The Power of Injectables
Offering quick and relatively easy solutions to newly named concerns like the “Zoom effect,” many aesthetic practitioners reported sustained consumer demand for injectables despite the pandemic. According to Robyn Siperstein, MD, of Siperstein Dermatology Group in Boca Raton and Boynton Beach, Fla., demand for injectables is up but with a post-pandemic shift in areas of concern.
“We are doing a lot more work off the front of the face, which used to be the main interest of those unhappy with their photos,” she shared. “Now treatments on the side of the face, such as the jawline, temples and lateral cheeks are more popular since patients are now unhappy with their 3D image and side profiles, which they see constantly on social media, Zoom and Facetime.”
Injectables were the most popular minimally invasive procedures performed in 2020, based on the latest American Society of Plastic Surgeons (ASPS) statistics. ASPS surgeons reported about 8.8 million botulinum toxin type A treatments (the number one minimally invasive procedure) and soft tissue filler procedures (second most popular) that year.
The most recent statistics released by the International Society of Aesthetic Plastic Surgery (ISAPS) suggest that while there was an overall decrease of nearly 11% in aesthetic surgery globally in 2020, nonsurgical hyaluronic acid (HA) filler procedures increased. The top five nonsurgical procedures globally mimicked the ASPS findings, with botulinum toxin leading in popularity, followed by HA fillers.
As positive as this sounds, it is only the beginning. “We are just beginning to understand the power of injectables,” stated Alexander Z. Rivkin, MD, assistant clinical professor at the David Geffen UCLA School of Medicine and owner of Rivkin Westside Aesthetics in Los Angeles, Calif. Furthermore, consumer acceptance of, and comfort with, cosmetic dermal filler and neuromodulation treatments are also in the early stages, he added.
Dr. Rivkin predicts exciting things to come, not only for clinicians as they learn more about injectables and have more products at their disposal but also for patients as they start to more fully embrace injectable treatments in the coming years. “Just over the last few years, the number of people admitting to using injectables, and millennials talking about injectables on social media, has increased,” Dr. Rivkin pointed out. “This is an entirely new phenomenon and I think injectable treatments will continue to grow in popularity, becoming more accepted and more of a routine in life.”
Trends, products and techniques are changing the injectable marketplace. Gideon Kwok, DO, co-owner and medical director of seven Skin Perfect medical clinics in Southern California, says he is seeing a few trends in the use of injectables. “One is a reversal of the old injectable ways, with more patients coming in to have their facial fillers dissolved because of migration issues, especially if their lips have been “overfilled” or the injector went into the deeper planes.”
The big lip look of the past is evolving into patients desiring a natural look to the lips, but still wanting to improve the height and definition of the borders. “They are not as interested in the huge juicy ‘overfilled’ lips,” Dr. Kwok reiterated.
A technique that helps achieve the desired outcome is the tenting technique, during which Dr. Kwok begins injecting fillers more from the top, at the vermillion border, and works down toward the mucosal, or wet-dry border. This technique, in which he threads the filler more vertically than horizontally, makes it less likely that the filler will migrate and creates a more open (less bulky) look to the lips.
Another evolution in the marketplace: natural fillers. Although there are many phenomenal HA fillers on the market, some patients and practitioners prefer to offer aesthetic solutions that are not synthetic, said facial plastic surgeon Kian Karimi, MD, founder and medical director of Rejuva Medical Aesthetics in Los Angeles, Calif.
“ezGEL from CosmoFrance (Miami, Fla.) allows practitioners to offer their patients a completely natural way to enhance their beauty,” Dr. Karimi stated. “ezGEL is created by a proprietary system of heating and cooling whole blood after centrifugation to create albuminrich, platelet-rich fibrin (PRF) and pure PRF – these two are mixed together to create the ultimate gel. ezGEL is useful for temporary volumization and improved appearance of areas such as under-eye circles and hollows. [It] can be injected into the skin, subcutaneous tissues, and used topically.”
It can also be mixed with commercial HA fillers to create a platelet buffer for some of these fillers. According to Dr. Karimi, “ezGEL is also an excellent solution for reconstructive issues with the face and body including hollows created by trauma, infection, prior surgery, or energy-based devices that caused an inadvertent loss of fat.”
Neurotoxin use also continues to evolve. For example, investigators are looking into delivering higher doses of concentrated neurotoxins to determine whether they can safely increase the duration of eff ect, Dr. Rivkin reported. While more research is needed to determine whether high-dose neurotoxins are safe and effective for a longer duration, not all dosing strategies pan out completely. On the other end of the spectrum, in Dr. Kwok’s experience, neurotoxin micro-dosing, which has been used in recent years at cosmetic practices, has its benefits and drawbacks.
