Fillers & Injectables
Bringing Xeomin®, Restylane®, Radiesse®, and More to the Boston, Massachusetts and Manchester, New Hampshire Area
Many patients would like to do as much as possible to reverse or soften the changes produced by aging and environmental conditions, but just do not want surgery. In response to this increasing demand, a number of products have appeared and become very popular. They are: Xeomin® (Botulinum Toxin Type A) (which safely weakens muscles creating facial creases or expression lines), and dermal fillers (such as Restylane® and Radiesse®) that augment and support the areas that have flattened or begun to sag as a result of aging; or fill out creases, lines, and folds. We offer both dermal fillers, like Radiesse® and Restylane®, and Xeomin® (Botulinum Toxin Type A) at our practice, located between Manchester, New Hampshire and Boston, Massachusetts.
Xeomin® (Botulinum Toxin Type A)
Xeomin® is a wonderful medication, and is particularly useful to decrease frown lines, the creases around the corners of the eye (“crow’s feet”), lines around the mouth (“smoker’s lines”), and can even lessen the bands that occur in the neck with aging. As an adjunct to the use of fillers to rejuvenate the lips and surrounding area, Xeomin® injections can also decrease the tendency of the corners of the mouth to turn down, which may give the patient an angry or unhappy appearance.
Xeomin® (Botulinum Toxin Type A) is especially useful in situations where lines are created by dynamic muscle activity (for example, frown lines or crow’s feet caused by constant muscle contraction). As time progresses, surgeons become more and more inventive in their use of this safe medication, and doubtless other applications will follow.
The Xeomin® treatment result is even better when used in combination with a filler to smooth area creases.
Fillers – Type and Application
Fillers are most useful in two ways: as treatment for lines that are “static” rather than “dynamic” (in other words, lines that are within the texture of the skin even when the face is at rest and are not produced by muscle activity); and as additional treatment in areas where Xeomin® (Botulinum Toxin Type A) has been used. For example, a patient with deep frown lines may have only partial improvement with Xeomin® injections alone, whereas the combination of Xeomin® injections and a filler can obtain more significant change.
There are numerous fillers on the market. Some are purely temporary, like Restylane®, JUVÉDERM™ Injectable Gel, and Radiesse®, and those are the type that I use most commonly. My concern about permanent fillers has been simply that if the result is not perfect, the imperfection will last indefinitely, whereas with a temporary filler it eventually disappears. In other words, the best thing about permanent fillers is also the worst thing about permanent fillers.
However, the idea of a permanent or semi-permanent filler is attractive, not only to decrease patient cost but also inconvenience. Over the last few years, I have developed a great deal of experience with the temporary fillers, which puts me in a better position to use semi-permanent fillers where they will be most effective with the confidence that the chance of an imperfect result for one of my patients will be very low.
The uses of fillers have greatly increased in the last year, so that it is now possible to smooth jowls, decrease the appearance of lower lid bags, or lift cheekbones with fillers. Even though most of the fillers are not permanent, results can often last 12 months or more.
Restylane®, a hyaluronic acid product, was the first of the fillers to be approved in 2003, and has become extremely popular, deservedly so. It is an excellent material that can be used to soften the folds on each side of the upper lip (the nasolabial folds), soften the creases that appear between the corner of the mouth and the chin (“marionette lines”), and improve crow’s feet, frown lines, or smoker’s lines. This is often most effective when Restylane® is used in conjunction with Xeomin® (Botulinum Toxin Type A) at our New Hampshire practice, south of Manchester and north of Boston, Massachusetts. Restylane® can smooth the jawline where jowls appear, and even lift the brows. Restylane® is especially useful where the lines or folds are created by skin texture changes rather than muscle hyperactivity (like forehead creases or frown lines), whereas Xeomin® injections should be used in conjunction.
In all of these areas the improvement lasts from four to six months.
Restylane® is also excellent for lip augmentation.
Restylane® Lower Eyelid Rejuvenation
Restylane® can also be used to decrease the crease that appears in the lower lid at its junction with the cheek. This crease becomes deeper with aging, and exaggerates any puffiness in the lower lids. Patients who do not wish to have blepharoplasty (which corrects both the puffiness and the crease) can undergo Restylane® injections into the skin overlying the crease instead, which softens the transition from lid to cheek and therefore makes the lower lids seem flatter. This is a simple procedure, and often lasts nine months or longer.
As a general rule, in most areas Restylane® lasts approximately six months, with some variation among patients, often longer and occasionally shorter. The material can be re-injected as often as the patient wishes, unlike Xeomin® (Botulinum Toxin Type A), which can only be repeated at three-month intervals or longer.
The amount of correction depends upon the depth of the crease and the condition of the skin. Some patient’s skin is coarse and stiff, and responds less strikingly, whereas patients with very fine skin and fewer aging changes will respond better. In most patients, at least a 50 percent improvement in the depth of the crease can be obtained.
