1. Dermal Fillers
Dr. Ali Habibi MD tehran – heravi sq. makran St. no18 exir daroo tehran –shariaty ave, qods sq. Sina shemiran clinic

2. Brief History of dermal fillers presented about 140 years ago in first filler was collagen ( human . Bovine ) second parallel invention was polymers ( poly acryl amid ) and PMMA (polymethylmethacrylate ) dis advantages of collagen and polymer : 1.FBG = foreign body granuloma 2.allergic reaction == local . General ( anaphylaxis ) 3.need skin test always == patient and physician discomfort 4.low tissue flexibility and integrity

3. 5. risk of fistula to superficial dermis 6
5.risk of fistula to superficial dermis 6.risk of displacement of filler specially polymers 7.low flexibility of injection technique 8.limlitation in injection sites such as lips , cheeks augmentation ….. Just for deep wrinkles like nasolabial fold 9.short duration time in tissue = 4-6 month -- collagen 10. too long absorption time = 5-13 years -- PMMA 11.Undercorrection is common and needs to repeatation Famous brands of first generation are : Collagen base fillers : zyderm . Zyplast , cosmoderm . Cosmoplast . Artecoll . Artefill Artefill and artecol : is mixed of collagen and PMMA Some of these having lidocaine in their mixture

4. Second generation dermal fillers
synthetic fillers CAHA ( caclium hydroxy apaptite ) == Radiesse Poly lactic acid ==== sculptra Advantages : 1.Slowly Biodegradable 2.Biocompatibe 3.Don’t need Skin test 4.Long term tissue durability 2-4 years 5.Good vulomization and augmentation 6.Easy to injection by various technique 7.Stimulate formation of new collagen ( neosynthesis in the skin )

5. Disavantages of Radiesse & Sculptra
FDA approved for treatment purpose = HIV associated lipo atrophy and severe facial folds limitations of usage = lips == if done results in cyst formation !!! Nodule formation in injection site == bumpy lumpy view == touchable bulging == visible nodes All of them may difficult to treat FBG if injection superficially == always hypoderm

6. Third generation of dermal fillers
Hyaluronic acid
Advantages :
Biological & immunological compatible = Same structure of skin matrix
Biodegradable
No need to skin test
Variable injection technique possible
Soonly Reversible by some methods = hyaluronidase & radiofrequency (RF)
best tissue integrity
Stimulate formation of new collagen ( neosynthesis in the skin )
Almost non adverse effect (allergy. Displacement.fistula.infection.cyst.nodule formatin )
Short time durability ( good or bad ?! ) = 6-9 max 12 month
Can use volumes as 20 ML per year
Hyaluronic acid obtain from bacterial fermentation ( streptococci )

7. Types of dermal fillers
Permanent == first generation even 5-13 years in PMMA and polymers Semi permanent == RADIESSE & SCULPTRA -- 2-3 years Non permanent == hyaluronic acid ---> less than 1 year

8. Indications
Facial Wrinkles : Superficial  peri orbital . Peri oral . Glabellar frown lines Medium to deep folds  nasolabial . pre jowl sulcus. Commissure line . Either : lip enhancement . Cheek augmentation Acne scars . Skin atrophy ( after corticosteroid injectin ) . Facial lipoatrophy . Facial deformity. Tear throghs

10. Contraindication
History of : Severe allergy Anaphylaxis Bleeding disorders Recent use of : aspirin . NSAIDS Hypersensitivity to one of the components in the product == HYLAFORM fillers obtains from avian ( bird) source  sensitivity to avian products or eggs ! History of sun burning and /or solarium . Laser . IPL . Infection . Abrasion . Skin inflammations

11. Some worldwide famous brands of hyaluronic acid are
Patient and product selection  physician should decide as the above details and indications and contraindications depend on physician exerptance
Some worldwide famous brands of hyaluronic acid are
Juvederm . Restylane . Perlane . Hylaform . Captique .
Famous brands use in iran :
Revanesse . Restylane . Juvederm . Varioderm . Variofill.
Perfect HA. Princess . Skinfill.teosyal . Radiesse . Glyton . Hylaform
Only some of above brands have health ministry registration number in iran (IRC)

12. Characteristics of hyaluronic acid these parameters affect filler performance
Degree of cross linking  DVS . BDDE PH & osmolality Particle sizes Percentage of hyaluronic acid Particle carrier  monophasic & biphasic Netral salt buffer = chloride . Sulfate . Phosphate . Acetate Additional hydrophylic polymers like dextranomer or cephadesx ….. Patent technology Hardness grade = G”

13. Injection techniques
serial puncture

14. linear threating
== retrograde & local injection

15. cross hatching fan like

16. Injection sites ( targets ) :
Superficial dermis == fine wrinkles
Mid to deep dermis == deep folds and wrinkles
Hypoderm == deep folds and wrinkles

17. AS a Global Rule in hyaluronic dermal fillers
Fine lines and superficial wrinkles ---
should correct with low viscosity fillers
-- inject should be superficially
Deep lines and folds -- should
correct with high viscosity fillers -
inject should be in deep dermis or hypodermis
Some parts such as cheek , dorsum of
hand , facial lipoatrophy correction , …
--- only should inject in hypodermis

