When Botox hit the plastic surgery market in 2002, aging clients flocked to their dermatologists to help them treat fine lines and wrinkles with this innovative botulinum toxin that temporarily freezes muscles. Approximately 11.8 million Botox cosmetic procedures have been administered in the U.S. since then, according to Allergan, and during that time, a world of injectables and fillers has opened up. Today, clients are able to partake in a variety of injectable and filler options for anti-aging. Frown lines and wrinkles can be treated with Botox and Dysport; volume is created with hyaluronic acid (HA) fillers like Belotero, Juvéderm, Perlane, and Restylane; and skin and lips can be plumped up with collagen fillers like Sculptra. Plus new injectables and fillers—and off-label uses—continue to make headlines, providing doctors with exciting new weapons to add to their anti-aging arsenals.
New Kid on the Block
One of the latest additions to the filler market is Juvéderm Voluma XC, the first FDA-approved filler to correct age-related volume loss in the midface. It provides results that can last up to two years, and many derms think it is a game changer in anti-aging. “Loss of volume in the cheeks is something that everyone will inevitably experience with age, and Voluma has provided a quick and easy way to subtly restore some of that youthful volume with virtually no downtime,” says Andrew Jacono, M.D., F.A.C.S., a dual-board-certified facial plastic and reconstructive surgeon with offices in New York City and Long Island, NY. “It can result in a dramatic lifting effect in the aging midface with proper placement and volume,” adds Sue Ann Wee, M.D., a laser surgery and cosmetic dermatologist at the Manhattan Center for Dermatology (New York City). “Another benefit of Voluma XC is that it is a hyaluronic acid-type filler that can be reversed, in most cases, by hyaluronidase if needed.”
Plus, according to Edward Farrior, M.D., a Tampa, FL-based facial plastic surgeon and the president of the American Academy of Facial Plastic and Reconstructive Surgery, the 24-month duration makes it a cost-effective alternative to some of the shorter acting fillers, which will appeal to price-conscious clients. “It is better because it lasts longer, requiring fewer office visits, and it is a step in the right direction for developing a permanent filler that is reversible,” he says.
Most importantly, Voluma XC offers doctors an FDA-approved option to the use of other fillers, including Perlane and Radiesse, off-label to fill the midface area, says Julius Few, M.D., of The Few Institute (Chicago and New York City). “Voluma XC is the first to be tested and indicated specifically for use in the midface, unlike other HA fillers, which are indicated for the treatment of wrinkles.”
Innovations in Injectables
Using fillers and injectables off-label is a practice that abounds in the industry. While most doctors agree that off-label injections should be performed only by qualified professionals, the use of off-label injectables can produce excellent results in innovative ways. Few says he thinks one of the smartest ways to use fillers is as a bridge to surgery. Nowadays, fillers have been effectively used for chin-implant substitution, jaw augmentation, and non-surgical nose reshaping. “By using fillers to create a temporary result that mimics or previews a permanent surgical result, such as rhinoplasty, patients can not only see but also experience what they will look like post-surgery,” says Few. Non-surgical nose reshaping, for example, is a procedure that uses injectable fillers and Botox. “Controlled and precise injections can make the nose look more proportional and smaller in the facial frame,” says Jacono. “The results are instantaneous, and there is essentially no recovery, unlike surgery. The most common filler used is Radiesse, which is made up of calcium hydroxyl appetite crystals, which are very similar to the mineral found in the bones of the nose.”
In the past year, Wee says she has noted rapid growth and advances in 3-D volumizing of the aging face and an increased understanding of how aging occurs. “Because aging is a three-dimensional process, whereby there is a loss of volume in bones, tissue, fat pads, and skin, this approach results in a much more natural result by focusing more on lifting and sculpting the face rather than filling only lines and furrows,” she says.