“Micro-toxin is beautiful, you can minimize wrinkling, tighten the skin, and things like that, but when you are talking about microdosing, you are also talking about less longevity to your toxins,” Dr. Kwok added. “With toxins, dose equals duration. Micro-toxin is a great concept for those who have the extra money and time to do it. But I think the other thing you need to think about is antigenicity – are you going to end up with somebody with neutralized antibodies?”
One way to potentially avoid neutralizing antibodies is by using products like XEOMIN® from Merz Aesthetics or, if it is approved, DAXI from Allergan Aesthetics, an AbbVie Company. As Dr. Kwok explained, these products are naked proteins. They do not have as many of the accessory proteins that, theoretically, can cause neutralizing antibodies. However, “The industry is still studying whether that is true or not,” he asserted. “The washout period is at least five years before re-trying neurotoxins, and when you re-try, you have to use the naked protein.”
While training clinicians on neurotoxin use, Dr. Kwok often hears students say they will use a lower dose for a more natural look. But that is not how it works; he contends. “Toxins have an on and off switch. The more toxins you put in, the longer the duration. The way you place your toxins in the muscle groups affects how you will create a more natural look based on hitting the origin, rather than the insertion of the muscle,” Dr. Kwok explained.
Dr. Kwok also warns injectors to beware of using neurotoxins in the upper lip, “Yes, you are adding a tiny amount, but your patients have to come in every six weeks to get neurotoxin. Unless you inject XEOMIN in the area, you are priming the body for potentially producing neutralizing antibodies. And is that muscle really going to relax enough to give that patient a lip lift?” he queried.
What and Where?
Dr. Rivkin is seeing a sharp increase in demand for temporary and permanent nonsurgical rhinoplasty. “Patients are very well educated by the internet and social media. They know that nasal contours can be corrected safely and effectively, even with permanent fillers,” he shared.
For temporary fi llers in nonsurgical rhinoplasty, Dr. Rivkin tends to use Juvéderm® Voluma (Allergan Aesthetics) and Restylane® Lyft from Galderma. He uses Bellafi ll® from Suneva Medical as a permanent filler in the nose. “I’ve been using Bellafill over the last decade and am very comfortable using it. I think it is a great product and is very safe. Now, most of my liquid rhinoplasties are becoming permanent noses,” Dr. Rivkin expressed.
Training is key for optimal liquid rhinoplasty outcomes. “Nose treatments are becoming more and more popular with online videos advertising ten-minute nonsurgical nose jobs,” Dr. Siperstein began. “While this procedure can be safe [from] those knowledgeable of anatomy and safer injection techniques, it can also lead to permanent blindness, especially from those without this knowledge.”
Dr. Kwok, who is admittedly a big Galderma filler user, thinks the company has done a great job in recent years with its XpresHAn™ technology, including Restylane® Kysse for the lips and, more recently, Restylane® Contour, which is indicated for the cheeks, but he is using it to make fuller lips.
“Contour takes Kysse to the next level. Kysse is more of a mild lip plumper while Contour is going to give you more of a look like you ate a jalapeno pepper, but still with naturalness and nice definition,” Dr. Kwok revealed. “I let my patients dictate what they want because, at the end of the day, it is something they have to live with. Still, I think patients are loving the use of Contour in their lips.”
Dr. Kwok also called out two important approvals: Radiesse® (Merz) for a jawline indication, making the calcium hydroxylapatite (CaHA) filler the first approved to contour the jawline, and Juvéderm®’ Volbella (Allergan), which is already approved for injection into the lips and skin around the lips, receiving an expanded indication for the infraorbital hollow.
Dr. Siperstein says she is excited about the first FDA approval for undereye filler granted to Juvéderm Volbella, so this area is no longer “off-label;” however, she recommends that future injectors are educated on best practices before starting in this advanced area.
While treating the undereye area can be incredibly gratifying, it can also cause many long-term aesthetic complications, Dr. Siperstein stressed. “Delayed onset swelling can happen many years after treatment, so it is important that patients and injectors are properly educated on this topic. I have had patients who went for extensive medical workup because their physician falsely assumed swelling could not be related to filler done five years earlier,” Dr. Siperstein shared. “It is vital that both patients and physicians are properly educated so that this side effect can be easily reversed by using hyaluronidase instead of sending patients for costly CT scans that subject them to unnecessary radiation exposure.”
As a tip, Dr. Siperstein suggests that when treating with fillers around the eye region, it is essential to place the majority of the product deep to prevent blockage of the superficial lymphatics, and always inject the cheeks first. Dr. Siperstein authored a retrospective review of over 700 infraorbital injections published in April 2022 in the Journal of Clinical and Aesthetic Dermatology (JCAD). She found no difference between side effects when using either Restylane-L, Juvéderm Volbella or Belotero® (Merz) in this area but did note that if less was used (<0.55), there was significantly less post-procedure swelling. In this article, she also shared her technique to decrease swelling by adding 1 mg of triamcinolone.
