Dermal fillers: hyaluronic acid and Radiesse

We are working with two dermal fillers with complementary properties, as we will see later on.

Wrinkle filling remains essential in the facial aesthetic approach. However it is important to understand the tissue alterations responsible for the appearance of the wrinkles we want to treat..

It is, for example, completely useless to treat the nasolabial fold if the cheeks have not been restored previously with volumizing injections. These injections lead to face remodeling by restoring sagging areas (cheekbones) or hollows (cheeks, hands).

This typical example shows a patient with a very deep nasolabial fold. However, just pressing the skin with a finger highlights the “valley of tears” running down from the dark circle initiated in the inner eye angle. It is the cheek fall that is responsible for the development of a nasolabial fold.

The “valley of tears” and the nasolabial fold have been highlighted on this picture. The cheekbone must absolutely be remodeled before injecting anything into the nasolabial fold.

The product is introduced with a fine needle, more or less deeply according to the wrinkle to treat. Experience is essential to introduce the product deep enough to obtain a volumizing effect, but not too deep as it would reduce the product life time. Slight redness and swelling may appear and persist from a few hours to a few days.

Several products can be used. The practitioner chooses the product according to the indications (depth of the wrinkle, its location) and with the patient’s agreement. Allergies, granulomas or superinfections have been reported exceptionally. It is essential to assess contraindications before the treatment, to choose an appropriate product and inject it thoroughly.

The most frequent complication is the haematoma, as a result from the bleeding of a blood vessel. These disappear after a few days and can easily be hidden behind some make-up.

A local anaesthesia is systematically performed in the treatment of the nasolabial fold to insure total comfort during the session.

The injections are almost painless, a bit like dentist injections. Nerve block – unfortunately not used much yet – offers unequalled comfort both for the patient…and the physician.

There has been significant progress in the last years with the marketing of products displaying both an excellent tolerance and long-term effects.

The two products we frequently use are the Teosyal (hyaluronic acid) and the Radiesse (calcium hydroxyapatite).

Hyaluronic acid: Teosyal

The hyaluronic acid is an essential component of the fundamental substance of the skin..

It can absorb several times its weight in water and thus contributes to skin moisturization. Technology has made the use of hyaluronic acid as an implant both perfectly tolerated and resorptive possible in the treatment of wrinkles of the face and the neck. No test is necessary as it is not an allergenic substance. Its safety in use and its seniority has made it the most popular dermal filler. Wrinkles are treated instantly. A few rednesses can be observed. A few bruises can be reported the day after the intervention, but these are easy to conceal.

Results last 4 to 6 months, a second intervention is than recommended to maintain the results. After the second intervention, sessions are scheduled on a regular basis every 10 months.

Nowadays, many formulas at various concentrations are available. Thus, both the remodeling of facial volumes and the smoothing of fine lines are possible.

This major product can be used alone or combined in most of the cases. We have tried most of the products available on the market and have finally chosen years ago the products of the TEOXANE laboratory. This laboratory has just received the 2008 Award of the best injectable product.

Two syringes will generally be needed. The first one will remodel the upper cheeks and correct the tear trough. The second one will fill in other facial lines such as the nasolabial fold. Light cases sometimes only require one syringe.

We highlight the relevance of a preventive intervention, which can be indicated from the age of 35. Then, a syringe per year will largely suffice to maintain tissue elasticity and to avoid deep furrows.

Typically, a “consolidation syringe” is injected 3 to 6 months after the first session so as to guarantee effective results up to 9 to 12 months. Then, a session per year will suffice to maintain the results. Click here to discover our Combined injectable packages.

New: Hyaluronic acid moisturization

The hyaluronic acid used in the treatment of wrinkles and folds is very dense and viscous – the main goal is a mechanical filling effect.

We recently acquired fluid hyaluronic acid that can be injected very close to the skin surface according to the principle of the mesotherapy. Numerous micro injections are performed so as to cover the area to be treated entirely.

Instead of spending loads of money in cosmetic creams with uncertain effects, it is much easier to give the skin the hyaluronic acid it lacks. Such is the principle of action of the HYDRATATION MESO hyaluronic acid. The intense moisturization and the improved skin texture obtained by such a treatment outshine the expensive creams supposed to provide hyaluronic acid. Results obtained after a 15-minute long session will last approximately 9 to 10 months.