Though Farrior says he discourages the use of off-label as a rule, due to the need for extensive consultation and informed consent, he has noticed developments in site-specific applications and the stacking of different fillers. “For example, you might use Voluma XC or Radiesse to raise the cheek, which would reduce the deep smile line,” he says. “That line can be further reduced by the injection of Restylane or Juvéderm in the deep dermis to fill the furrow and Belotero into the fine crease in the superficial layer of the skin.” Few says he finds that HA fillers, hyper-diluted with local anesthesia, are also effective for treating very fine lines and wrinkles, especially on the upper lip, particularly when combined with a laser. Jacono, meanwhile has used fillers to develop a patented lip augmentation technique called French Lips, which delivers fuller, younger looking lips in minutes with no downtime. “I use hyaluronic acid-based fillers, like Juvéderm or Restylane, and target 15 different anatomic zones to deliver completely natural-looking results, as opposed to the overdone lips that can result from injecting only the lip line site,” he says.
Off-label use of fillers is also popular beyond just the face. Wee finds that fillers injected into the back of the hands can decrease the look of prominent veins and wrinkles, and she’s also noticed fillers used in the lateral brow, the under-eye tear trough area, and chest wrinkles in the décolleté. Farrior says he foresees Voluma XC being used off-label for the hands and Juvéderm or Restylane to help tighten a stretched pierced ear lobe. “Some surgeons are even using HA products in an effort to reduce scar tissue in surgical wounds,” he adds.
A Note of Caution
While the innovations in injectables are certainly exciting, the experts agree that medical spas should take certain precautions when it comes to injectables, particularly when using them off-label. Wee says she thinks it is vital for a medical spa to have a board-certified dermatologist or board-certified plastic surgeon on staff with extensive experience using injectables and overseeing their use. She also suggests that only qualified, properly trained healthcare practitioners should perform these types of injections. “There are potentially disastrous consequences if fillers are not performed correctly,” she says. “Blindness, tissue death, and infection are some of the potential serious complications that can occur from filler injections.”
Farrior advises medical spa staffs to do as much independent research as possible and visit a trained facility where the product has been used for a reasonable length of time and observe a physician inject actual patients. “See authentic results for yourself before deciding whether or not to offer the service,” he says. “The best advice is to start slow. It is always easy to supplement but difficult to undo.”
Then, in addition to meeting with the brand’s representative, Jacono says he always asks to review scientific materials, independent data sources, and clinical studies that support the claims. “Review the literature, and consult with your on-staff M.D. to ensure safety and efficacy of any new product or technique before bringing it into the business,” says Few. “Second, and equally as important, get plenty of expert hands-on training offered through professional medical aesthetic courses.”
Once you have taken the proper precautions and have decided to offer some of these unique injectable services at your medical spa, shoot lots of before-and-after photos, take advantage of social media, and ask your satisfied clients to spread the word. Consider hosting seminars, classes, and informational meetings about your new offerings to help your clients feel comfortable and to answer their questions.
Also, think about approaching some of your younger patients with these non-surgical procedures. “Many are experiencing the early signs of aging, and some are looking to prevent the signs of aging before they even begin,” says Jacono. “These patients are not candidates for surgery but are prime candidates for injectables, specifically the newest ones that deliver subtle, natural-looking results. They’re looking to subtly restore or enhance certain features, rather than make a drastic change to their appearance.”
When it comes to injectables, the innovations keep coming. Farrior believes autologous material, which is tissue derived from the patients themselves, and the development of more reliable use of autologous material, such as skin cells and fat, will impact the future of injectables. Jacono, meanwhile, was introduced to a new infrared imaging device by Christie Medical Holdings, called the VeinViewer, at the recent American-Brazilian
Aesthetic Meeting in Florianópolis, Brazil. “It maps the veins and can be used as a guide during injectable treatments, which in turn will help minimize bruising from Botox and fillers,” he says. “While the downtime for these treatments is already fairly minimal, this technology will help lessen or eliminate bruising completely,” making them even more enticing to your clients. Want to inject your medical spa with new clients and revenue? Stay on top of innovations in injectables, and watch your business thrive.