1.Moderator Dr Amit Malhotra

2. INTRODUCTION Dermal fillers are substances used in soft tissueaugmentation to enhance or replace volume that is lost in any part of the skin or subcutaneous fat. Fillers form an effective tool in rejuvenation, either asa stand-alone treatment or in combination with other procedures such as Laser resurfacing or botulinum toxin. 3. CLASSIFICATION Fillers can be classified based on different criteria:1) Based on longevity: Temporary-Temporary fillers are also referred to as nonpermanent fillers. Their stay in the tissue is for less than 12 months and hence, they have the advantage of spontaneously disappearing if the patient is not satisfied with the results. Similarly, an adverse event with such fillers is also a temporary one, as seen in the majority of the cases. 4. Some of the common temporary fillers available in India are described here: Bovine collagen-based products Zyderm 1 Zyderm 2 Zyplast Human tissue-derived collagen Cosmoderm Cosmoplast Synthetic fillers: Hyaluronic acid-based fillers A wide range of hyaluronic acid products is available with varying hyaluronic acid concentrations and cross-linking structure . 5. Semipermanent- these fillers undergo slowdegradation with time over a period of 12 years. Side effects with semipermanent fillers are more common and longer lasting than temporary fillers. Permanent these are the fillers that remain forlonger than two years in the tissue. Side effects with permanent fillers tend to be more permanent, and complication is the main issue with any permanent filler. 6. 2) Based on site of placement Dermal Subdermal Supraperiosteal 7. 3) Based on origin of filler material Heterografts: (a) Bovine collagen-(1) zyderm 1 and 2 (2)zyplast (3)restoplast (4)artecoll (b) Hyaluronic acid derivative implant-(1) restylane (2) perlane (3) hylaform (4)dermalive (5)reviderm intra (c) Porcine collagen- (1) permacol (2) fibrel 8. Allografts : human derived collagen(a) dermalogen (b) alloderm (c) cosmoderm Autograft: (a) autologous fat (b) autologous collagen Synthetic material: (a) polytetrafluoroethylene(b) silicone (c) biopolymer 3 (d) bioplastique 9. IDEAL DERMAL FILLER 10. INDICATIONS Facial lines (wrinkles, folds) Lip enhancement Facial deformities Depressed scars(a)post surgical (b)traumatic (c) resulting from acne and other diseases Breast, buttock augmentation Periocular melanoses, sunken eyes Dermatological diseases-angular cheilitis, scleroderma, AIDS lipoatrophy 11. CONTRAINDICATIONS 1. 2. 3. 4.5. 6.Positive skin testing Patient with autoimmune diseases History of serious anaphylactic reaction in past Active local disease like acne Keloidal tendency Unrealistic expectations 12. CONDITIONS REQUIRING CAUTIONS History of facial herpes simplex. 2. History of atopy. 3. History of bleeding disorder or use of anticoagulants. 4. Current or long term use of immunosuppressive therapy. 1. 13. Preoperative Preparation History taking should include history of medications used, history of allergies, e.g ., the chances of bruising might increase in a patient on anticoagulant therapy. Clinical examination, particularly of the area being injected. Skin test should be done if heterograft implants are used. Counseling . Preoperative photograpy is preferable. Informed consent should be taken. 14. SKIN TEST It is done in two steps 6 and 2 week prior to treatment. Bovine collagen 0.1ml and porcine collagen .05 ml(diluted in normal saline) is injected intradermally on the flexor aspect of forearm. A positive skin test develops as early as 6 to 48 hrs or 4 wk after the test dose . There is erythema , puritis or prolonged induration that is for more than 4 days. 15. Inspite of negative skin test ,there is a 1.2 to 6.3 %chance of hypersensitive ,hence a second skin test after 4 wks is advised . If there is no sign of positivity after 2 wk of second test,bovine /porcine collagen implants can be given with minimal risk of allergy. 16. INTRAOPERATIVE PROCEDURE Surgical preparation of the part. Topical anaesthetics like EMLA or prilox can be used 1-2 hr before injection. 3. Local anaesthesia required in upper lip and in uncooperative patient. 4. Patient is to be treated under proper lighting in semi reclining or upright position for the gravity to maximize wrinkles. 5. All dermal fillers come with prefilled syringes and desired gauge needle (26-32G) depending on the particle size. the needle should be screwed carefully on to the syringe to avoid waste of material. 1. 2. 17. 6. The syringe should be levered over thumb of non operating hand for proper angle and depth of injection. 