Where we stand

HW: In the US, obviously we’ve been a lot slower to get to market on a lot of the fillers. However, it’s not as though we need hundreds of options. The biggest change for our market was when Voluma was brought in, because that was the first larger HA that could give us the kind of lift that previously we needed to use a significant amount of HA to increase volume, or we had to use CaHA. Now we have a longer-lasting filler that gives lift, but can also be erased.

DD: I totally agree, Voluma is one of the most natural, softest-looking products I’ve seen.

HW: In my practice we still use a lot of the other fillers. I still use PLLA, I use CaHA, and I use some of the smaller HAs, but for certain patients I do find that Voluma is more helpful.

DD: Part of it is getting comfortable with the new fillers as they come on the market, knowing the best places to use them, and also the risks. With Voluma I’m finding that it’s my go-to product more and more, as I learn all that it can do, and as I’m seeing patients back looking beautiful, natural and so happy with their results. But I have my favorites for different places, so I still prefer Restylane or Belotero under the eyes, and Juvéderm for the lips. The only product I use in the hands is Radiesse. If I need a volumizer for someone who’s a fitness trainer or someone who has a lot of lipoatrophy, sometimes I’ll use Sculptra for a few sessions just to build them up a little bit locally or pan-facially, and then I’ll start building with an HA. So, Voluma is starting to eat a little bit into my Perlane and Juvéderm Ultra Plus types of volume, and starting to cannibalize that just a little bit, but otherwise we have a very nice mix.

HW: I think we have similar approaches. We both have some patients who go to SoulCycle twice per day, who are very tiny and will often require pan-volume. If their skin is not too terribly sun damaged, and if it’s less of an age thing and more to do with the health of their skin, then I like pan-volumizing with Sculptra. I also find that it’s great for the temple area because we can reflux from the plunger, we can feel safer in certain areas, but it also does take a certain kind of patient who is willing to do the homework of massaging, but is also willing to wait to see the results.

DD: Some people like the initial subtlety and that gradual result, and that’s another area where Sculptra really excels.

HW: I agree, and I think that that is one of the decisions that as physicians we make. We have to find out: we look at the patient, we evaluate the patient, we decide what our recommendations are, and our recommendations may come down to a choice of two different products for one area, another product for a different area, and then we present it to the patient and see what fits with the patient’s lifestyle and needs — do they have an event they have to look good for, or are they looking at just looking better gradually for life? And like Doris, I will also layer these fillers, so I may use Sculptra for pan-volumizing or use Radiesse as scaffolding for the jaw line. For the lower lids and tear trough I like a combination of Restylane and Belotero.

DD: Me too.

HW: And I do a lot in the lateral forehead now, as well as the mid-forehead and the temple.

DD: Me too. What do you do there?

HW: If I’m not using Sculptra, with a cannula I will use Radiesse or dilute Voluma in the temples, otherwise I use Restylane. As with Doris, as we’ve been using Voluma more and more, and seeing our patients back, I’m now extending it and using it as some of my Canadian colleagues have recommended, in a more dilute manner to spread it like a layer in the temple area, and even into the lateral forehead. In the forehead generally though, I’m layering Restylane and then for some fine lines above, Belotero. I think for those of us who do a lot of fillers, we have this armamentarium of tools, and we’re figuring out and constantly changing our ideas, adjusting and tailoring them to our patients.

DD: And we’re using devices as well. We’re using Ulthera, Thermage, Fraxel and fractional CO₂ to complement and enhance treatments. These are all very effective on every layer of the skin, using more than just one tool. Fillers, lasers, and other devices — it’s really a global combination approach.

HW: It’s very different to when we started in practice. If you think of 20 years ago, we had collagen and you could fill a line for about 4 months and you were always starting from scratch. Now we are looking at growing old while staying youthful-looking and natural because our patients are coming in earlier. Someone might visit in their late 20s or early 30s because they’re starting to notice the brow and frown lines, or are concerned about dark circles under the eyes that make them look tired. So we might start tweaking, put a little bit of an HA for example, a little toxin.

