FILLERS

Current Concepts in the Use of Small-Particle

Hyaluronic Acid
Vince Bertucci, MD, FRCPC
Carrie B. Lynde, MD, FRCPC
Toronto, Ontario, Canada
Background: Soft-tissue augmentation with hyaluronic acid (HA) fillers has
become one of the most popular cosmetic procedures performed. HA fillers
represent safe and commonly used fillers. Several different HA fillers are avail-
able. The differences lie in the manufacturing process, allowing for tailored
uses. A small-particle HA with lidocaine (SP-HAL; Restylane Silk; Galderma,
Uppsala, Sweden) was approved by the US Food and Drug Administration in
June 2014 but has been available for many years in Canada as Restylane Fine
Lines and in Europe as Restylane Vital.
Methods: Relevant articles were reviewed relating to the composition, effec-
tiveness, and safety of SP-HAL. We also discuss the author’s extensive clinical
experience in the use of this product in Canada.
Results: SP-HAL has demonstrated proven benefits for lip fullness, augmen-
tation, and treatment of perioral rhytides. Although off-label in the United
States, SP-HAL is also well suited for the treatment of superficial fine lines,
including periorbital, forehead, marionette, and smile lines. In addition, it
has also been used in the tear trough region. A novel application for SP-HAL
includes use as a skinbooster with intradermal micropuncture. In this tech-
nique, small aliquots of product are injected so as to gradually rejuvenate the
skin in areas such as the face and hands. Side effects of SP-HAL were generally
transient and mild. The most common side effects were swelling, tenderness,
bruising, pain, and redness.
Conclusion: SP-HAL is an effective and safe HA filler with varied clinical
uses.  (Plast. Reconstr. Surg. 136: 132S, 2015.)

S
oft-tissue augmentation with hyaluronic acid
(HA) fillers has become one of the most
popular cosmetic procedures performed in
the United States.1–3 A member survey conducted
by the American Society for Dermatologic Surgery
revealed that 1.01 million soft-tissue filler treat-
ments were performed in 2014, making injectable
fillers the second most popular of all cosmetic
procedures performed by dermatologists, second
only to neuromodulator treatments.4 HA dermal
fillers have become the material of choice, given
their ease of use, low immunogenicity, reversibil-
ity, and longevity.5 The better the ability of the gel
to resist deformation, the higher the lifting capac-
ity of the HA filler.6 The cross-linking process
used to manufacture HA fillers serves to preserve
the entanglements of natural HA and to prolong
product persistence in tissue.7
From the Division of Dermatology, University of Toronto.
Received for publication April 3, 2015; accepted June 25,
2015.
Copyright © 2015 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000001834
Multiple HA fillers are available in different
markets, each with their own unique characteris-
tics. Nonanimal stabilized hyaluronic acid fillers
are one example of commonly used HA fillers
with favorable clinical characteristics. Some other
fillers available in different parts of the world
include the Juvederm, Emervel, Belotero, and
Teoxane families of products. In the nonanimal
stabilized hyaluronic acid family, a new small-par-
ticle HA with lidocaine (SP-HAL, Restylane Silk;
Galderma, Uppsala, Sweden) was approved by the
US Food and Drug Administration in June 2014
and is indicated for submucosal implantation for
lip augmentation and dermal implantation for
correction of perioral rhytides in patients over the
age of 21.8,9 The same SP-HAL has been available
in Canada and Europe for many years, marketed
Disclosure: Dr. Bertucci has been an investigator,
speaker, and consultant for Allergan, Galderma,
Merz, and Valeant. Dr. Lynde has no financial
­interest in any of the products, devices, or drugs
­mentioned in this article.

