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Dermal fillers

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 Dermal fillers: Help patients put their best face forward

Dermal fillers
Help patients put their best face forward
By Victor Czerkasij, AS, BA, MA, MSN, APRN-BC, FNP-C

n 2009, the American Society for Aesthetic Plastic changing both physical wellness and outward appearance,

I Surgery revealed that in spite of the recession and

decrease in personal financial security, Americans
spent approximately $10.5 billion dollars on cosmetic pro-
cedures; men accounted for nearly 10% of the estimated 10
million procedures.1 Surgical interventions included lipo-
suction, breast augmentation, eyelid surgery, and breast
reduction, and popular nonsurgical interventions included
botulinum toxin product injections, laser hair removal, and
microdermabrasions. The antiaging field encompasses a
wide array of cosmetic and surgical interventions aimed at
including cosmetic dermatology.
One of the fastest-growing options is injectable der-
mal fillers, which offer the advantage of quick, relatively
inexpensive, and increasingly longer-lasting results for
facial wrinkles and deeper folds. Dermal fillers have
become the first-line treatment for nonsurgical options,
as they are safe, efficient, and result in improvements
for age- and photodamaged areas of the face with mini-
mal adverse effects. NPs need to understand the differ-
ences between the types of fillers and their use, as many

www.tnpj.com The Nurse Practitioner • October 2010 43

Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Dermal fillers: Help patients put their best face forward
supportive scope-of-practice bylaws allow NPs to per-
form these injections.
Although some NPs do not consider themselves in-
volved in “cosmetic procedures”, many do have daily
encounters with patients seeking assistance with conditions
they feel are important to their well-being, but are not
medically necessary and not categorized as traditional cos-
metic procedures. Patients present with acne and warts;
acrochordons (skin tags); seborrheic keratosis; melasma
(brown facial patches); liver spots (flat, brown patches on
sun-exposed areas such as the dorsal surface of the hands,
forearms or neck); vitiligo; stretch marks; keloids following
invasive surgery; alopecia or generalized thinning at the top
of the scalp; or bruising and purpura in elderly patients,
due to aspirin use, warfarin therapy, and thinning skin.
Every healthcare practitioner will see patients who have
had or may want cosmetic procedures, and today’s NP,
trained in the model of incorporating the whole person,
is well situated to inform and educate patients on age-
Three-dimensional view of the skin
Stratum corneum
Stratum lucidum
Stratum granulosum
Epidermis
Stratum spinosum
Stratum germinativum
Basement membrane
Dermis
Dermis
Arrector pili muscle
Blood vessel
Sebaceous gland
Subcutaneous tissue
Nerve to hair follicle
Source: Porth CM, Matfin, G. Pathophysiology Concepts of Altered Health States. 8th ed. Philadelphia, PA:
Wolters Kluwer Health/Lippincott Williams & Wilkins, 2009, 1546.
44 The Nurse Practitioner • Vol. 35, No. 10
Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
prevention techniques, improving health practices that
increase confidence and self-esteem (ie. exercise, smoking
cessation), and the rapidly evolving cosmetics field.
■ Understanding the skin
The skin is the largest organ of the body. Proper knowledge
of the skin’s structure helps practitioners understand how
to maintain smoothness and suppleness and how dermal
fillers can work properly. There are three main layers of
skin: epidermis, dermis, and subcutaneous tissue (see Three-
dimensional view of the skin). Although they work together,
each is responsible for particular functions.
The top layer is the epidermis. It is the thinnest of the
three layers and works as the main barrier to the body. This
surface is subjected to daily exposure from the sun, weather,
bacterial and viral infections, trauma, and the general stress
of interacting with the environment. The epidermis contains
melanin that defines skin color and sheds old keratin. It can
become dry and scaly, and produce papules and macules
or benign brown moles, red spots, or
skin tags that patients seek to remedy
whether by purchasing over-the-counter
products or consulting a healthcare
practitioner for advice.
The second layer is the dermis.
Composed of blood vessels and nerves,
it is mostly a sea of collagen, a durable
protein that supports the epidermis.
Collagen gives skin a smooth, supple,
Epidermis lifted to reveal
papillae of the dermis and elastic feel depending on the health,
age, and thickness of the layer. The term
“collagen” is used loosely, as there are
nearly a dozen types of collagen in the
dermal matrix, all working together to
Papillae
provide resilience and stability. The
dermis is also the cornerstone of the cos-
metic industry: manipulating the dermal
layer is the key to younger-looking skin.
The final layer is the subcutaneous
tissue, which stores fat. With age, how-
ever, its volume can decrease in the arms,
legs, and face, while increasing in the
abdomen in men, and in the thighs and
buttocks in women. The classic treat-
ment for fat deposits is often mechanical
Nerve
endings removal by liposuction or surgery by
“tucks.”
Sweat gland
■ Preventive skin care
Any discussion of new research and
trends in cosmetic dermatology must
www.tnpj.com
 Dermal fillers: Help patients put their best face forward

