Hyaluronic Acid Fillers

Hyaluronic Acid Injectable Fillers Soften Facial Expression Lines and Restore Volume
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John Q. Cook, M.D.

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Restylane®, Perlane®, Juvederm Ultra®, Juvederm Ultra Plus®, Belotero®, and Voluma® provide a wide range of options for patients at the Whole Beauty® Institute in Chicago and North Suburban Winnetka

Led by Dr. John Q. Cook, the highly experienced team at the Whole Beauty® Institute offers our patients in-depth knowledge about a wide range of injectable fillers made of hyaluronic acid. We have found that each of these fillers has a specific role to play in injectable facial rejuvenation. During our detailed consultation we will explore your areas of concern and develop a custom plan to restore missing volume and reduce facial expression lines. For some patients this may involve a single type of filler that fits the role perfectly. For patients with more complex needs we will make use of several different types of fillers, each of which is suited to a particular task. Often our treatments with HA fillers are combined with relaxants such as Botox® and Dysport® as well as a wide range of other therapies that we offer for skin rejuvenation. By combining different treatments we are able to provide our patients with an optimum appearance.

Hyaluronic Injectables Overviewby Dr. John Q. Cook

FDA approval of hyaluronic injectables opened a new era for facial soft tissue augmentation in the United States. In many applications these versatile filler have significant advantages over other materials available to soften lines and restore volume. The purpose of this overview is to provide you with an understanding of the nature of hyaluronic injectables, the range of medical applications, their characteristic advantages and disadvantages, and the qualities you should look for in the clinician who will treat you.

What is Hyaluronic Acid?

haHyaluronic acid (HA) is a natural material that is found throughout the human body. It has a simple chemical structure that is know as a glycosaminoglycan; in other words, it is simply made of two slightly different sugar molecules that repeat themselves in long chains and form particles of various sizes. The chains connect themselves with chemical bonds known as cross-linking.

Cross-linking is an important characteristic of HA, since without it, the HA will rapidly disappear if it is injected in the body. Think of the cross-linking between the chains of sugar molecules as the “glue” that keeps the HA stable. Companies that manufacture HA can also select various particle sizes. In general, bigger particles are useful when heavy lifting is necessary under a deep crease or in a hollow cheek, while smaller particles are more useful closer to the skin surface. skin

Although HA is found in many tissues in the body, we will concern ourselves predominantly with the HA that is found in the skin. The skin can be viewed as having two main layers, an outer cellular layer (the epidermis) that protects us from the external environment and a deeper structural layer (the dermis) that provides resiliency, tone, and support.

The dermis is largely made up of bundles of collagen and elastic fibers that run through a squishy pudding of HA. The dermis also contains fibroblasts, cells that manufacture collagen and other materials including hyaluronic acid. As we age our fibroblasts can’t make as much of these good materials, so the skin becomes thinner.

What Makes Hyaluronic Acid so Useful?

The clinician has quite a few choices available for soft tissue augmentation in the United States and an even greater range of options in other countries. This is one of the reasons I have spent significant time in recent years traveling to medical conferences and visiting clinicians in European countries. In Europe, an almost Darwinian struggle goes on between all of the possible materials that compete for a doctor’s limited attention. In many ways this is quite good; the beneficial and useful materials tend to gain market share, while the ones with problems or disadvantages tend to fade away. Since medical materials and drugs come to market much quicker in Europe than in the United States, an American physician such as myself, who can speak some French or German, can monitor the Europeans and predict future developments in the United States. It’s hard for me to say which knowledge has been of greater benefit to my patients: knowing what will probably turn out to be useful or knowing what to avoid at all costs. I’ve certainly seen plenty of examples of both. Ten years ago I noticed that European doctors were abandoning other injectables and moving to HA products. As I learned from my European colleagues and began to develop my own approach to injection technique, I was struck by certain advantages inherent in the hyaluronic products.

First of all, they are soft. There is less of a problem with lumpiness or palpability than with many of the other injectables. A pair of lips may look beautiful, but if you feel a firm ridge when you kiss them, they lose much of their appeal.