7. 15 degree angle for superficial and 45 degree for deeper dermal implants are maintained. 8. Needle is inserted with bevelled surface facing upwards. 9. Blanching should be avoided. 10. The requisite depth of injection depends upon the nature of material used. . 18. 11. The material is injected in serial puncture ,linear threading ,fan or cross hatching technique. 12. The defect fills up immediately. 13. Over correction is recommended only for lip augmentation. 14. Stop injection prior to withdrawal of needle to avoid unnecessary spillage. 15. Treated area is massaged lightly to mould the material appropriately and avoid lump formation. 19. 16. Maximum of 2 ml of filter per treatment session is indicated. 17. Care should be taken to avoid injecting into a blood vessel. 18. If needle gets blocked the pressure on the piston should not be increased rather injection should be stopped and needle replaced. 19. Repeat injection for correction should only be administered after 2-4 wk when inflammation subsides totally. 20. INJECTION TECHNIQUES (1) LINEAR THREADING TECHNIQUES-Full length of the needle is inserted into the defect and the implant is injected while pulling the needle slowly backwards so that the material is placed lengthwise in the wrinkle. 21. (2) SERIAL PUNTURE TECHNIQUEMultiple injections are placed serially along the length of the treated area so that it merges into a continuous line which lifts the wrinkle. 22. (3) FAN TECHNIQUEAfter injecting one line of implant by the linear threading technique the direction of the needle is changed and injected as before along a new line. 23. (4) CROSS HATCHING TECHNIQUE linear threading technique is used at the periphery of the defect .then the needle is withdrawn from the skin and inserted 5-10mm adjacent to the first site of injection and procedure is repeated. This method is then carried out at right angles to the original line. 24. POST PROCEDURE INSTRUCTIONS Avoid exposure to extreme cold or heat Avoid massaging treated areas for six hours Avoid strenuous physical activity for six hours Sleep with the head elevated for one night Pain medication can be taken if needed Resume skin care products such as retinoids, alphahydroxy acids the day after the procedure. 25. Chemical peels ,laser treatment should be spaced outat least 2wks to avoid inflammation of injection site. Repeat injections are spaced after 3-6 months or longer depending upon the longevity of the material ,site of injection and the technique used. 26. Combination technique Combining two fillers of different particle size or othermaterials for enhanced cosmesis. 1. Sandwich method: is a layered technique using zyplast in deeper dermis and zyderm above it in mid or upper dermis. 2. Botox and fillers: botulinum toxin injected 1 wk prior to dermal fillers gives a synergestic effect. Botox reduces the amount of implant for augmentation and also helps to increase the duration of the fillers in the treated area by reducing supposed muscle atrophy and prevent immediate microextrusion from injection sites by repetitive muscular action. 27. Complications Immediate complications Pain Bruising Erythema Asymmetry, bumpiness, lumpiness Anaphylaxis Edema Acneiform eruptions Infections reactivation of herpes simplex 28. Late complication Inflammatory nodule Tyndall effect Allergic reactions Vascular occlusion Granulomas Implant migration Telangiectasia Lipoatrophy Hypertrophic scarring Sterile abscess 29. Advantages of dermal fillers 1. 2.3. 4. 5.Instant results .no down time. Easy technique compared to other procedures for scar or wrinkle correction i.e punch excision ,punch graft replacement etc. Does not require special surgical expertise. Simple , OPD procedure. Large area /multiple lesions covered at one sitting. 30. Disadvantages of dermal fillers It is short lasting hence has to be repeated once in a year. 2. Costly treatment. 3. Not manufactured in india. 4. Chances of adverse reactions. 1. 31. CONCLUSION In a short span of time, fillers have come to play animportant role in the nonsurgical management of ageing skin. The technique is a safe, simple and effective modality, when used by a properly trained physician. Proper knowledge of the anatomy of the area of injection, aesthetic sense and proper patient selection are essential. 32. Fillers can also be combined with other aesthetictreatments such as Botox, microdermabrasion, peels, thread-lifts, and Laser resurfacing. As in all aesthetic techniques, proper patientcounseling with respect to achievable results is important. 33. THANKS