The treatment is easy to perform. A very fluid solution of hyaluronic acid (contrarily to that used to restore volumes, which is very thick) is injected with a microfine needle under the skin.

The complexion brightens up immediately, the moisturization is intense. The product of choice to complete the effects of dermal fillers or to get prepared to sessions of fractional laser. Many patients discover aesthetic care with this moisturizing treatment. Click here to discover our Combined injectable packages.

Calcium hydroxypatite: the Radiesse

It is a calcium phosphate, the main form of calcium contained into the bones. The skeleton contains 1100 to 1200g of calcium. It thus provides calcium to the rest of the organism when osteoclasts are activated (cells making the bone tissue) by hormones of the calcium and phosphorus metabolism such as the parathormone.

The mineral phase essentially consists in calcium hydroxyapatite crystals with a general formula defined as Ca10 (PO4) 6 (OH)2 and shaped as 600 Å long needles, giving to the bone its strength.

This biomaterial – CaHa – has been used in orthopaedics, neurosurgery, dental surgery and ophthalmology for more than twenty years. This mineral component of bones and teeth is naturally created by the organism. Radiesse® is a synthetic product compatible with the human body. Wide spread clinical tests have been undergone since 1995 with good safety and efficiency results.

The major advantage of this product is its significant volumizing effect combined with the durability of the implant (approximately a year and a half to two years).

This product is our favourite in the treatment of cases requiring significant remodeling. Age induces cheek sagging, which must be treated using a well-tolerated and long-lasting product.

Patients often ask us to correct a deep nasolabial fold, but we explain in most cases that the volume of the cheeks must be restored first, so as not to treat the nasolabial fold uselessly.

The Radiesse treatment is extremely precise, as the practitioner must inject the exact quantity of product needed at the exact depth, and create support “beams”. Radiesse is the product of choice in the case of patients presenting with sagging cheeks resulting in a very deep nasolabial fold, or if volume loss at the chin level is so important that the face is not oval anymore.

The Radiesse syringe is more expensive than that of hyaluronic acid, but its total cost is lower, as the effects of the Radiesse last 1 year at least, sometimes 2 in most favourable cases (areas where muscles are not used much). Click here to discover our Combined injectable packages.

New: aging hands can now be treated with the Radiesse. Click here to see the video illustrating the treatment.

Botox: the main treatment for frown lines, and forehead and crow’s feet wrinkles

Paracelse has written “All substances are poisons; there is none which is not a poison. The right dose differentiates a poison and a remedy”. A homeopath will not refute such a statement… The botulinum toxin is a poison, like many others such as digitalin or curare. The paradox is that a poison at high doses can become a precious drug when administered at low doses (Reversal of action from Arnd and Schultz).

The botulinum toxin has become in 10 years the major technique used in aesthetics. One aesthetic treatment in four is a Botox injection, due to the high quality and safety of the method.

Remaining young

Abrasive paste recipes have been found on ancient papyrus scrolls, which proves men have always been looking for eternal youth. Aging is inevitable, but in the XIXth century, people were old at 40 years old; today people are old at 80 years old or more. People live longer and want to remain active and integrated in social life.

People thus want to look younger, for themselves, their partner, their family and towards society. It is both a desire and a pleasure (in these words noble sense), that is the desire and pleasure to remain active, in good health, and attractive. People look more active, more creative when they look younger or at least in the prime of life.

The trick does certainly not consist in getting younger, but in taking care of oneself and feeling attractive aware of one’s age.

Taking care of oneself to grow old serenely

Life hygiene is fundamental in the physical, dietetic, moral and intellectual fields. Sedentary lifestyles are to be avoided, as well as excessive physical or sport activity. It is essential to sleep well.

The first thing to do is stop smoking, and reduce alcohol and drug intake. A constitutional homeopathic treatment can of course be used to remain in good health or to recover one’s health.

Hahnemann, the creator of homeopathy, has written: “A healthy, robust and agile body makes the mind work more easily and successfully; all the time spent on body exercises is largely compensated by the happy effects they produce on intelligence itself; they give intelligence tone and movement; they allow the man of study to do in half an hour what he would usually not be able to do in half a day, when confined in a room all day long. They transform strenuous and ineffective efforts into a free and easy impetus”.

