Aesthetic Dermal Filler Injections for

Facial Rejuvenation
Donald Brideau, MD, MMM, FAAFP
 ACTIVITY DISCLAIMER
The material presented here is being made available by the American Academy of Family
Physicians for educational purposes only. This material is not intended to represent the
only, nor necessarily best, methods or procedures appropriate for the medical situations
discussed. Rather, it is intended to present an approach, view, statement, or opinion of the
faculty, which may be helpful to others who face similar situations.

The AAFP disclaims any and all liability for injury or other damages resulting to any
individual using this material and for all claims that might arise out of the use of the
techniques demonstrated therein by such individuals, whether these claims shall be
asserted by a physician or any other person. Every effort has been made to ensure the
accuracy of the data presented here. Physicians may care to check specific details such as
drug doses and contraindications, etc., in standard sources prior to clinical application. This
material might contain recommendations/guidelines developed by other organizations.
Please note that although these guidelines might be included, this does not necessarily
imply the endorsement by the AAFP.
 DISCLOSURE
It is the policy of the AAFP that all individuals in a position to control content disclose any relationships
with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed
for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of
participation. Only those participants who had no conflict of interest or who agreed to an identified
resolution process prior to their participation were involved in this CME activity.

All individuals in a position to control content for this activity have indicated they have no relevant
financial relationships to disclose.

The content of my material/presentation in this CME activity will include discussion of unapproved or
investigational uses of products or devices as indicated:

• Discussion of use of some fillers for facial rejuvenation in areas not necessarily FDA
approved. Slides will indicate which areas are approved or not approved.
Donald Brideau, MD, MMM, FAAFP
Chief Operating Officer and Chief Medical Officer, Inova Health System, Inova Mount Vernon
Hospital, Alexandria, Virginia; Family Physician, Alexandria; Associate Clinical Professor, GWU
Medical School; Course Director for “Administrative Medicine” GWU Med School

Dr. Brideau is a graduate of George Washington University School of Medicine & Health
Sciences, Washington, DC. He completed undergraduate studies at Georgetown University in
Washington, DC, and a Master's degree in medical management at Carnegie Mellon University
in Pittsburg, Pennsylvania. Dr. Brideau practices family medicine part-time in Alexandria,
Virginia. He has been a teacher of American Academy of Family Physician courses for the past
15 years. Topics he has covered include tobacco cessation and cosmetic skin care treatments.
Dr. Brideau hopes to see more family physicians performing cosmetic procedures in their
practices, not only as an additional source of income and variety within their scope of practice,
but also as an additional service to patients.
 Learning Objectives
1. Assemble plans to address requests for dermal fillers, particularly
among patients who may want injections to reduce the signs of
aging.

2. Outline appropriate treatment modalities and duration of action

required for dermal filler injections.

3. Assess the costs involved in ordering and performing dermal filler

injections.

