Cosmetic Fillers:
Restylane, Perlane, Radiesse, Sculptra, and Artefill

While bovine Collagen (Zyderm ® and Zyplast ®) has been the main product used for correction of facial wrinkles and folds since the late 1970's the field of facial fillers has mushroomed over the last several years to an amazing array of exciting new products.  In Dr. Zemplenyi's practice Collagen and Cosmoderm have been replaced with new fillers including Restylane, Perlane, Juvederm, Radiesse, Sculptra and Artefill. Each of these substances has its own advantages for wrinkle treatment discussed below. Injection of any of these fillers may be combined with an addition rejuvenation of forehead and crows feet with Botox. 

All of the available fillers are very useful for treatment of wrinkles, folds and depressed scars (acne and traumatic) as well as sagging of tissues due to age-related volume loss.  For reduction of bruising and swelling Dr. Zemplenyi suggests use of Arnica Montana and avoidance of aspirin and  ANSAIDs such as Motrin and Alleve for about one week prior to the wrinkle treatment injection. Cooling with ice or a special cooling machine is sometimes used for increased comfort.  Dr. Zemplenyi also sometimes prescribes oral Prednisone on the day of the wrinkle treatment for further decrease of swelling especially with injection of the lips.   Following resolution of mild redness, swelling and bruising (if any), all fillers look about the same a few days following their injection if used in equivalent volumes.  However, persistence of the fillers depends on many variables such as the site of injection, the natural rate of degradation and absorption and patient's metabolism and the injection technique utilized.  All of these substances with the exception of Artefill  are fully absorbable by the body, and thus they require periodic re-injections.

Restylane ® (hyalorunic acid) became available in the United States in 2004 while it has been used extensively and very successfully in Canada and Europe since late 1990's.  Restylane™ is available as a clear, smoothly-injecting gel packaged in 1cc syringes.  Hyalorunic acid, a large sugar molecule (polysaccharide), occurs naturally in the base membrane of the human skin. Commercially it is manufactured using bacterial amplification technology. Hyalorunic acid molecules do not produce allergic reactions, and thus skin testing for allergies is not necessary prior to the treatment. Correction of folds and lines may be achieved during the first consultation with Dr. Zemplenyi.  Mild burning, redness, tenderness, swelling and bruising may sometimes be seen at the site of the injected folds and may last for a few days.  The procedure is tolerated very well, cover-up make-up may be applied immediately following the injections and downtime is eliminated or minimized. The vast majority of patients do not experience any need for interruption of work or social obligations. Correction of the lines and folds lasts about six months but some additional filling of lines may be needed sooner and is recommended on a follow-up visit within two weeks of the original injection. Upper and lower lips may be enhanced with Restylane or Perlane, and Dr. Zemplenyi often performs this wrinkle treatment procedure using a topical and a local anesthetic block for maximum patient comfort. 

Juvederm ® is another hyalorunic acid released in the United States in 2007 by Allergan (the manufacturer of Botox A) designed to compete with the very successful Restylane.  While each syringe contains more cross-linked material in a higher concentration than Restylane uniformly dispersed in a gel,  Dr. Zemplenyi finds Juvederm Ultra ™ to be very comparable but not superior to Restylane with respect to duration, filling or ease of use. 

Perlane ® is a sister substance of Restylane containing larger particles of hyalorunic acid in a higher concentration.  It stays longer than Restylane in the augmented, treated folds, wrinkles, lips and scars. It was released by the FDA in the United States in 2007, and is quickly becoming a very popular hyalorunic acid product.  Perlane may be used in the same sites as Restylane and Juvederm but it is injected into a deeper plane under the skin surface.  Because of its longer duration Perlane may also be used for volumetric augmentation (correction) of cheeks, orbital rim hollowing, wasting of the temples, etc. Patient's own (native) collagen synthesis may be induced by the longer presence of Perlane in the tissues. 

Radiesse ® (synthetic hydroxyl apatite), formerly called Radience, is a naturally occurring component of the matrix found in bones. While large experience exists with this product in an "off-label " application since about 2002 the FDA approved Radiesse for cosmetic application in 2006.  For increased comfort Radiesse is injected along with small amounts of a local anesthetic at the injection sites, and the treatments are very well tolerated.   Application of ice diminishes the discomfort. In some patients persistence of augmentation exceeding one to two years, especially if a touch-up correction is performed  in two to four weeks following the initial treament.  Radiesse is somewhat more expensive than the hyalorunic acids but each 1.3 cc syringe contains more of the filler substance material making the higher charge a cost-effective choice. Radiesse is now FDA-approved for cosmetic improvement of facial folds and wrinkles as well as for augmentation treatment of volumetric loss and lipo-atrophy such as seen with aging or in patients with HIV.

Sculptra ®, known in Europe as Nufill, that has been available outside of the United States for about ten years for treatment of volumetric defects of cheeks related to loss of fat and muscle. In 2004 it was officially approved by the FDA for treatment of lipo-atrophy such as seen in men infected with HIV.  It is now used very successfully for volumetric augmentation and reversal of soft tissue atrophy as seen with the aging process of the face.  Sculptra (L-polylactic acid) has been demonstrated to induce synthesis of patient's own (native) collagen at the injection site, and this effect may persist for more than two years.  While it is clear that new collagen formation occurs, there exists individual variation in the actual amount of collagen produced by each treatment. In general three or more serial treatment sessions spaced about four weeks apart are needed to promote enough collagen synthesis. Due to the actual particulate size, Sculptra is injected through a larger gauge needle than Restylane and Collagen, and some bruising is possible. Sculptra plays an important role not only for patients needing augmentation of larger volumes of soft tissue, but it may be used as the main cosmetic filler for three-dimensional improvement of all facial regions. While Sculptra is injected into the deeper tissues and takes several weeks for a maximal effect to appear, it may be combined with Restylane injected into the superficial layers of skin for an immediate improvement.

Artefill ® has stirred much excitement over its approval - after much investigation by the FDA in 2007 for augmentation of naso-labial (melolabial) folds.  Artefill is an improved reformulation of Artecoll that has been used since mid 1990's in Europe and Canada.  It consists of a permanent, non-absorbable substance (polymethyl methacrylate microspheres) that has been used for hard contact lenses for many years. The non-absorbable microspheres are suspended in a bovine, absorbable collagen gel.  As the bovine collagen is broken down by the body, new native collagen is synthesized as a reaction to the non-absorbable polymethyl methacrylate microspheres.  This native collagen has been shown to persist for at least five years. Thus,  patients may achieve very longstanding or permanent correction of folds.  However, a patient being treated with Artefill must accept a very small risk of a significant, local foreign body reaction that may rarely occur as the skin over-reacts to the injected, permanent foreign substance.  While such a rare foreign body granuloma is treatable a permanent scarring at the site of the reaction could result.   A collagen skin test is required prior to treatment with Artefill.  While Dr. Zemplenyi has been selective and cautious with the use of Artefill,  the treated patients have been so far extremely pleased with the achieved results.