A second advantage that springs from this softness is the remarkable versatility of HA injectables. With many of the other materials the clinician is limited to a small number of sites where he can inject safely: lip borders, nasolabial creases, and other facial grooves and furrows. With HA injectables, the highly experienced clinician can actually build up three-dimensional structures in certain facial zones, especially around the lips. This allows for more of a sculptural approach. At the Whole Beauty® Institute we use a variety of HA filler to restore deep volume to the cheeks, then temples, the chin, and other areas that have become hollow from the aging process or from weight loss.

A third advantage is durability. HA injectables persist for months longer than many other forms of soft tissue fillers. To the patient this means fewer trips to the doctor for restoration.

The fourth advantage, non-permanence, may at first seem paradoxical; why wouldn’t it be better just to inject something that will persist for years? After all, there are products out there that supposedly will do just that. There are two powerful reasons why non-permanence is a desirable characteristic. First of all, if the patient doesn’t care for the result, it will eventually melt away. To achieve their true potential HA injectables require a highly skilled and visually sophisticated clinician on the other end of the syringe. If a patient is treated by someone who lacks these characteristics, eventually the filler will diminish.

An even more important advantage to non-durability came to me during a visit to one of the European medical congresses. I noticed that physicians with a high level of experience and skill who had used so-called permanent injectables in the past were warning others not to do so in their lectures. In each case, the reason was the same: delayed granulomas. No matter what the material, the message was remarkably similar: at first the doctors loved using a type of injectable, but after several years they began to notice that in a certain percentage of patients changes began to appear in the skin above the area of injection. These changes consist of granulomas: itchy, raised, red bumps that do not go away. As I looked into the record of these injectable materials, I was struck by the similarity of the pattern.

Stage I: the physician thought he or she had found a permanent injectable that didn’t cause long-term problems.

Stage II: aggressive marketing on the part of the company that manufactures the injectable material and uncritical acceptance on the part of certain physicians.

Stage III: several years later the physicians discovered delayed granulomas. Since Hyaluronic Acid is a material that naturally occurs in the body and is broken down through normal turnover, granulomas should be extremely rare. As a practical measure, the team at the Whole Beauty® Institute has performed thousands of injections with various HA products, and we have never encountered a granuloma in any of our patients.

The aging process continues after a person has been injected with a filler. With a permanent filler this may become a problem, since the shifting and settling of facial structures might move a permanent filler to an area where it is not desirable. This problem is largely avoided with HA fillers. Hyaluronic fillers have the additional advantage of reversibility. Hyaluronidase is an enzyme the body uses to break down HA in tissues. This enzyme is available for clinical use. If for some reason too much HA has been injected, so that an area is fuller than a patient desires, it is possible for the clinician in inject hyaluronidase into that area and melt the HA down to a desired size.

The fact that Hyaluronic Acid is naturally present throughout the body has great appeal. The simplicity of its structure and its gradual natural breakdown in the tissues are added benefits.

What is the worldwide experience with hyaluronic injectables?

When it comes to facial injectables, there truly is safety in numbers. The more patients who have been treated with a given material and the longer the treatment experience, the more intelligently one can talk about safety. If I were considering treatment with a facial filler, the first question I would ask is, “How many people have been treated with this material?”.

It is reassuring that millions of facial soft tissue augmentations have been carried out with HA injectables. At the Whole Beauty® Institute in Chicago and Winnetka our team has performed thousands of treatments with hyaluronic injectable fillers. Our extensive experience works to our patients’ advantage.

How to find the best practice for treatment with hyaluronic injectable fillers?

Hyaluronic injectable fillers are not commodities. Although the physical characteristics of a given filler determine part of the effect, a more important issue is the skill and background of the person carrying out the injection. In any business, the owner ultimately determines the standards and ethics of the organization that he or she leads, so it is worthwhile to know the credentials of the owner of the facility where you are considering treatment. Dr. John Q. Cook, a recognized leader in aesthetic plastic surgery and medical aesthetics, leads our team at the Whole Beauty® Institute. Dr. Cook’s experience spans over 20 years. Our skilled teams of nurse and PA injectors have been trained directly by Dr. Cook so that there is a high level of technical skill and a strict adherence to artistic principles.

