Meeting International Mater Course on Aging Skin
Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Derm projects that HA products will provide all the many tools needed for lunch-time filling

BY REBECCA BRYANT, STAFF CORRESPONDENT
Boston – Although hyaluronic acid (HA) fillers have become the treatment of choice in the U.S., according to Gary D. Monheit, M.D., many questions remain: Can Hylaform, Restylane, and Juvederm be improved to achieve more than a three- to six-month longevity? How will the fillers compare, after more extensive head-to-head testing? And where will HA products ultimately fit in an armature, ranging from bovine collagen to polylactic acid? Those questions notwithstanding, he says, “Looking toward the future, I think the full family of HA products—Restylane, Hylaform, and Juvederm—will gives us all the necessary tools we need for lunch time filling.”
HA vs. Collagen An associate professor of dermatology at the University of Alabama in Birmingham, Dr. Monheit has conducted dozens of clinical trials on fillers. He attributes the most favored status of HA products partly to the allure they’ve gained as the latest generation of proven technology. But they do have an significant position in relation to theadvantage over the collagen products they’ve succeeded. “The HA molecule is hydroscopic,” he says, “and its ability to bind water gives it a viscoelastic feel. After injection the product will swell, adding more volume. This is in contrast to collagen, which loses water suspension after injection.” Even after the cosmetic benefit dissipates, a substantial amount of hyaluronic acid remains in the skin for up to a year. Thus, a second, follow-up treatment will often induce a larger and longer lasting benefit than the first. On the other hand, the HA generation lacks some of collagen’s advantages. Hylaform, Restylane, and Juvederm inhibit the clotting cascade and are formulated without lidocaine. “It’s a good idea to use very fine needles, like the 30-guage Maxflo, to minimize trauma, bruising, bleeding, and discomfort when injecting HA products,” says the dermatologist. He adds, “I find that vibration produces excellent analgesia when injecting the nasolabial folds.” Because HA products are crystal clear, they can appear blue if injected close to the surface due to the Tyndall effect. “HA products should be injected 1-2 mm below the surface to avoid creating the blue color,” he says. “This is not a big deal or something to worry about; it’s just something derms need to be aware of.”
Distinguishing HA products “Both Hylaform and Restylane, which have FDA approval, are particles of HA bonded together and suspended in a gel,” says Dr. Monheit. “Juvederm, which is in the clinical trial phase, is a homogeneous gel-based HA.” Thus, when compared to Juvederm, Hylaform and Restylane have increased surface area exposure with increased susceptibility to enzymatic degradation. There is also more friction upon injection and increased exposure to free radicals. Approved for correction of soft tissue contour deficiencies, such as wrinkles or acne scars, Hylaform binds to water up to 1,000 times its volume, resists degradation, feels natural, and does not clump. The family of products—Hylaform Fine Line, Hylaform, and Hylaform Ultra—correlate to superficial, mid, and deep levels of dermal filling. Dr. Monheit often uses Hylaform in combination with Cosmoplast. The collagen provides structure, while the HA adds volume. The combination (achieved either by mixing the products and injecting them together or by injecting Cosmoplast first) also causes less pain and bruising than the use of Hylaform alone. Produced via a bacterial fermentation process, the Restylane family line tailors particle size to tissue matrix. Use Restylane Fine Lines (reformulated in January 2004) for treatment of superficial lines and wrinkles around the eyes, forehead, and smile lines. Restylane is for treatment of moderate lines, wrinkles and folds, and lips, while Perlane targets deep tissue improvements, such as enhancement of lips, chin, and cheeks. Inject Restylane products as superficially as possible within the recommended tissue depth. Techniques include serial puncturing, linear threading, fanning, and cross-hatching. Also manufactured via bacterial fermentation, Juvederm gained CE approval in 2000 and is distributed as Hydrafil in Europe. As a single-phase gel without particles, it is homogenous, more resistant to in situ degradation, more pliable and viseoelastic, and less inflammatory than its FDA-approved counterparts. “Of the two product lines now approved by the FDA, I find Restylane very favorable for nasolabial folds and marionette lines where volumetric filling is needed,” says Dr. Monheit. “Restylane, though, can produce moderate inflammation for two to five days, and this must be explained to the patient. “If you need a non-inflammatory HA filler, I would recommend Hylaform, as it produces very little inflammation. It is also useful in the lips where inflammation and lumpiness can be a problem. “Mid-dermal fillers can be improved with a lighter filler injected above. I use Cosmoderm above HA to eradicate the fine line wrinkle usually found below deeper grooves on the nasolabial folds, lip lines, and marionette lines.”