Getting more attractive and seductive

Aging is characterised by skin flaccidity, loss of volume and pigmentation disorders. Beauty requirements change with periods, but there is one constant: you must look as if you were rich. When peasants were meagre, malnourished and burnt by the sun, the beauty requirements were to be plump and to have a skin as white as possible. It is today the complete opposite…

The physician can use a whole range of devices: the dermal fillers, the laser peel to restore the skin surface, and the botulinum toxin to smooth the folds created by muscle contractures.

The principles of Botox

This molecule inhibits transitorily the conduction between nerves and muscles and weakens or blocks (according to the dose used) the muscular game responsible for the wrinkle.

The Botox (Vistabel®) will thus be used if the wrinkles on the forehead and the glabella (frown lines) are too numerous to be treated by dermal fillers.

The major indication is the crow’s feet, on the external border of the eye, where wrinkles are characterised by their number and fineness. It would be impossible to treat them all with hyaluronic acid. Moreover, the skin in this area is so thin and fragile that performing multiple injections of dermal fillers is out of the question.

Botox injection in the corrugator muscle, which acts as a powerful piston responsible for the glabellar wrinkles, also called frown lines.

A thorough knowledge of anatomy

The toxin must be injected at the correct dose and most of all in the right area, that is right in the muscle in which contractions must be inhibited. This face is made of numerous muscles forming kind of a complex network. These muscles command facial expressions and an exaggerated use can generate undesired wrinkles.

The injection of Botox is performed in a few minutes after having thoroughly chosen the areas to treat. The effects are visible as soon as the first days and are stable during 15 days – 3 weeks. A correction may be necessary 3 to 4 weeks after the injection session. The action of the botulinum toxin lasts during 3 to 4 months after the first treatment, often longer when it is renewed.

There are

• the muscles of joy, consisting in elevating and dilator muscles. The risorius muscle laterally extends the labial angle. This muscle is specific to mankind. It combines its action to the orbicularis oris which stretches the lips to produce a smile or express satisfaction.

• the muscles of sadness, dominated by depressors, with depression of transversal apertures. The corrugator muscle is often associated with sagging and frowning eyebrows; it expresses pain and sadness. The depressor anguli oris depresses the angles of the mouth and creates the bitterness folds. It gives a gloomy look.

• the muscles of attentiveness are the frontalis and the corrugator muscles. The forehead is creased and the eyebrows frowned, leading to the appearance of horizontal forehead wrinkles and of frown lines.

• the muscles of emotion are the corrugator muscle, that frowns the eyebrows, and the procerus, creating horizontal lines on the root of the nose.

This picture illustrates a Botox injection in the frontalis muscle, responsible for the horizontal forehead wrinkles. The toxin spreads easily in this flat muscle. Delicate massages will help obtain a natural result, which does not paralyze facial expressions.

There is thus a vast choice of injection sites, different for each personal case. However, Botox is mainly used in three areas:

• the forehead area

• the glabellar area (frown lines)

• the crow’s feet (fine wrinkles around the eyes)

The first treatment lasts approximately 3 months, then each injection extends the duration of the previous one. Ideally, people undergo one treatment every 6 to 9 months.

Conclusion

There are no contraindications to the injection of the botulinum toxin, except for pregnancy and myasthenia. A few transitory side-effects may be observed, such as an accentuation of the eyebrow angle and an excessive drooping of the eyelid during a few weeks, as well as more or less important headaches.

The botulinum toxin is a major contribution to forehead and eye aesthetics. It is the best product to treat areas that cannot be treated with injections: the forehead, the crow’s feet, the frown lines. Its efficiency and safety enables to delay or avoid a forehead lift. Associated to dermal fillers, it provides very satisfying results, even on a long term.

We have become less suspicious with time, and now believe that the botulinum toxin is completely innocuous. However, the principle of precaution should not be forgotten, and we always explain to our patients that there can be an unknown medical risk, even at very low doses. It is important for patients to be informed on botox before initiating a treatment.

The practitioner’s skill will consist in injecting the necessary and sufficient quantity of toxin. The goal is to smooth the wrinkles and most of all not to paralyze facial expressions.

By working artistically with the toxin so as not to inhibit facial expressions, the practitioner obtains a “zen” effect on the look that is very appreciated. Click here to discover our Combined injectable packages.