techniques one at a time. In addition, carefully analyzing your results and patient satisfaction levels is critical. This, along with advice from colleagues and professional sources, is the only way you, too, will become an expert.

Dr. Schlessinger is an advisory board/consultant, researcher, or stockholder with Allergan, Stiefel/GSK, Galderma, Obagi, Ortho Pharma (Johnson & Johnson), Medicis, and Revance. He is also President of FixMySkin, which recently introduced the 1% Hydrocortisone FixMySkin balm line.

Joel Schlessinger, MD is Founder and Course Director of Cosmetic Surgery Forum. He practices in Omaha, NE. The 2012 Cosmetic Surgery Forum will be held from Nov. 29 – Dec. 1 at the Venetian/ Palazzo in Las Vegas, NV. For more information and to register, visit www.CosmeticSurgeryForum.com