Dr. Kwok no longer uses Volbella or other fillers with Vycross technology because of the potential for late onset nodules. In a study published in 2019 in Dermatologic Surgery, researchers concluded: “The introduction of [Vycross] HAs introduced a new variable that may be changing the immune tolerance of these substances, resulting in a higher incidence of delayed nodules than previously expected.”
For the under eyes, Dr. Kwok uses Restylane products, especially Lyft and Kysse, “I think it is best for practitioners to figure out their tools in the toolbox and understand rheology, or the characteristics of these products,” Dr. Kwok emphasized. “I use Restylane Lyft when I am treating the undereye area because it is more of a filler to use in the upper mid-cheek to create foundational support, which is what I want. For a softer undereye, or to treat slight undereye hollowness, I might use something lighter, like Belotero or Restylane Kysse. You can also combine fillers, using one as a foundation and another superficially.”
For lips, the mid-face and temples, Dr. Rivkin speculated that a filler not yet approved for use in the U.S. might make a big splash; “Profil from Allergan is a more robust HA filler that is great for sculpting the jawline, chin and cheeks,” he began. “I think it will be an interesting tool because it is a firm, long-lasting filler. It will be helpful for temples as well because you will be able to put it in very deep.”
Thoughts about fat
Fat grafting is more limited to dermatologists and plastic surgeons who have surgical experience and offer liposuction, which is how one harvests the fat, Dr. Kwok stated. There is; however, an off-the-shelf option: Renuva from MTF Biologics. “MTF Biologics has taken and killed off all the live fat cells but left the honeycomb, called the fat matrix. You slightly rehydrate it and inject it into the face, buttocks or wherever, and you can cause the body to stimulate fat to grow into those areas,” Dr. Kwok explained. Dr. Rivkin stated that he does not use much fat for cosmetic injection, “I don’t think fat is a reliable volumizer, so I do not use it. I use both temporary and permanent fillers and my results are really good, so I have not needed to go to fat.”
Know your anatomy and how to use these products
While FDA approvals are to evaluate a product’s longevity and safety, and are often based on perception and subjective values, Dr. Kwok believes that cosmetic injectors need practical training in each indication to achieve the best outcomes. “We highly recommend that injectors continually and constantly further their education and skills. They can go to conferences, hire people they know in the industry for private training or do a shadowing day with leaders in the industry,” Dr. Kwok advised. Even company training on a specific filler, while valuable, has its limitations. Trainers can only train on-label and cannot talk about off-label products.
Knowledge of facial anatomy is critical to safe and effective injection techniques. Understanding the location of the important vessels is key to avoiding complications like ischemia and necrosis, Dr. Rivkin added.
Overfilling the face with dermal fillers is also an issue, Dr. Kwok indicated. “We know from studies with CT scans and ultrasounds that fillers can be detected in the tissue for 12 years and longer,” he reported. “Patients need to understand that they should not get overfilled. They need to understand that the face ages in totality, so it is not appropriate to do the same thing you did six months ago. We potentially need to inject other areas to avoid overfilling.”
Some injectors have started using ultrasound as an injection tool to increase safety. And while ultrasound increases one’s visualization of an area, making it easier to avoid blood vessels, Dr. Kwok feels the technology also takes away from the clinician’s artistry. “When injecting with ultrasound, you do not see what you are changing,” Dr. Kwok elaborated. “I am not sure of the viability of ultrasound in the majority of practices. I think having ultrasound is nice from a teaching perspective, but I am still questioning how it will be used in the mainstream.”
In Dr. Siperstein’s opinion, visualization technology is a great tool. Along with the use of microcannulas for filler injection, she said the Accuvein vein visualization technology has transformed her practice by decreasing bruising substantially.
Tentech (South Korea), claims that the cross-linking agent used in its line of HA fillers is among the differentiators of its dermal fillers. These fillers, which are not yet FDA approved, include Fine Fill, for fine lines under the eyes, eye bags and lips; Rhino Fill, for elevating the nose; and Regevan Fill, for overall volume on the cheekbones, nasolabial folds, temples, forehead and chin.
According to the company, many cross-linking agents, which are essential for HA fillers, can be highly toxic. Tentech claims to have found a solution to the existing cross-linking agent problem with a completely new material, divinyl sulfone (DVS).
“The reaction [from DVS] is over in 20 minutes,” said Ro Young Woo, MD, a dermatologist at Cheongdam Oracle Dermatology in Seoul, South Korea. “The fact that the reaction in the body ends quickly means that there is no crosslinking agent remaining in the body, thus there is no instance of the human body being exposed to toxic cross-linking agents long-term. And these fillers last for 8-14 months…,” Dr. Woo stated.