Basics of Dermal Filler Flashcards
What are dermal fillers and what can they do?
Dermal fillers
-helps to restore the volume of the face (~fill) which we lose when we age due to loss of subcutaneous fat
-help to diminish the appearance of fine lines, wrinkles or hollowed areas
Fillers can be used for a variety of purposes:
-fine lines, wrinkles (crow’s feet, marionette lines, nasolabial folds, worry lines or laugh lines)
-hollowed areas (cheek or eye troughs)
-restore volume of lips
-skin dimpling from acne scarring
-scars from burns
Explain the different types of dermal fillers and what they can be used for:
-calcium hydroxapatite (radiesse)
-hyaluronic acid (juvederm etc)
-polylactic acid (sculptra)
-polyakylmide (aquamid)
-PMMA (bellafill)
Types of dermal fillers
-hyaluronic acid vs stimulatory fillers (stimulate collagen for example sculptra or radiesse)
-temporary fillers (e.g hyaluronic acid) vs semi-permanent fillers (PMMA bellafill or polyakylmide aquamid)
1.calcium hydroxapatite (radiesse)
Natural Mineral found in the bones and teeth in the body. As a filler, it stimulates fibroblasts to produce collagen and elastin +proteoglycans. Therefore, it is useful in treating areas where there is loss of collagen due to ageing or in HIV patients where there is facial lipoatrophy.
Treat areas:
-deep nasolabial folds
-facial wasting in HIV patients on anti-retroviral therapy
-loss of volume in midface
- hyaluronic acid (juvederm etc)
Naturally found in skin, connective tissue and joint areas in the body. It is hydrophilic and attracts water, therefore is useful in restoring volume of the face.
Treat areas:
-thin lips
-cheek area where there is loss of volume
-skin pitting from acne
-fine lines around eyes, nasolabial folds, forehead etc.
- polylactic acid (sculptra)
Stimulatory filler that stimulates fibroblasts to produce collagen. Takes time for collagen production and produces a more subtle result. Need 3 monthly treatments and 4-6 weeks to see full effect.
Treat areas (esp good for lower half of face)
-nasolabial folds; marionette lines
-restoration of midface volume loss
- polyakylmide (aquamid)
Semi-permanent filler that also stimulates collagen production.. again treats areas which need more collagen - PMMA (bellafill)
Semi-permanent filler that works differently from the rest. For patients that want a more permanent, long-lasting result instead of collagen stimulating fillers. Normally used by plastic surgeons in patients with permanent surgical implants
What are the contraindications of dermal filler?
Contraindications of dermal filler:
-allergies to local anaesthetic agents like lidocaine; to hyaluronic acid; severe allergies/anaphylactic reaction
-skin cutaneous disorder or local infection/inflammation at site
-pregnant/breastfeeding/undergoing IVF treatment
-mental health problems like body dysmorphic disorder
What are some of the common side effects of filler?
What are the adverse effects to warn them about?
How long does filler last for and what are the factors that affect the longevity?
What aftercare advice would you give regarding filler?
Common side effects of filler include:
-redness, swelling at the injection site (subside within a few days)
-temporary lumps/nodules
-assymetry
-overtreatment or undertreatment of area
Adverse reactions to filler:
-infection (e.g abscess in injection site, aseptic technique v important)
-vascular occlusion causing:
a. skin necrosis-mottling of skin/skin discolouration like pale or greyish/pins and needles/pain
b. blindness
Duration:
Filler can last from 3-12 months depending on the type of filler used, the injection technique, skin type.
Aftercare advice:
-avoid touching/rubbing face/applying makeup for at least 24 hours to prevent infection. Avoid any facials as well.
-avoid exercise, going to sauna and drinking alcohol for at least 48h to prevent redness at the injection site.
-safety netting for vascular occlusion: if they experience any changes in vision or discolouration of skin at injection site-> to contact aesthetic clinic immediately
What is G’ prime?
High G’ prime vs low G’ prime- which one is more suitable for different areas? Give examples.
Talk about the duration and G’ prime of the following Juvederm fillers:
-Volux
-Voluma
-Volift
-Volbella
-volite
G’ prime refers to the fluidity and elasticity of the filler
High G’ prime fillers are more sturdy, dense and are more suitable for deeper areas. They also last longer. E.g of high G’ prime fillers include Volux and Voluma
Low G’ prime fillers are softer and more malleable and more suitable for superficial areas. They last for a shorter period of time and are more forgiving. E.g of low G’ prime fillers include volift and volbella
Which area is suitable for high G’ prime vs low G’ prime?
High G’ prime fillers are more sturdy, dense and are more suitable for deep medial cheek fat area
Low G’ prime fillers are softer and more malleable and more suitable for superficial lateral temporal cheek fat area
How do cross-links of hyaluronic acid affect the longevity and fullness of filler?
Cross linkage of hyaluronic acid via 1,4-Butanediol diglycidyl ether (BDDE) makes it stronger and harder for enzymes to break down. Therefore lasting for longer period of time
Cross-linkage also attracts more water (more hydrophilic) to create volume
Describe the surface anatomy of lips
What are the important things to consider in examination of patient before treatment of lips?
-lip expression: puckering to look at fullness of lips
-looking at vermillion border to check for definition
-jaw: whether retrognathic or prognathic
-droopy oral commissures
Treatment of vermillion border
How would you treat the vermillion border of patient’s lips? What layer are you injecting?
What injection technique is used?
Visualize how you would do this
Vermillion border treatment:
0.25ml of filler in retrograde linear technique. Needle points towards GK point at vermillion border
Stretch the lips to allow injection. Injection of filler targets layer 2 of the subcutaneous fat; should be able to see gray of the needle (v superficial to avoid superior labial artery).
upper lip: 2X 3 injections in each vermillion border of the lip followed by 2X downward injection at the cupids bow.