132S www.PRSJournal.com
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 136, Number 5S • Use of Small-Particle Hyaluronic Acid
under different names (Restylane Fine Lines and
Restylane Vital, respectively), and is indicated
there for facial tissue augmentation and correc-
tion of thin, superficial lines.10 It is a transparent,
viscous, and sterile HA gel isolated from a Strepto-
coccus species.
HA fillers from different manufacturers vary
in characteristics, such as total HA concentra-
tion, modulus, particle size, degree of cross-linking,
percentage of cross-linked HA, the amount
of unmodified HA present, and the extrusion
force.11–13 HA gel is stabilized during the manu-
facturing process to create a molecule that is
resistant to mechanical and enzymatic degrada-
tion,14 as tissue half-life is only 1–2 days without
cross-linking.1 The stabilization process varies
according to manufacturer and explains differ-
ences in product longevity and viscosity.15 SP-HAL
is chemically cross-linked with 1,4-butanediol
diglycidyl ether and stabilized and suspended
in phosphate buffered saline at pH = 7 and a
concentration of 20  mg/mL.8 It contains 0.3%
lidocaine and is commercially available in a 1-mL
disposable glass syringe.8
The particle size or calibration of this prod-
uct family is set during the manufacturing pro-
cess by passing stabilized HA gel through screens
with a specific pore size, producing well-defined
gel particles that are uniform in both shape
and diameter.16 Each form of HA has a differ-
ent gel particle size (Table 1) (Fig. 1).15 SP-HAL
is a low-density, less viscous filler indicated for
more superficial dermis, whereas another prod-
uct in the product range, small gel–particle HA
with lidocaine (Restylane-L; Galderma), is com-
posed of medium-density particles and is more
viscous and better suited for augmentation of
the mid-dermis.1 Finally, a third product in the
line, large gel–particle HA with lidocaine (Per-
lane; Galderma), is a high-density, longer-lasting
HA filler that is useful for deep dermal injection
and can be clinically used for deep subcutane-
ous and supraperiosteal injection such as in the
mid-cheek.1
Contraindications include patients who
have severe allergies with a history of anaphy-
laxis, multiple severe allergies, severe allergies
Table 1.  Particle Size of Nonanimal Stabilized
Hyaluronic Acid Family of Products
Product Gel Particles/mL
Small-particle HA (Restylane Silk) 200,000
Small gel–particle HA (Restylane) 100,000
Large gel–particle HA (Perlane) 8000
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
to Gram-positive bacteria such as streptococcus,
bleeding disorders, or hypersensitivity to amide
local anesthetics.8 Safety has not been established
in patients who are pregnant, breast-feeding, wish-
ing to become pregnant, or under the age of 22
years or over 65 years.8 Anecdotally, SP-HAL has
been safely used in an off-label fashion in individ-
uals under the age of 21.
Products that are somewhat comparable to
SP-HAL include, among others, Belotero Bal-
ance (Merz Pharmaceuticals, Greenboro, N.C.),
a soft-tissue filler that has been available in the
United States since 2011. It may be used for sim-
ilar indications, but it differs in that it does not
contain Lidocaine. Outside the United States,
other products such as Juvederm Volbella
(Allergan, Irvine, Calif.) compete with SP-HAL.
The latter product has a lower HA concentra-
tion (15 mg/mL) than SP-HAL and an even less
viscous consistency. Its rheological properties
make it appropriate for very superficial injec-
tions such as for subvermilion sheeting in the
lips to efface lip rhytides and to improve fine
perioral rhytides.
CLINICAL USE
Lips
The effectiveness of SP-HAL for lip fullness
augmentation and treatment of perioral rhytides
was evaluated in a randomized, evaluator blinded,
no treatment–controlled study.17 Two hundred
twenty-one subjects with very thin or thin lips
based on the Medicis Lip Fullness Scale (MLFS)
were randomized 3:1 to SP-HAL or no treatment.17
Subjects randomized to treatment at baseline were
retreated at 6 months and subjects randomized to
no treatment at baseline received their first treat-
ment at 6 months. Treatment success was defined
as at least a 1-grade increase from baseline in the
MLFS for the blinded evaluator assessment at
week 8 compared with the baseline assessment.17
A total of 76.1% of subjects who received SP-HAL
were assessed as combined upper and lower lip
MLFS responders by the blinded evaluator at 8
weeks compared with 11.6% of subjects who were
not treated (P < 0.001)17; 90.1% of treated subjects
assessed themselves as improved or better from
baseline at 8 weeks and 75.6% at 24 weeks. Fifty-
two subjects with Fitzpatrick types IV and V skin
were enrolled in the study with results similar as
the overall study.17
Clinically, SP-HAL is effective in lip augmenta-
tion, reducing perioral lines and effacing super-
ficial rhytides within the vermilion of the lip
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 Plastic and Reconstructive Surgery • November Supplement 2015

Fig. 1. Schematic representation of nonanimal stabilized hyaluronic acid (NASHA) filler manufac-
turing process with respective particle sizes. Reprinted with permission from Galderma. Copy-
right 2015, Galderma Laboratories, L.P.

