Ophthalmologists who use botulinum toxin type A to help patients improve their appearance should add the use of hyaluronic acid (HA) fillers to their procedures because they have many ideal characteristics, recommends one oculoplastics specialist. HA fillers are made of natural substances; no toxic effects are known. They can be used alone or in combination with permanent procedures such as fat transplantation; they have a combined effect with botulinum toxin; and they can be eliminated, if needed, through the use of hyaluronidase. HA fillers also have a low incidence of side effects, are easily stored, do not need to be refrigerated, and come in preloaded syringes with small needles.
HA fillers have many ideal characteristics, said Dr. Perry, an oculoplastics specialist at Cleveland Clinic's Cole Eye Institute, which sponsored the meeting. They are made of natural substances; no toxic effects are known. They can be used alone or in combination with permanent procedures such as fat transplantation; they have a combined effect with botulinum toxin; and they can be eliminated, if needed, through the use of hyaluronidase.
"They have a low incidence of side effects, and their use is technically quite straightforward," he said. "The materials are easily stored, they do not need to be refrigerated, they come in preloaded syringes, and there is a small needle size for delivery."
They also work well with periorbital hollows, elevation of the corners of the mouth, and lip contouring, Dr. Perry said. "There are many, many uses-including the jaw line and the hands-and the uses are expanding," he said. "The only limitation is the ingenuity of the injector."
Types of fillers
Basic HA fillers available in the United States today include Captique (Allergan), Hyala-form (Inamed Aesthetics, a division of Allergan), Restylane (Medicis Aesthetics), and Juvéderm (Allergan), Dr. Perry said.
Hyalaform also was approved in 2004, he said, but it has its own downsides: it is made from rooster combs, so it theoretically contains animal antigens, and although it lasts longer than Captique, it does not last as long as Restylane.
Juvéderm was approved in 2006, and its two formulations-Juvéderm Ultra and Juvéderm Ultra Plus-have a smoother consistency than Restylane, Dr. Perry said. He said he uses it in the nasolabial folds and periorbital hollows with good success.
"I find it works a little better in the lips and around the eyes because it is a little less bumpy, which yields greater patient satisfaction," Dr. Perry said. "My early experience with this is very encouraging."
He called Restylane the gold standard of the HA fillers. It originally received FDA approval in 2003 and now comes in three formulations for use in the United States: Restylane, Restylane Fine Lines, and Perlane. All have the same amount of HA but differ in their particle size. The fine-lines formula is best suited for the more superficial dermis, the regular formula is suited for the mid dermis, and Perlane is best for the deep dermis, Dr. Perry said. Perlane received FDA approval for use in the United States in May.
Restylane formulations will last 6 to 18 months and are best for static rhytides and hollow areas that need volume augmentation, as opposed to botulinum toxin, which is better for dynamic rhytides, he said.