Lower lip: start centrally. 2X 3 injections at border
Treatment of lip body
How would you treat body of patient’s lips? What layer are you injecting?
What injection technique is used?
Visualize how you would do this
Lip body treatment
Start with retrograde linear technique towards GK point underneath vermilion border. Injection of filler targets layer 2 of the subcutaneous fat
Inject 0.05-0.1 ml bolus towards body of lip
Avoid injecting large boluses only small amounts to avoid nodules
Volume to cupids bow
How would you add volume to cupids bow
Pinch cupids bow such as in the picture. Inject 0.05-0.1ml of filler in downward linear fashion
Aftercare of lip fillers:
What would you do after injecting fillers?
Massage lips with sterile gauze to allow filler to evenly spread
Apply plenty of antiseptic/savlon cream. Do not use occlusive products like vaseline as it can occlude injection site.
Lifting oral commissures of lips
Demonstrate technique of lifting oral commissures
What are the signs and symptoms (early and late) of vascular occlusion?
Early and late signs of vascular occlusion
Early:
Mottling of skin
Prolonged cap refill 3s
paraesthesia
pulselessness
Late:
Skin necrosis and breakdown
Infection
Symptoms:
Pain
pins and needles
Bounding pulse on palpation (as compensation for occlusion to help with perfusion)
Patient in clinic comes to you with concerns regarding lumps in her lip that have not resolved 4 weeks after her lip filler treatment?
What are the steps of hyaluronidase in controlled dissolution?
What concentration of hyaluronidase do you use in emergency dissolution?
What are the indications of hyaluronidase in controlled dissolution?
Large haematoma
Persistent nodules
Tyndall effect-where you get light refracting off particles and skin appears bluish
malar oedema-swelling in malar area after cheek filler
What do you do in the event of a filler complication?
Who should you seek advise from?
Who should you report to?
in the event of a filler complication:
-seek medical-legal advice from insuring company
-make sure that informed consent and photography is documented
You should report to the MHRA(medical and healthcare products regulatory agency) via the yellow card scheme
Also report to manufacturer
Hyaluronidase
- What are the absolute contraindications to hyaluronidase?
-What are the possible drug reactions?
Absolute contraindications:
-pregnancy/breastfeeding
-allergic reaction to hyaluronidase or allergy to insect bites/stings (saliva of biting or stinging insects have hyaluronidase)
-malignancy/infection at potential injection site
Drug reactions
-antihistamines or ibuprofen can cause resistance to hyaluronidase
Hyaluronidase
Pharmacology of drug-describe structure of hyaluronic acid
MOA-how does hyaluronidase work
What is the half life and duration of action of drug? How is it inactivated?
Brand name of drug in UK
Storage of drug:
What temp do you need to store hyaluronidase at
Pharmacology of drug-
HA is Glycosaminoglycan (GAG)-polymer of disaccharides: D-glucuronic acid and D-N-acetylglucosamine linked with B1,4 and B1,3-glycosidic bonds.
hyaluronidase is enzyme that breaks B-1,4 linkages
Half life of drug: 2-10 min; duration of action 24-48h
Brand name of drug in UK: Hyalase (wockhardt)
Storage of drug
Drug needs to be stored at cold temps 2-8 degrees. If stored at 25 degrees or more, it wont last for a long period of time (stability only for 12 months)
How do you perform intradermal patch testing?
What is a positive test?
Intradermal patch testing to check for allergies
-use large volume protocol-dilute 1500 U of hyalase in 10ml of saline. Inject 30U (0.2ml) in forearm and compare it with normal arm
Positive test
>8mm
-wheal
->50% increase in size
Hyaluronidase
What is the diff between large vs small volume protocol?
What is the indication to use large vs small volume
What other scenarios would you use higher doses of hyaluronidase
Large volume (dilute in 10ml) but low concentration. 1500U in 10ml of saline
Small volume (dilute in 1/2ml) but high concentration. 1500U in 1 or 2 ml of saline
Indication for large or small volume protocol
Small volume but high conc protocol-> useful for emergency scenarios like vascular occlusion or retinal occlusion
Large volume but low conc protocol-> for non-emergency scenarios like correction due to misplacement; nodules etc.
Think about clinical effect, what you want to achieve. High doses of hyaluronidase are useful for:
-if you want to dissolve large amount of filler
-if HA product is highly cross-linked; or high conc of HA in gel
Patient in clinic comes to you with concerns regarding purplish discolouration of her cheek where filler was injected 2 days ago. You review her.
In the event of vascular occlusion,
What are the steps to take?
Low or high volume HA? What cannula should you use? Depth of injection?
How long do you have to wait before repeating if necessary
Aftercare-how long should you observe patient in clinic for?
Follow up-how should you follow this patient up
Hyaluronidase in emergency scenarios-vascular occlusion
- Consent
-ensure no absolute contraindications: allergy to hyalase/insect bites or stings/pregnancy/breastfeeding
-ensure no malignancy or infection of area - inspect
-look at site and check skin colour, cap refill, pain. Mark out area of site and compare it with healthy site - clean
-aseptic technique to avoid risk of infection - Serial punctures of cannula use at trajectory of artery and around site using high conc/low volume hyalase. Treat depth and site area. 30G cannula with long needle
- firm massage over area to distribute product + warm compress
- wait for 5-10 minutes-> check site for colour, cap refill, pain if resolved. If still pale and cap refill >4s-> can repeat steps in 1h time
Aftercare-observation of patient 30-60min in clinic
Follow up-every few h that day. Get the patient to send you videos of them doing cap refill on their lips