4. Assess the risks and benefits involved in performing dermal filler

injections.
 Why consider fillers in your practice?
• Patients are seeking these procedures:
– Top 2 non-surgical cosmetic procedures in 2014 were
• Botulinum toxin injections (6.7 million procedures- up 3%
compared to 2013)
• Dermal Fillers (2.3 million procedures-up 7%)
• FPs are trained in minor surgical and dermatologic
procedures
• Many patients prefer their own physician if properly
trained.
 Soft Tissue Augmentation: Effects
• Plumping of the skin in the dermal and
subdermal layers
• Eliminate static wrinkles
– Use botulinum toxin to decrease dynamic
wrinkles
• Temporarily rejuvenate the aesthetic
appearance of the face
 3 D’s of Aging
• Deflation
– Loss of muscle mass causing excess skin
– Estimate 10 ml volume loss per decade
• Degredation
– As we age, we produce less collagen and therefore
less elasticity in the skin
• Descent
– Gravity takes hold causing dropping
– All 3 D’s increase the appearance of aging
 Collagen
• The building block to our dermis
– 70-80% of the dermis is collagen
• Loss of collagen begins in mid-20’s to
early 30’s
– Decrease affected by smoking, genetics, sun
exposure, and hormones
 Filler Sources
• Autogenic: Derived from the patient
dermis, fat, plasma, collagen, fibroblasts)
• Allogenic: Derived from another human
cultured or cadaveric collagen or fascia)
• Xenogenic:Derived from animal or bacteria
bovine collagen, hyaluronic acids from
rooster comb or bacteria e.g., Juvederm,
Restylane)
• Synthetic : Derived in the Lab:
Calcium Hydroxylapatite
Poly-L-Lactic Acid
 Fillers commonly used
• Based on their ease of use, length of
duration, non-allergenic
– Hyaluronic acid ( Restylane Products1, Juvederm Ultra2 and
Ultra Plus2,Voluma2 ,Belotero3)
– Calcium hydroxylapatite ( Radiesse3)
– Poly-L-Lactic Acid ( Sculptra4)

– 1=Medicis 2= Allergan 3= Merz 4= Valeant

 Fillers You Probably Won’t Use
• Mostly historical at this point
– Bovine Collagen: My old presentation
– Human Collagen
• Used by Plastic surgeons:
– Fat Transfers
 Hyaluronic Acid
• Major component of connective tissue
• Synthetic is identical to animal types
• Last 1-2 years
• Binds water at 1000x its own weight
• 3 Major Products in US
– Juvaderm Ultra and Juvaderm Ultra Plus and VOLUMA by Allergan (makers of Botox)
– Restylane Product Line (regular, Lyft and Silk) by Galderma (makers of Dysport)
– Belotero by Merz (makers of Xeomin)
 Collagen stimulators
• Poly-L-lactic Acid (Sculptera)
– 1999 Approved in Europe
– 2004 Approved in US for Fat loss for HIV
– 2009 Approved for cosmetic wrinkles
– Biocompatible
– Mixed in Office
– Side Effects: Lumpiness in 9%
• Calcium hydroxylapatite (Radiesse)
– Looks like toothpaste, found in bone
– Injected into subcutaneous layer, not dermal
– Doesn’t calcify, not bone
– Absorbs H2O
– Allows collagen to regrow between the calcium hydroxylapatite molecules
 Collagen stimulators
• Calcium hydroxylapatite (Radiesse)
– Biocompatible
– found in bone but not bone
– Absorbs H2O
– Allows collagen to regrow between the
calcium hydroxylapatite molecules