be preceded by an emphasis on prevent-

ing damage to the skin. The simplest Facial muscles
and most well-documented practice is
limiting the amount of sun exposure, as
early research suggests that UVA and
UVB may reduce production of colla-
gen over time.2 The use of appropriate
sunscreens, awareness of increased UV Frontalis
light in the late morning and afternoon
hours, and lightweight clothing can Levator labii superioris
Orbicularis alaeque nasi
dramatically lower the damage of skin oculi

over a patient’s lifetime. Both inexpen-

sive and effective, sunscreen also reduces
photosensitivity issues with medica-
tions, pigment changes of mottling and Levator labii
superioris
patching, wrinkling, and skin cancer Nasalis and
risk from prolonged UV light exposure. Zygomaticus nasalis transversus
minor
There are also many daily moisturizers Modiolus
Zygomaticus region
that contain sunscreen that can delay major
lentigines and wrinkling. Patients Levator anuli Orbicularis
should be advised to avoid tanning beds oris oris
unless medically prescribed. Risorius Depressor
UVA exposure, which causes cancer anguli oris

and wrinkles (UVB causes sunburn), is Deprsoor labii

sometimes ignored by manufacturers,
and NPs must educate patients to seek
out products that contain both UVA
and UVB ratings. Also, most patients do
no apply the sunscreen as thickly as it is Source: Fischer, JE. Mastery of Surgery. 5th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott
applied in testing. The FDA is examin- Williams & Wilkins. 2007; 300.
ing ways to implement stricter rules as
well as implement a rating strategy for UVA on sunscreen
products by the summer of 2011.
■ Injectable dermal products
These fillers, or volumizers, are available as outpatient pro-
cedures and result in nearly immediate natural-appearing
improvements. Some results can last up to 5 years. The
products come in three broad categories: temporary fillers
such as neurotoxins that act as muscle relaxants; human- and
mammalian-derived collagens and hyaluronic acids; and
semipermanent, collagen-stimulatory fillers such as calcium
hydroxylapatite and poly-L-lactic acid (permanent fillers
such as fat and silicone are beyond the scope of this discus-
sion). A thorough knowledge of facial anatomy and an
understanding of how to use the product are required when
injecting dermal fillers (see Facial muscles).
Neurotoxins
Botulinum toxin product, a potent FDA-approved injectable
neurotoxin, is used for treating frown lines in the forehead
Mentalis inferioris
(frontalis muscles), vertical lines between the eyes (these
look like the number “11” [procerus muscles]), and crow’s
feet (orbicularis oculi). OnabotulinumtoxinA (Botox, Botox
Cosmetic) is a purified protein complex derived from the
bacterium Clostridium botulinum that loosens and smooths
muscles by blocking transmission of acetylcholine impulses.
Results are seen in days. AbobotulinumtoxinA (Dysport) is
also FDA approved and was released in 2009. While Botox
is formulated with human albumin, Dysport contains lactose
and albumin, and there are currently no published studies
comparing the strength, time to onset, and longevity of
effect between the two products.3 Recent concerns that long-
term use of botulinum toxin may cause the neurotoxin to
slip into the bloodstream or lymphatic system and move
toward the brain have been proven in mice, but implications
for human use are unknown.4
In addition, the FDA has required manufacturers of
botulinum toxin to include a black box label with their
product warning of a very rare complication of the use of
the toxin. It appears that when botulinum toxin is used for