DD: I’ve started asking patients to bring in pictures from when they were in their late 20s or 30s, sometimes mothers and daughters come together, and I’m even going one step further. Instead of looking at someone and saying ‘here’s where you’re deflated, here’s where you’ve lost’, I can look at someone now who is 30 who is just in the very early stages of deflation, I can just see the signs of it coming and I think the commonality of the ageing experience is intrinsic. You can actually start adding in volume very gently, just a little bit in part of their face, in their early 30s and perhaps before they really notice that they’re ageing, and you can actually not have to catch up later. It lasts longer, it looks better instantly, but they also stay looking better for years to come.

HW: I agree. I would say that even if I look back at some of my patients over the last 15 years or so, we may have started doing a little Restylane here, a little there, and tweaking. Then as the patient has aged and as our tools have increased, we adjusted as we need and you can pretty much keep them at a very good baseline.

DD: And then we need less product, less often. So people we’ve been treating for over 15 years, they’re 15 years older but they look better and they don’t need as much as often to maintain that look. Just as we have preventive neuromodulators, now we’re starting to have a preventive filler. And it’s not to change how you look, but to keep you at a great place and to keep that balance. It also links to education — you don’t want someone coming in asking for ‘more more more’; it’s a matter of putting in just enough and in the right way to keep them in a good place.

HW: I think that as we get some of the newer products like Voluma, even with the products that we’ve had, there’s always been this risk of practitioners who are not looking at the patient as a whole, not looking at the face from all angles. For Drs like Doris and I, we’re spending our time telling patients what not to do; we’re saying no and we’re spending the time to educate. We would move a lot quicker if all we did, for example, in the US was treat what’s on-label, because unlike other countries, in the US when something has an on-label indication, that’s all that the direct-to-consumer advertising can cover. So in the past, with the nasolabial folds we had to spend a lot of time discussing with patients that if you just fill the nasolabial folds you’re going to look very strange. Now for our patients and staff, the concept of doing the cheek is very natural, but now that Voluma has that indication we’re talking more about that and that’s very helpful for us and again, it doesn’t mean that it’s taken away our use of Radiesse, Sculptra, Belotero or Restylane. I think that, as Doris said, there are some of the mid-level fillers that it’s going to change.

What’s coming?

HW: The reasons many of us are talking a lot about Voluma are that it brought in a new technology — Vycross technology — and based on the way it’s produced, it’s less hydrophilic so you get less swelling, and yet you get a good amount of lift per volume. Previously, we could only get that amount of lift per volume with CaHA. Now, we have this and so the next one we should be getting, hopefully, in another 2 years would be Volbella. I think when that comes in, although there will still be people using Juvéderm Ultra and Ultra Plus, it will likely replace them and then we may see how we can use that in other areas. The next one would be Volift, and I can’t tell you where that’s going to go because a lot of our colleagues in other countries haven’t figured out where that fits in as yet. There’s also the rest of the Belotero (Anteis) product line — the one I’m most looking forward to getting is Modélis, which hasn’t started in US trials yet. It flows very smoothly like Belotero Balance and will be a competitor to Voluma. There’s the Teoxane line of products and colleagues like them very much, but when they come to the US they won’t have any anesthetic, so we’ll have to see where that fits in and how it can be competitive.

DD: I like the idea that we have competitive products coming through and I hope that the extension of the Voluma line will also happen because it’s an excellent product and I hear great things about Volbella. There are exciting new products in the pipeline — a lot to look forward to and it may end up replacing Juvéderm.