– Typically last at least 12 to 18 months
 Old Bovine Collagen
• Made from cowhide
• Not used as much but it was standard
• Purified to make it non-immunogenic
• 3-5% of patients have allergies so must perform
a 30 skin test
• Superficial lines
• Last 6-12 weeks
 New Bovine Collagen
• Technology has changed the life span in one product: Bellafill
by Suneva Medical Inc.
– 80% Bovine Collagen Gel with 20% Polymethylmethacrylate
microspheres (used in Plexiglass and contact lenses), with lidocaine
– Indicated in Nasolabial folds and for acne scarring.
– Collagen results in immediate improvement then absorbed.
– Microspheres stimulate firm matrix with lasting results up to 5 yrs
– Used in all skin types.
– Needs Skin testing 4 weeks prior
– 4.1% develop lumps but typically resolve.
 Overall Indications for Fillers
• Fine Lines
• Furrows
• Volumizer
• Lips
– ALL of above depend on the type of filler and
MD experience to get the best effects
Clinical Uses: approved and not
– Nasolabial fold
– glabella folds (off label)
– tear trough( nasojugal groove) (off label)
– cheek bone augmentation (off label)
– peri-oral lines (off label)
– lip augmentation (On Label Restylane, Juvederm Ultra)
– marionette lines
– nasal bone augmentation (off label)
– sub mental crease (off label)
– prejowl sulcus (off label)
– Hand Rejuvenation ( Radiesse on label)
 Contraindications
• Pregnancy
• Lactation
• Sensitivity to product
• Skin disease in area to be treated
• Abnormal clotting
 Side Effects
• Hypersensitivity for some products – Old collagen
fillers
• Granuloma
• Erythema
• Swelling
• Pain and Tenderness
• Itching
• Bruising
• Rash
 Preparing the Patient
• At consult
– Set Appropriate Expectations !!!!!
– Use before and after pictures of preferably
your patients to show results as examples
– Advise fine wrinkles may remain
– Obtain Consent
 Decreasing Pain
• Topical Anesthetic
• Products with Lidocaine already mixed
• Use skinniest needle appropriate for
viscousity
• Advise will at least sting
 TOPICAL ANESTHETICS
• EMLA Cream (AstraZeneca)
• Ela-MAX 4% (Ferndale)
• Compounding pharmacies make preparations of BLT
(Benzocaine, Tetracaine and Lidocaine)
• Wash off prior to the procedure
Where do I inject? Skin Anatomy
 Injection Guidelines
For Products discussed in basic:
Limited to upper and middle dermis (generally)
If too shallow, may result in blanching of the skin or
bluish color (Tindle Effect). Lumpy appearance.
If too deep, reabsorbed faster, takes more product
to reach effect but safer than too shallow
 Approach Depends on Depth of
wrinkles
• For Fine lines
– Approach: Shallow angle 10-15 deg
– Filler type: Less Viscous
– Superficial Papillary level
– Example: Peri-oral or orbital
• Moderate to Deep:
– Approach: 30-45 degrees
– Filler type: thicker viscousity
– Into Mid Reticular level of Dermis
– Example: Nasolabial folds/Marionette Lines
 Approach Depends on Depth of
wrinkles
• For Deep Rhytids lines
– Approach: Shallow angle >= 45 deg
– Filler type: Most Viscous
– Deep Dermal or below
– Example: Cheek/tear trough
 How Do I Know I am at the Correct Depth?