(Figs. 2–4). Thus, SP-HAL may be described as a
refining and defining soft-tissue filler.
Superficial Fine Lines
Although indicated for lips and perioral lines
in the United States, SP-HAL is also well suited for
superficial fine lines, including periorbital, fore-
head, marionette, and smile lines. In some clinical
practices, it may be injected in a layered fashion,
in combination with other HA products that are
injected more deeply, so as to address not only super-
ficial lines but also improve contour and structure.
In the premarket US trial, there was a statisti-
cally significant and clinically meaningful improve-
ment in perioral rhytides as assessed by the blinded
evaluator at weeks 8–24. A total of 56.5% of
patients in the perioral rhytides treatment group
were responders, while only 20.9% of those whose
upper lip only was treated were responders (P <
0.001). Seventy-two percent of treated subjects
assessed themselves as improved or better from
baseline at 8 weeks and 64% at 24 weeks.17
As with many HA fillers, care should be taken
to avoid superficial injection so as to reduce the
risk of developing a blue hue, often referred to as
the Tyndall effect.
Nasojugal Groove/Tear Trough
In the author’s experience (V.B.), SP-HAL
may be used to improve the appearance of valleys
and shadows in the so-called tear trough region.
Treatment of this area requires deeper injection,
below the plane of the orbicularis oculi muscle.
This can be accomplished using the needle pro-
vided or with a cannula, such as a 27-gauge, 1.5-
inch cannula.
A prospective, randomized, split-face clinical
study produced excellent and safe results in 10
subjects with prominent nasojugal grooves. SP-
HAL was injected into one nasojugal groove using
serial puncture intradermally with a specialized
injector (Restylane injector) that dispensed 10
μL per injection. Normal saline was injected into
the other side. Blinded evaluators’ mean score

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 Volume 136, Number 5S • Use of Small-Particle Hyaluronic Acid

Fig. 2. A 32-year-old woman before (above) and after (below) treatment with 2  mL of SP-HAL
in the lips, perioral lines, and commissures and 1 mL of small gel–particle HA with lidocaine in
the nasolabial folds. Note improved lip projection, enhanced lip size, and reduced rhytides while
maintaining natural contours. Reprinted with permission from Galderma. Copyright 2015, Gal-
derma Laboratories, L.P. Photographs by Ava Shamban, MD.

on the treated side was statistically higher than
control side at both 4 and 8 weeks, while at 24
weeks, it remained higher but was not statistically
significant. At 24 weeks, 50% of subjects reported
satisfaction compared with their status before
treatment.18 Use of a standard needle or cannula
is also effective for the nasojugal groove. The ben-
efit of a cannula is that the risk of intravascular
injection may be diminished if the cannula is used
gently, taking care to avoid advancing the cannula
when significant resistance is met.
Skinboosters and Microinjection
Injections of SP-HAL as skinboosters have
been shown to be efficacious and well toler-
ated.19–23 SP-HAL skinboosters involves delivery of
HA using intradermal micropuncture with small
aliquots of product. This technique is designed to
gradually rejuvenate the appearance of the skin
in areas such as the face, hands, neck, and décol-
letage with a series of treatments.22 Although less
commonly utilized in North America, this tech-
nique is more popular in parts of the world such
as Europe.
Kerscher et al19 injected 19 subjects with SP-
HAL into the lower part of the cheeks bilaterally in
3 sessions: week 0, week 4, and week 8. Intradermal
injections approximately 1 cm apart using a serial
puncture technique were utilized, with each subject
receiving approximately 1 syringe per session. The
vast majority of subjects (85%) rated the outcome
as “very good” or “good,” with the remaining sub-
jects rating the treatment outcome as “moderate.”
There was statistically significant improvement in
both skin elasticity and roughness.19
Williams et al20 compared the effect of micro-
injections of SP-HAL on the hands with nonsta-
bilized HA. Twenty-five subjects were injected at
weeks 0, 4, and 8 with random assignment of left
and right hands to either SP-HAL or nonstabi-
lized HA (ie, native HA). There was a significant
improvement in skin elasticity, surface roughness,
hydration, and transepidermal water loss at week
12 compared with baseline.20
Microinjections for discrete depressed “ice
pick” acne scars have also been shown to be effec-
tive. Twelve patients who responded well to laser
treatment, but who still exhibited scattered deep