Different hyaluornic injectable fillers fit different needs.

Although there is a more limited range of fillers available to patients in the United States than in other advanced countries, patients and physicians have better choices than a few years ago. Each filler has a range of applications where it works best. Some are thick and relatively good for lifting tissue. Others are thin and better for very fine lines. Some are of intermediate consistency.

Voluma® is the most robust filler currently available in the United States.

Voluma® is one of several fillers that are manufactured with a process known as Vycross technology, which allows for a greater percentage of low molecular weight hyaluronic acid and also a relatively high degree of cross-linking. The net effect is a filler that is relatively smooth in feel but strong in lifting ability.

Because of its characteristics, Voluma® works well in areas that were hard to fill with less robust fillers. Voluma® has been approved by the FDA in the United States to restore deep volume in the cheeks, but it has also been shown to be useful in a variety of other areas including the temples, the chin, and in other facial zones. Clinical trials with Voluma suggest a longer life span than typically seen with “thinner” fillers such as Juvederm® and Restylane®, perhaps due to different cross-linking.

At the Whole Beauty® Institute Dr. John Q. Cook and his clinical team make extensive use of Voluma®, often in combination with other fillers. We frequently utilize a blunt needle technique that is derived from Dr. Cook’s 15 years of experience with facial fat grafting.

Juvederm Ultra Plus® and Perlane® can be viewed as intermediate strength Hyaluronic Fillers

In our experience, we have found that Perlane® and Juvederm Ultra Plus® behave similarly. They add strength and structure at the mid-level of the facial soft tissues. We have found them to be useful under deep creases that sometimes occur beneath the corner of the mouth and beneath relatively deep creases between the upper lip and cheek (nasolabial folds). They can be used in other specialized applications in the face, where a greater degree of “heavy lifting” is required. Often we layer Restylane® or Juvederm Ultra reg; on top of these fillers to achieve three-dimensional volumization.

Juvederm Ultra® and Restylane® Offer Excellent Structure Closer to the Skin

These fillers, due to particle size, concentration, and degree of cross-linking are a little less “thick” than their cousins, Juvederm Ultra Plus® and Perlane®. They have a wide range of applications at more superficial levels of the facial structure. These fillers are frequently used to add volume to the lips. In our practice, we often use Restylane® to soften the tear trough, the hollow that can develop between the lower eyelids and the cheek.

Injectable filler patient picture front view

Injectable filler patient picture side view

Injectable filler patient photos before and after.

Belotero® for Fine-Tuning of Surface Lines

Belotero® is formulated in a way that allows for injection beneath very fine lines of the face. Other thicker fillers often become noticeable when placed near the surface of the skin, but this is less of a problem with Belotero®. We have had better luck with Belotero® than with other fillers when we treat fine lines of the lip, forehead creases, and “crows feet” lines. We often combine Belotero® with relaxants such as Botox® and Dysport® to soften the activity that causes the lines and to partially fill in the lines.

How You Benefit from Big Picture Analysis at the Whole Beauty® Institute

When you come to us for a consultation at the Whole Beauty® Institute you will experience a detailed analysis that takes into account your goals and priorities. You will benefit from the depth and breadth of our analysis. For some patients revolumization with one or several fillers will achieve the desired result. For others it is a matter of assembling several different pieces of the puzzle to achieve a synergistic result.

Often when fillers are combined with relaxants such as Botox® or Dysport® the power of the rejuvenation is multiplied. There are also surface treatments that can improve skin texture, reduce fine lines, restore even pigmentation, and give back a youthful tone to the skin.

Due to Dr John Q Cook’s extensive knowledge of aesthetic plastic surgery, we also know when non-surgical treatments won’t achieve your goals. We believe that we offer our patients the best service when we can intelligently discuss the entire range of surgical and non- surgical rejuvenation.

If you would like to schedule a consultation contact the Whole Beauty® Institute today or call 312-751-2112.

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