• Thin fillers: Juvederm Ultra and Restylane in Mid Dermis

• Thick fillers: Juvederm Ultra Plus, Perlane and in deep dermis

• Radiesse and Sculptera into subcutaneous area.

Too Superficial Too Deep, but OK Deep Dermis Injection Plane

More product will be required
This will result in uneven
appearance
 Method of injection
• Appropriate Needle selection.
– Needle size is determined by filler viscosity.
– Use the smallest bore needles possible allowing
for viscosity
– Withdraw while injecting to avoid cannulation of a
vessel
– Multiple thin lines better result than one to two
thick lines
 Injection Technique
• Threading
• Fanning
• Cross hatching
• Push Ahead
• Serial Punctation
Threading
• Single line per Injection site
• Inject filler as needle is
withdrawn
• Steady pressure and speed to
prevent lumpiness
– Ever caulk your tile in
bathroom
Fanning
• Multiple lines per injection
• Inject filler as needle is
withdrawn
Cross Hatching
• Multiple lines per injection
• Inject filler as needle is
withdrawn
• Similar to fanning but lines
intersect
Serial Puncture
• Injecting in series of individual
close punctures
• Inject filler into site creating
filling effect
• Smooth deposited filler by
massaging
 Consult to Follow Up
• Patient History
– Risk of bleeding, scar formation
– History of HSV
• Need to pre and post treat with antivirals
– Prior treatments-
– Examination with setting expectation
– Allergies to meds, lidocaine, etc
– Medications:
• Avoid NSAIDS, ASA, St. John’s Wort, Various herbals that
increase bleeding.
 Obtaining Consent
• Discussing side effects
– Bruising, bleeding, over or under-correction,
granuloma, sensation of filler at site, skin necrosis
• Alternatives
• Types of Injectables
• Alternative Clinicians- Derm/Plastic
• Consent to photography
 Patient prep
• Decision to use topical Anesthetic
– Start 30 minutes at least prior to procedure
• Cleaning Skin with alcohol
• Mirror for patient to assist in evaluation
 Post Injection
• Smoothing after injection
– May not be required for HA due to smoothness
– Can be done for all if you need to push filler to better
result
– May result in increased bruising.
• Warn about over correction appearance for 1-2
weeks
– Real view (minus blood bruise) immediately after
injection
 Basic Injection Sites
• Start with areas associated with most common
injections and lower risks
• Most common
– Nasolabial folds
– Marionette lines
– Fine lines (peri-oral, Crow’s feet, forehead)
• More Advanced
– Tear Trough, Cheek Augmentation, Pre-sulcus jowls
 Nasolabial Folds
• Use thicker products
– Perlane, Juvederm Ultra Plus, Radiesse
• Threading technique more common, multiple close
together
– May use Puncture technique for upper triangle
– 0.05cc with each pass
• Topical Anesthetic or products with lidocaine in it
• Don’t underestimate amount to save $
 Nasolabial Folds
Before After
 Video on Nasolabial Folds:
Hyluronic Acid and Ca Hydroxylapatite
 Marionette Lines
• Can use same products as for Nasolabial
fold or for finer lines depending on volume
to be used
• Usually a cross hatch technique
• Goal is to lift corner of the mouth and
eliminate/soften the lines
 Marionette lines with Radiesse
Before After
 Finer lines
• Products
– HA such as Restylane Silk, Juvederm Ultra
• Technique
– Serial puncture, threading with bent needle,
– More superficial than larger lines
• Avoid blanching
 What do you need to do to start?
• Business Planning
• Additional Costs
• Advertising
 Building the Business Plan
• Why Should I even consider it?
• Do we have the patient base?
• What procedures would I like to perform?
• What product(s) should I buy and why?
 Additional Costs
• Malpractice
– Usually not an issue for injectibles
• Advertising
• Opportunity Costs
• Personnel Costs
 Advertising
• Office ads
• Pamphlets
• Web sites
• Radio, TV
• Newspapers
• Lectures
Advertising:
Promos
 Marketing the practice
• Current Patients
• New Patients
• Business Relationships
• Differentiating from others doing the
procedure
 Marketing to current practice
• Data Analysis
• In-Office posters/pamphlets
• Dr. Buy In
• Direct mailing
 Developing New patients
• Outside advertising
• Word of Mouth
• Patient referral discounts
• Other physicians
• Local paper articles
 Resources
• Sales representatives
– Provide product, set up account, provide training via
courses
• Training tapes
– Aesthetic Video Source at www.videoshelf.com
• Books
– Cosmetic Dermatology: Principles and Practice
by Leslie S. Baumann : McGraw-Hill Professional; 2nd edition
– Procedures in Cosmetic Dermatology Series: Soft Tissue Augmentation.
by Jean Carruthers (Editor), Alastair Carruthers (Editor)
 Resources
• MedEsthetics Magazine
– Free at medestheticsmagazine.com
• Ho d, Jagdea J. Voluma: Asytematic review of clinical experience.
J Drugs Dermatol. 2015;14(9): 934.
 Practice Recommendations
• Upon returning to your practice:
– 1. Determine demographics for Filler type
patients discussed.
– 2. Contact Companies related to Filler products
– 3. Schedule hands on training through
companies, courses, or via colleagues already
trained.
– 4. Provide discounts to first few patients
scheduled.
 Contact information
Donald Brideau, MD, MMM
Chief Operating and Chief Medical Officer
Inova Mount Vernon Hospital
2501 Parkers Lane, Alexandria VA 22306
Work Phone: 706-664-8597
Email: donald.brideau@inova.org

Inova Family Medicine, Springfield

Inova Medical Group,
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