HW: I agree. One of the things that has become clear in the past year, as we see acquisitions and trades among companies, is that physicians are concerned not only about about getting access to products, but also making sure that they remain at reasonable price points for us and our patients, that education is available so the products are used appropriately and don’t give the products or us a bad name. It is critical that funding continues in the US for CME programs during which we can discuss not only FDA approved indications, but off-label uses that allow an holistic approach and a balanced discussion. As Doris alluded to, R&D is also very important to ensure that new products and new indications continue to expand in the US and abroad. It will be interesting to see what happens now that Galderma has Restylane and Perlane worldwide and Sculptra in the US..

DD: I hope Sculptra doesn’t fall by the wayside and I hope that companies start to get creative in terms of seeking FDA approval for different areas of the face and body, perhaps with more trials to look at the chin,
the brows, look at safe ways to inject in those areas so we can have them as on-label uses and have proper education. You brought up so many great points, and that increasing the on-label use and increasing education so physicians aren’t just erasing lines and wrinkles and going over the same things that they know to do, but are looking at faces as a global aesthetic and really doing what the patient needs.

HW: I think that’s one of the reasons why there are lots of doctors out there, and I think there will always be lots of doctors and lots of patients for different doctors, because patients need to find the doctor who matches their aesthetic. One of the things I stress is, as a cosmetic physician, you need to be an example of your own aesthetic. So, if you have a natural look, you shouldn’t be making everyone unnatural. When I say ‘unnatural’ obviously it sounds negative; we do see people who look more stylized, who clearly look ‘done’ and in some places looking ‘done’ is a good thing because they want people to know what they’ve spent and had done, or because of what they do for a living. The patients Doris and I see in the New York area tend to be very conscious of not looking overdone. Their aesthetic is more conservative or natural — they want to look like they aren’t trying hard to look good, or that they are spending a lot of money on their appearance.

DD: The other thing about having things on-label and increasing the use there is because of patient education. To touch on what you said about patients looking garish, with Juvéderm all patients want is nasolabial folds because that’s all they know to ask for, but it’s not really what they want. They want to look better. And so, once you have more areas you can treat and more things you can do, you can really present that. And they’re starting with that, with the whole global aesthetic because now they have cheeks and folds and other things they can do, so they can expand their educational level. Part of it is on the physician side, having on-label uses, proper education, expanding the mind of the aesthetic physician to think differently and go beyond areas they’re originally comfortable with. And on the other side, its educating the patient on what helps you to look your best in a natural and subtle way, not what they thought before, not chasing lines and wrinkles, and it isn’t catching up — it’s starting to stay ahead and having that whole new educational approach.

HW: I agree. Patients come in insisting they want their nasolabial folds injected. We need to show them that if you lift the central face and zygoma upward, you improve that pseudoptosis of the nasolabial fold and create a more natural, youthful contour. The nasolabial fold does not exist because we’re specifically losing fat there; it exists because we’re losing fat in areas above and lateral. As physicians that’s part of our responsibility, as Doris said, not to just do what the patient says they want, but to try to help them achieve an aesthetic. Certainly, there are patients for whom you are going to do procedures you know won’t make them look younger, but will still make them happy. One of my first patients in practice was a woman in her late-80s with end-stage COPD, who came in a wheelchair and on oxygen, and all she wanted before she died was not to have her lipstick creep up into those lines, so we would remove her oxygen and put some collagen in there. Was I making her look younger? No. But, for her that was significant and so for the last 2 years before she died she could put her lipstick on and it didn’t creep up.

DD: I’ve had a similar situation with a patient with lung cancer, who came in and said, ‘I just want to look better’.

HW: And that’s a very interesting point. If you’re a woman going through chemo, for example, it changes everything and you get quite hollow. So, if the patient’s on chemotherapeutics that are not reducing their white count to any dangerous level, then we can treat them with filler and I will see patients in the midst of their chemo so they never get that really gaunt, hollow look. Generally the oncologists won’t let us use toxins — they have in mind that they don’t want that and I’m going to respect them. But if they let me do filler for patients, I will do filler during that time period to try to keep the patient with some healthier contours.