18. Procedues and methods
1. anesthesia = topical anesthetics = lidocaine 2 % . Lidocaine 2.5 %+perilocaine 2.5% ( Emla ) . Licocaine 5% ( lyracaine ) . BLT cream ( benzocaine 20 % + lidocaine 6 % + tetracine 4 % )  dermaplanet =local anesthesia infiltration nerve bolck

19. Local anesthesia
Techniques : surface anesthesia = application of local anesthetic spray, solution or cream to the skin or a mucous membrane. The effect is short lasting and is limited to the area of contact. = lidocaine 2% gel . Lidocaine 2.5% & tetracaine 2.5 % cream (EMLA.XYLA-P . Lidocaine-p) infiltration anesthesia = injection of local anesthetic into the tissue to be anesthetized. Surface and infiltration anesthesia are collectively topical anesthesia. = Lidocaine 2% . Liocaine2%+epinephrin1/80000 Field block = subcutaneous injection of a local anesthetic in an area bordering on the field to be anesthetized Peripheral nerve block - injection of local anesthetic in the vicinity of a peripheral nerve to anesthetize that nerve's area of innervation. Preferred injection Site : between 1st and 2nd premolar at upper jowl and lower jowl

20. Dosage of anesthesia
Lidocaine 1-2 % maximum Total Dose Per Procedue mg/Kg not to exceed 300 Mg = Volume of maximum Total Adult Dose = 30 ml of 1% or 15 ml of 2 % = onset < 2 min Duration withoiut epinephrine min Duration with epinephrine min Maximum dose without epinephrine 4.5 mg / Kg Maximum dose with epinephrine 7 mg / Kg

21. Anesthesia for lips and nasolabial injections

23. Special characteristics :
Monophasic == more particles in 1cc syringe = better result
Tissue suitable PH & Osmolality
Same particle saize
Same percentage of HA == 25 mg
Lowest BDDE and Highest inter branch links = more effectivity
and bulging and lower degenaration time .
= Lower false swelling = lower technical faults = no over
correction . No under correction
= tissue effectivness diagram is flat from month 1-9 then
decreases
In rats high dose BDDE links to cancer !

24. Revanesse prosucts family
Revanesse Ultra  high voscosity ( means more hardness grade or G”)
Highest potency to correct folds and wrinkles so uses for Deep Folds
= Nasolabial . Lips . commisure . Pre jowl sulcus .
Injection site : Deep dermis or Hypoderm
Retrograde inj. Linear threading And cross hatching
Duration Time : 9 – 12 month

25. Indications : Vermilion . Philtrum . Lips .
Commisure  Best choice .
Subcutaneous and deep dermis .
Duratin : 9 – 12 month
Retrograde injection and fan like

26. Lowest viscosity
Indications : barcode lines around mouth .
Around eyes . Glabella .
Duration time : 9 – 12 month
Inj. Site : superficial dermis
Retrograde injection linear threting

27. Indications : Nasolabial . Facial contouring . Cheeks
Inj. Site : hypodermis or Deep dermis
Retrograde inj. Fan And cross hatching
Addition : cephadex positive charge beeds 25 mg
Inj . For lips prohibited == cyst formation
Superficial inj . == FBG
Duration : 12 month

28. Indications : Nasolabial . Facial contouring . Cheeks
Inj. Site : hypodermis or Deep dermis
Retrograde inj fan And cross hatching
Addition : cephadex positive charge beeds 50 mg
HA percentage is : 17 mg
Inj . For lips prohibited == cyst formation
Superficial inj . == FBG
Duration : 24 month

29. Mesotherapy = facial fine wrinkles . Dehydrated
skins : atopic dermatitis . Xerous dermatosis . Post
menopausal womens . Increasind skin elasticity and
Texture .
Duration : 10 – 14 days
Protocole : monthly inj. * 3 then every 6 month
Inj. Site : very superficial  serial pucture or
retrograde

30. Pre procedure care
1.anesthesia 2.prophylactic vit k ( arnica ) recomen to reduces bruising 3.prophylactic antibiotic not needed routinly 4.cutaneous disinfection with betadine . Alcohol . Cutasept. Alprospt , …. 5.store in room temperature 20 min before inj. Reduces filler Viscosity 6.usage of two different filler brand in same site is prohibited but one company fillers is not 7. patients with history of herpes ( cold sore ) should take prophilactic acyclovir one tab per day

31. Post procedure care
1.gentle massage for about min two fingers by one hands or one finger by two hands 2.some side effects ( or comlications ) are : swelling . Redness . Bruising . Slight bleednig . Tenderness . Bumps & hardness in skin . Itching Normal duration is 1-3 days may be 7 days long . corticosteroids & NSAIDS not needed usualy only in extent tissue swelling first choice is IM steroids . = normally = first day = ice pack or cold copmress 20 min ON & OFF and then warm compress enough . 3.if btissue bletchinh appears = stop inj. Immeditely = warm compress = massage = topical nitroglycerine 4.avoid physical exercise in first 24 hours. 5.avoid make up until 24 hours . 6.correction always should perform after 3-4 weeks

32. Thanks
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