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Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • November Supplement 2015
Fig. 3. A 59-year-old woman before (above) and after (below)
treatment with 1.0  mL of small gel–particle HA with lidocaine
in the nasolabial folds and 2.8 mL of SP-HAL in the lips, perioral
lines, and oral commissures. Note improvement in perioral rhyt-
ides and restoration of lip volume and contour. Reprinted with
permission from Galderma. Copyright 2015, Galderma Labora-
tories, L.P. Photographs by Ava Shamban, MD.
ice pick scars, were treated with intradermal
microinjections of SP-HAL via the Restylane injec-
tor. All subjects were satisfied with the procedure
and exhibited visible improvement in scars.24
INJECTION TECHNIQUE
In the authors’ experience and as substantiated
in the literature, SP-HAL may be injected utilizing
a number of different techniques depending on
patient characteristics and the treating physician’s
experience and preference.
Linear Threading
Linear threading involves fully inserting the
needle into the middle of the wrinkle, fold, or
lip and injecting the filler along the track like a
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Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
“thread.” Threading is usually accomplished as
retrograde such that the needle is fully inserted
and is being withdrawn as one injects the filler;
however, it may also be done while advancing
the needle in an antegrade approach.8 Although
some injectors prefer the retrograde threading
technique to enhance the vermilion of the lip
and nasolabial folds, others prefer the antegrade
approach; product flow with the latter technique
may help to “push” vessels out of the way, theoreti-
cally reducing the risk of intravascular injection.
Serial Puncture
Serial puncture is accomplished by multiple,
closely spaced injections along wrinkles, folds,
or lips. The injection sites are close together to
ensure the material merges into a smooth, con-
tinuous line that ultimately lifts the wrinkle or
fold.1 Serial puncture allows for tight control
and precise product placement. This technique
is often used for fine superficial rhytides and
nasolabial folds.1 Serial puncture for treating lips
was found to have fewer adverse events, includ-
ing pain, swelling, bruising, and tissue mass, than
the linear anterograde technique in one random-
ized, evaluator-blinded study.16 These data may
indicate that despite multiple injections, serial
puncture may cause less tissue trauma than the
submucosal tunneling of the lip that occurs with
linear techniques.25 Having said that the author
(V.B.) anecdotally finds the linear threading
technique less traumatic as there are less needle
puncture sites.
Fern Pattern Technique
The fern pattern technique involves injecting
along the fold, in a linear fashion using a series
of punctures. The needle is inserted perpendic-
ular to the fold and advanced a few millimeters
away from the fold, and the product is injected
in a retrograde fashion.26 This is repeated along
the length of the fold alternating between the left
and right sides of the fold. Modifications of this
technique employ antegrade product injection.
This technique is especially helpful for dynamic
facial lines, such as smile lines, superficial nasola-
bial lines, and marionette lines.26 This technique
is not effective for deep injection.
Fanning
With the fanning technique, the needle is
inserted similar to linear threading; however,
before it is withdrawn, its direction is changed
and product is injected along a new line creat-
ing linear deposits in a wheel spoke pattern.1 This
 Volume 136, Number 5S • Use of Small-Particle Hyaluronic Acid
Fig. 4. A 25-year-old woman before (above) and after (below)
treatment with 0.8 mL of SP-HAL in the lips. Enhanced lip con-
tour and partial effacement of superficial rhytides within the
vermilion are evident. Copyright 2015, Dr. Vince Bertucci.
technique can be used submucosally to efface ver-
tical wrinkles in the lip proper.
Specialized Injector Devices
Specialized injectors are devices designed
to allow precision control of quantity of HA dis-
pensed. They generally allow the operator to con-
centrate solely on the placement of the gel and
facilitating an even distribution of the gel across
the injected area.18,22 These devices may be espe-
cially useful for novice injectors as they become
familiar with product characteristics such as flow
and extrusion pressure required to inject HA.
SAFETY
The safety of SP-HAL has been demonstrated
with most side effects being transient and mild. In
the premarket trial, all subjects were monitored
for 1 month after the 6-month treatment. The
majority of events (85%) was mild in intensity
and resolved in 2–7 days. The most common side
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
effects reported in the subject diaries included
swelling (98%), tenderness (91%), bruising
(81%), pain (77%), and redness (70%), all of
which are typical of lip injections.8 Seven percent
of subjects had abnormal lip firmness, almost all
of which were mild and 99% of which resolved
by 2 weeks after the first treatment.27 There were
no cases of severe abnormal lip firmness at any
point in the study, and none of the lip assess-
ments (texture, firmness, symmetry, movement,
function, mass formation, and device palpability)
were remarkable or presented safety concerns.8,17
Five serious adverse events were reported in 3
subjects; however, none were related to treat-
ment with SP-HAL. In addition, given the similar-
ity of the chemical compositions of SP-HAL and
other products in this family, studies previously
conducted support conclusions of the safety and
effectiveness of SP-HAL.8
CONCLUSIONS
SP-HAL is effective and well tolerated for lip
augmentation and for the correction of perioral
rhytides. In addition, SP-HAL has been clinically
used for the correction of other fine lines, such
as periorbital, forehead, marionette, and smile
lines. SP-HAL has a proven safety record, and side
effects are generally mild and transient in nature.
Some of the novel uses of SP-HAL include micro-
puncture techniques as a skinbooster to gradu-
ally rejuvenate the skin in areas such as the face,
hands, neck, and décolletage.
Vince Bertucci, MD, FRCPC
Division of Dermatology
University of Toronto
8333 Weston Road, Suite 100
Woodbridge, Ontario L4L 8E2, Canada
vince.bertucci@utoronto.ca
patient consent
Patients provided written consent for the use of
their images.
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