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Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Dermal fillers: Help patients put their best face forward
illnesses that require high doses of the product for thera-
peutic levels, there is a possibility the toxin may spread
beyond the injection site and cause neurological complica-
tions, which resulted in 16 deaths in 2009. This has not been
noted a single time when used for cosmetic purposes,
though adverse events occur when mixing different brands
which may be manufactured to be dosed at different levels.
■ Replacement fillers: Collagens and hyaluronic acids
Collagen is plentiful in the dermis. UV light, aging, and sun
exposure result in the production of collagenase, an enzyme
that breaks down collagen. Injecting collagen, or “soft tis-
sue augmentation,” is a stopgap measure designed to reduce
the loss of volume and enhance smoothness. Depending on
the place and amount injected, the effects of collagen and
hyaluronic acid can last from 3 months to a year. These
NPs must educate patients to seek out
products that contain both UVA and
UVB ratings.
products were designed for lip augmentation, scar treatment,
fine and deep wrinkles, furrows, and volume replacement.
Due to allergic reactions to bovine products, many
people prefer bioengineered human collagen, but the effects
generally only last 3 months. Human-based collagen prod-
ucts (CosmoDerm and CosmoPlast), are cultured from
bioengineered human skin and placed on special meshes in
5
bioreactors where the mammalian cell cultures are grown.
These products also contain lidocaine (Xylocaine) to reduce
injection pain in sensitive areas and can be used safely in
conjunction with hyaluronic acid, and can offer enhanced
results. CosmoDerm and CosmoPlast are contraindicated
in individuals with autoimmune disorders. The higher cost
to produce these fillers results in markedly higher prices,
but public acceptance and few adverse events make human
collagen a good choice.6
Bovine-derived collagen (Zyderm I, Zyderm II, and
Zyplast), is less expensive, widely used, and, since its intro- ■ Additional fillers
duction nearly 20 years ago, bovine collagen has proven
effective. To detect possible allergic reactions, two skin tests malive, Dermadeep, and Fascian. The two complemen-
are required before injection. Working on the same prin-
ciple as a patch test, hypersensitive reactions occur in a small hyaluronic acid–based products combined with acrylic
fraction of the population. Patients should be reassured that
contamination is lessened as the collagen is collected from
protected cattle herds.7
A hybrid of both purified bovine collagen and poly-
methylmethacrylate, Artefi ll is the first nonresorbable,
46 The Nurse Practitioner • Vol. 35, No. 10
_ . .
Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
lidocaine-aesthetic injectable for correction of nasolabial
folds. Approved in late 2006, it is undergoing postmarketing
safety studies.8 Artefill is both a dermal filler and a stimulant
for collagen production. As the bovine collagen is absorbed,
it is replaced by the new stimulated collagen. Its effects
appear to last up to 5 years.
Hyaluronic acid is a naturally occurring polysaccharide
that has the ability to bind with water up to 1,000 times
its own volume. This allows the product to create volume in
lips and around the eyes, fill in acne scars, and treat deep
wrinkles that are resistant to other treatments.6 Hyaluronic
acid is derived from avian or bacterial sources, and can be
used for very fine lines as well as deep folds. It does not require
allergy testing, nor is it associated with autoimmune disorders
such as lupus or psoriasis. Adverse reactions are rare, and
usually consist of temporary redness, swelling, itching, and
tenderness at the site of injection, which
resolve in a few days to weeks. Granulo-
matous formation is extremely unlikely.
The non-animal stabilized hyal-
uronic acid injectable gel, Restylane, has
been leading the dermal filler category
as far as sales since its introduction in
2003, and along with the hyaluronic
acid gel, Juvederm, is preferred for fine lines and deep wrin-
kles.8 Research has demonstrated that in patients injected
with Restylane, collagen synthesis was observed just 1 week
later, and still seen 3 months later.9
Perlane, another hyaluronic acid filler, has a larger
molecule than Restylane, and can easily fill deep wrinkles
and folds. Perlane’s larger gel particles offer enhanced
volume and lifting power, ideal for wrinkle and fold
correction in deeper layers of the skin. Results peak at
4 months, and touch-up work is recommended every
8 months. Additional hyaluronic acid fillers include Pura-
gen, a non-animal-based hyaluronic acid gel, which is
derived from bacteria; Hylaform and Hylaform Plus (made
from the combs of roosters); and Captique, a plant-based
filler. Prevelle Silk and Elevess also contain lidocaine in
their formularies.
Additional fillers that are difficult to categorize are Der-
tary fillers, Dermalive and Dermadeep, are long-lasting,
hydrogel. They are used in Europe and currently undergo-
ing FDA trials for use in the United States. As the hyal-
uronic acid begins to steadily degrade, it is absorbed in
the body, while the acrylic remains. Some have experi-
enced 5 to 10 years of results with very little maintenance
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or reinjection. This thick gel has also been used for chin
augmentation.
Fascian is a purified human connective tissue in liquid
suspension. Grafts are obtained from cadavers, typically
from the gastrocnemius fascia, then irradiated, processed,
purified, and thickened with hyaluronic acid. It is FDA ap-
proved and subject to a highly regulated process. Although
considered safe and hypoallergenic, the effects last for 3 to