Ideal properties

HW: I’m going to separate that into two questions. One thing I would say is that it isn’t so much the ideal filler overall, but what we don’t have in the US that I wish we had. We still don’t have anything great for the neck and décolletage. We can use something fine like Belotero or a bit more substantial like Restylane for finer or deeper rings on the neck.  I’ve now used dilute Voluma to give support for the lower-mid décolletage crepiness we see with sun damage, especially by the upper cleavage. But we don’t have anything that we can really spread safely and effectively over the entire neck and chest. Some colleagues do use very dilute Sculptra in that area, but my concern is that if the patient gets any small lump or bump it will be visible.

DD: For an ideal filler, it’s one that you can place in any layer of the skin, that will stay where you want, flatten as you want, and lift as you like; no risk of it causing a vascular accident and won’t bruise anybody.

HW: That’s one thing we miss now that collagen is gone — collagen is hemostatic. So, as you injected it, the bruising was limited. On the other hand, HA fillers bring in more fluid so they are in essence helping along the bruising to bruise more. In an ideal world, as Doris said, we’d have one filler that we could tailor to all areas and all needs.  So you could use it as is for lift and volume, and dilute it to spread evenly for the chest.

DD: Or even not — if it could adapt to each environment, so you could just use it straight up. If we’re talking ideal, I like your idea of diluting, but it’s still giving me work to do. If it’s really ideal, I could put it into any layer and it could do the right thing in that layer — like the foundation you can put on that will melt into your skin color and match you perfectly.

HW: And be reversible, and when we say reversible, remember reversibility is also if you want to look at an ideal world. Ideal would be to give someone a pill if it got into a vessel and it would get into your bloodstream, dissolve it and fix everything quickly. Even things we can dissolve, if it’s already gone into a vessel there can still be damage. So that’s very critical. In terms of injecting, obviously something that’s not painful. We do use anesthetic either pre-mixed into these products or we add it, and I think that something that would not be painful and also not swell would be great.

DD: Yes, so that what you see is what you get.

HW: Right. That you could do a one-to-one fix on the patient and see it rather than having to under-treat or over-treat. I think that would be quite helpful. As we treat people, we’re always trying to look ahead and based on the patient’s health and physical characteristics, as well as their socioeconomic characteristics, trying to figure out the best treatment for them. But there are a lot of patients who come in, in whom we’ll see a lot of excessive swelling in an area or we will see they get an untoward reaction and there are times you don’t know why. Also, if the agent were bacteriostatic, that would be ideal. This is the hard part, because you want something that will build collagen, but you don’t want something that will lead to a granulomatous reaction, so you want it to affect fibroblasts in a positive way. As Doris said, we are always working on algorithms to decide and better know in advance which patients will do best with which products and procedures. Anecdotally from my practice and from others, it appears that many patients who do well with Sculptra are also those who respond best to Thermage radiofrequency tissue tightening. I think that has to do with characteristics of the procedures and of their skin — their fibroblasts are healthy and responsive. There are other people who do not respond as well. It would be ideal if we knew how we could prep people’s skin in some way to make them all respond to all procedures, that would be ideal. Even the patients who you inject with just some Juvéderm or Radiesse, they disappear, return 2 years later and look great, but they’ve had nothing done! Clearly their skin and subcutaneous tissue held on to the product longer — their metabolism is such that they haven’t broken it down as quickly and their collagen has been stimulated more over time. Even without PLLA, which gives you that glow after multiple treatments, they will get some of that glow, and we don’t know who those people are until they become those people. It would also be nice if we knew which topicals worked best. Both Doris and I are very interested in cosmeceuticals and are actively prescribing skincare regimens for our patients — but those are often somewhat independent of injections. We’re telling people they need both, but I don’t tailor my cosmeceutical regimen based on the filler. Do you Doris?

DD: I don’t.

HW: Right, because we don’t know whether there’s an interaction.

DD: That’s a very good point. Some studies in this area need to be done as well.