Radiesse® was approved by the FDA in 2006. It is an injectable filler material composed of synthetic calcium hydroxylapatite microspheres suspended in a carrier gel. The components of the calcium hydroxylapatite occur naturally in the body and therefore are completely compatible with human tissues. Like Restylane®, the results from extensive studies demonstrate that the material is biocompatible, non-toxic and non-irritating. Unlike collagen injections, to which occasional patients are allergic, sensitivity testing is not required.
Radiesse® can also be used to fill out hollows in the cheeks, marionette lines, lines around the lips (but not in them), jowl area and the corners of the mouth. Radiesse® is always performed under a combination of regional nerve block local anesthesia and direct infiltration to minimize discomfort.
Because of its composition, Radiesse® is “thicker” and “stiffer” as a material; think of the difference between injecting a material like molasses (analogous to Restylane®) and toothpaste (analogous to Radiesse®). For this reason, Radiesse® is more supportive and is used in a slightly different way.
Injected under the nasolabial folds, Radiesse® can lift the fold like Restylane®. However, injected over the cheek bone prominences (an area that flattens with aging), Radiesse® will lift the cheeks and therefore flatten the folds below it (in the nasolabial and marionette areas). Additional Radiesse® injected into those locations and along the jowls, can give additional improvement.
Mechanism of Action
When placed into soft tissue, Radiesse® provides immediate correction. Over time, the carrier gel is absorbed and the calcium particles remain. Local tissue response at the injection site appears to result in the production of new collagen around the calcium, therefore prolonging the improvement.
Over time, the calcium particles are broken down and eliminated through the body. The report of longevity of correction in the face ranges from 10 – 14 months, with an average correction of one year.
Radiesse® Facial Rejuvenation
Radiesse® is mixed with an anesthetic to provide an analgesic effect before injecting. Radiesse® can be used to lift the tissues over the cheek bones, which does two important things. First, the extra support under the cheek bone skin lifts the tissues below it, in some patients almost to the jaw line; and secondly, bringing the cheek bones forward makes the lower lids appear flatter and more youthful. Thus Radiesse® can change the relationship between the aging lower lid (which often protrudes in front of the cheek bone) and the more youthful lower lid (which is behind the cheek bone).
In addition, Radiesse® can be used to bring the chin pad forward, to fill in the “marionette line” areas below the corners of the mouth, and to smooth the jowls, fill cheek hollows to smooth the nasolabial fold areas, and soften upper lip lines as a result of aging or HIV infection.
Xeomin® (Botulinum Toxin Type A) and Filler Combinations
Because Xeomin® (Botulinum Toxin Type A) and dermal fillers each treat different “wrinkle” aspects, combined use of both is often better than either used alone.
Smoker’s lines, frown lines, forehead creases, crow’s feet, and lines at the corners of the mouth may benefit from such dual treatment. On occasion, we can administer both a filler, such as Restylane®, and Xeomin® (Botulinum Toxin Type A) in one session at our office near Manchester, New Hampshire and Boston, Massachusetts, but sometimes the result is better if one is done first and the other about 14 days later.
All of the fillers and injectables can be performed in the office under either topical cream anesthesia or regional blocks with injected local anesthesia. Most patients need no sedation and can drive themselves home or back to work following the procedure. However, if a patient prefers, we can supply oral medication that would be taken in the office shortly before the procedure to decrease anxiety; in that case, the patient will feel relaxed and perhaps slightly sleepy, and would need a ride home.
Limited Surgical Procedures
Please remember also that many additional procedures for the aging face have become simpler and less invasive: the “no touch” blepharoplasty, in which the fat and skin are altered but the muscle is not touched, decreases recovery time; the neck lift through a single incision under the chin; and the short scar facelift, in which the cheeks are tightened through an incision in front of the ear, without extensions behind the ear or into the hair bearing scalp. These procedures are covered under their appropriate sections.
Unlike surgery, which requires outpatient hospitalization and general anesthesia, patients return home or to work immediately after filler and Xeomin® injections. However, there is a small amount of recovery after filler treatment. After Restylane® injections, the treated areas are firm, slightly tender, and there is a small amount of swelling and redness in the surrounding tissues. All of this fades over 7 – 10 days and can be easily disguised with make-up. It is not necessary to take time off from work. There will be bruising after Radiesse® injections that can last for 2 – 3 weeks. Arnica Gel used topically and taking Arnica tablets help reduce the severity and duration of the bruising. Bruising may be covered with make-up. Our Nashua office uses GLO Minerals Make-up, a mineral-based make-up.
In combination, Xeomin® (Botulinum Toxin Type A), Restylane®, and Radiesse® can accomplish a great deal of non-surgical lifting and smoothing of facial structures. Compared to surgery, there is of course less cost and less recovery, with no hospitalization. However, fillers and surgery cannot reach the same endpoint because they are different modalities. Some patients will select one and some the other; we are happy to provide whichever pathway a patient selects.
Contact Our Practice
If you are considering treatment with a product like Xeomin® (Botulinum Toxin Type A) or Restylane®, please contact our New Hampshire practice, between Manchester and Boston, Massachusetts.