12 months. There are also autologous preparations, such as
isolagen, in which a patient’s own cells are extracted, mixed
with hyaluronic acid, and then reinjected. Isolagen, which
is used in Europe but is currently not FDA approved, has
completed phase III studies demonstrating safety and effi-
cacy, with no serious adverse events, and 93% of patients
note improvement at 6 months.10
■ Semipermanent collagen-stimulatory fillers
Sculptra is an FDA-approved, collagen stimulator poly-L-
lactic acid dermal filler that promotes tissue growth in HIV-
positive patients who have lost facial fat. It is a synthetic
polymer from the alpha-hydroxy acid family that has been
used for centuries as a natural product from citrus fruit and
is known for its exfoliative properties. It is biocompatible
with humans and biodegradable over its 2-year life span as
a filler.
The only FDA-approved calcium hydroxylapatite,
Radiesse has a unique combination of naturally occurring
chemicals present in the body. Unlike the concerns over
botulinum toxin products, Radiesse does not migrate to
other body systems or organs, and the calcium and phos-
phate ions suspended in the water-based gel eventually
degrade and are absorbed by the body. The manufacturer
claims that collagen production is stimulated at the time of
delivery, and growth has been verified around the injection
site. The effects last for 1 year.
■ Injection technique
Injections are generally made by five recognized methods:
straightforward 90-degree depot or bolus injections; serial
punctures of multiple drops placed along the length of a
wrinkle or fold; cross-hatching, which treats a frown line
from opposing sides; linear threading, in which the full
length of the needle is inserted and the filler injected while
pulling the needle backward so the filler is released; or fan-
ning, which requires a single insertion while the filler is
released by a pivot and swivel motion to the left and right.11
The NP should exercise a “treat, wait, and assess” approach
to determine whether further injections are warranted.2
Manufacturers often state on their websites that the
public should seek either a board-certified physician or NP
who has undergone training for these procedures. The
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Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Dermal fillers: Help patients put their best face forward
official position of the American Society for Dermatologic
Surgery states that, “Under the appropriate circumstances,
a physician may delegate certain procedures to certified or
licensed allied health professionals,” and “shall be physi-
cally present on-site, immediately available, and able to
respond promptly to any question or problem that may
occur while the procedure is being performed.”12 All health-
care providers must seek out and receive extensive training
by working in partnership with a practitioner experienced
in these techniques and/or taking a certification course
offered by the manufacturer. NPs also must understand and
uphold their own state’s scope of practice regulations.
■ Conclusion
Because of the pressures in American society to uphold a
certain physical appearance in spite of the natural process
of aging, NPs will encounter more and more patients who
either wish to try dermal fillers or may already have experi-
enced the procedure. At a cost of $500 to $1,000 per session,
and often combined with a botulinum toxin product, the
budget for cosmetics use can be significant to some con-
sumers. NPs must assist patients in recognizing realistic
personal goals and also remain knowledgeable regarding
current products available.
REFERENCES
1. The American Society for Aesthetic Plastic Surgery. Top 5 procedures:
Surgical and nonsurgical. http://www.surgery.org/sites/default/files/2009
Top5_Surg_NonSurg.pdf.
2. Fligiel SE, Varani J, Datta SC, et al. Collagen degradation in aged/
photodamaged skin in vivo and after exposure to matrix metalloproteinase-1
in vitrol. J Invest Dermatol. 2003; 120(5):842-8.
3. Schlesinger J. A new form of botulinum toxin. Skin Aging. 2009;17(10):38-40.
4. Begley S. A new reason to frown: does Botox get into the brain? Troubling
research contradicts earlier findings about the treatment. Newsweek. 2008.
www.newsweek.com/id/131749.
5. BioNews Online. What is a bioreactor? 2008. www.bionewsonline.com/o/
what_is_bioreactor.htm.
6. Baumann L. Dermal filling agents: making the right choice for your patient.
Skin Aging 2007;15(3):38-44.
7. Sherman RN. Sculptra: the new three-dimensional filler. 2006;33(4):539-550.
8. Tierney RK. Pumping up the volume. MedEsthetics Magazine. 2008:27-32.
http://www.michelegreenmd.com/index-4.html
9. Wang F, Garza LA, Kang S, et al. In vivo stimulation of de novo collagen
production caused by cross-linked hyaluronic acid dermal filler injections in
photodamaged human skin. Arch Dermatol. 2007; 143(2):155-163.
10. Meyer E. Cosmetic dermatology update: highlights of recent news and
trends. Isolagen therapy safe and effective treatment for skin quality and
wrinkles. Skin Aging. 2008. http://www.skinandaging.com/content/cosmetic-
dermatology-update-highlights-recent-news-and-trends.
11. Michaels J, Comstock J. The advanced art of facial fillers. Skin Allergy News.
2008:S1-S8.
12. American Society for Dermatologic Surgery. Position Statement on Non-
Physician Practice Of Medicine And Use Of Non-Physician Office Personnel.
http://www.asds.net/PositionStatementonNonPhysicianPracticeOfMedicine
AndUseOfNonPhysicianOfficePersonnel.aspx.
Victor Czerkasij is a clinical instructor at Vanderbilt University, associate lecturer
at Fitzgerald Health Education Associates, and a dermatology nurse practitioner.
DOI-10.1097/01.NPR.0000388207.23981.02
The Nurse Practitioner • October 2010 47