A Word About Some Of The Products Listed-
I’ve done my best toProf. Injectable Dictionary include the more popular injectables in this list. New ones come out often and if there is a product you think should be included, please contact me through this website. Also, I’ve used some of these products literally thousands of times in my practice and training others for pharmaceutical companies. Some I have never personally used. I will note the ones with which I have had success and why I believe in the product.
And, like any Practitioner, I am obliged to state the obvious- Nothing in this list of definitions, or for that matter on this website, should be construed as medical advice or should take the place of your own Practitioner’s knowledge and advice.
Do Your Patients Have Concerns About On-Label vs. Off-Label Treatments?
Sometimes a patient will hear about a product being used “Off Label” and become concerned. They may even wonder if it is “legal” to use products Off Label. Discussing their concern is a great opportunity to put their mind at ease and educate them about injectable treatments.
I first remind the patient that the FDA only approves pharmaceuticals for specific treatments, and does not give “blanket” approvals. One great example to pass on is the almost 30-year history of use in the United States of BOTOX® Cosmetic by Allergan. In 1989 Botox was approved by the FDA for the treatment of eyelid spasms. As the word spread about its temporary wrinkle treatment efficacy Practitioners began using Botox “Off Label” to treat wrinkle lines in several places. Thousands of times every year!
It took BOTOX® Cosmetic until 2002 to gain FDA On-Label approval for wrinkle treatment. And the only area approved On-Label was for “frown lines” between the eyebrows. All other areas were still done Off-Label. Since then Botox has been approved for many uses from incontinence to migraine headaches. But it is still Off Label for treatments that are prescribed and commonly used thousands of times a year. Exactly the same scenario plays out every day with Practitioners, aesthetic product manufacturers, and their patients working in a joint effort to get a specific efficacy and outcome.
NEUROMODULATORS (alphabetically listed):
Botox (onabotulinumtoxinA) by Allergan, is actually trademarked and registered for cosmetic use as BOTOX® Cosmetic. Botox is arguably the most recognized name in prescription injectables. A few days after being properly injected, the patient will notice how lines and wrinkles are greatly diminished, if not completely removed. Botox temporarily improves the look of forehead lines, crow’s feet, frown lines between the eyebrows, and most other facial lines by softening the indentations wrinkles make. Among other uses, BOTOX® has been successfully used for treating uncontrolled blinking, muscle spasms and muscle movement disorders, chronic migraines and overactive bladder.
Dysport (abobotulinumtoxinA), by Galderma, is another neuromodulator product. You will notice a small difference in the spelling in the botulinum toxin between BOTOX® Cosmetic (above) and Dysport by Galderma. That does not mean they have a completely different makeup. They both use the same core molecule. The only difference is the surrounding “shell” of protein. Also, studies have shown that after mixing the product with saline, 75% of this protein has dissipated and the neurotoxin is in free form. There was anecdotal evidence that Dysport will respond more quickly. Now, more recent studies have concluded that Dysport has more toxin per dose than Botox, Xeomin, or Jeuveau. However, keep in mind that for years all studies have shown that quick results are more dependent upon the individual patient than the neuromodulator product.
Jeuveau (prabotulinumtoxinA-xvfs), by Evolus, is a newer product that I have used with success, but I am still in the beginning stages of using it for my patients. I’ll keep you posted as to my results.
Xeomin (incobotulinumtoxinA), by Merz Aesthetics, is another neuromodulator product and theirs has yet another spelling of the botulinum toxin. Xeomin calls their product incobotulinumtoxinA. However, they all have the same core molecule. Xeomin has chosen to eliminate the “shell” of protein, which as discussed in the Dysport definition, is 85% dissipated upon mixing the product.
NOTES FROM BKM: Like most Aesthetic Practitioners, I use neuromodulators daily. Like most Practitioners, they are in the top drawer of my “toolkit”. Properly injected, neuromodulators make “age lines” a thing of the past. A neuromodulator treatment will last anywhere from two to four months, with effects diminishing over time. I find in my practice that many first-time clients come in asking for Botox. A smaller amount will ask about Dysport. So far, very few will ask for either Jeuveau or Xeomin. However, that can always change. I’ve found that most new clients are very open to suggestions from the Practitioner, but existing patients don’t want to make a change away from a product with which they are satisfied. Also, while I’ve used very little Xeomin in my practice, I have used Jeuveau and like the product. I will update you on my results as I begin to use more.
Now a quick note here: The challenge most Practitioners have with neuromodulators is not so much which product to use, but whether to participate in what been called the “Botox Wars”, where offices compete to see who can offer the lowest price. I’ve had victims of “cut-rate” offices come to my waiting room for help, as have many Practitioners. Some are not a pretty sight, and there’s very little we can do to help. The best advice you can give a patient calling for your “Botox price” is to encourage them not to believe any of the ads for neuromodulators, and don’t shop over the phone. Ask your prospective patient to check out reputations, schedule a visit, and let the Practitioners expertise and the patient’s own common sense dictate a decision.
FILLERS (alphabetically listed):
Bellafill by Suneva® Medical Inc. Based in California, their filler promises to fill areas such as acne scars with two substances at the same time. Each injection is comprised of 80% Collagen and 20% a more permanent substance they call Polymethyl Methacrylate Microspheres. Bellafill is more permanent than other fillers and does require a skilled, meticulous, and experienced Practitioner. This product has a permanent aspect that needs to be taken into consideration.
Belotero Balance by Merz Aesthetics®. This product is a hyaluronic acid (HA) filler that temporarily fills lines and wrinkles. It’s On-Label approval is for moderate to severe nasolabial folds (lines from the side of the nose to the corners of the mouth).
Juvéderm® is the name of Allergan’s filler collection. Right now there are five products in the Collection. Juvéderm Ultra XC® & Juvéderm Volbella® XC for lips, Juvéderm Volluma ®XC for cheeks, and Juvéderm Vollure™ XC , & Juvéderm Plus for nasolabial folds. Juvéderm is a hyaluronic acid (HA), a natural substance in the skin that delivers nutrients, helps the skin retain moisture and softness, and adds volume.
All Juvéderm XC products are gel fillers and contain lidocaine to minimize discomfort during injection. Each product varies in viscosity (thickness) and hardness so it can be used for different areas on the face. For instance, if your patient had thin lips and wanted to “plump” them, you would use Juvéderm Ultra XC®, a product with more consistency. If they just had fine lines in their lips that needed attention, the lower consistency product, Juvéderm Vobella® XC, would be perfect. Studies show the results can be seen almost immediately and last about one to two years depending on the product and the individual.
Breakdown of the collection:
Juvéderm Ultra XC® – Inject to add fullness (plumpness) to naturally (or age affected) thin lips. Also indicated for lines and wrinkles.
Juvéderm Ultra Plus® XC – Indicated for more severe lines and wrinkles.
Juvéderm Volbella® XC – Formulated to add subtle volume to lips. Also, if your patient is bothered by fine vertical lines in their lips, these lines can be softened or even eliminated almost immediately with this product.
Juvéderm Volluma ® XC – Cheeks can flatten and “hollow” as age related mid face volume is lost. This product, properly injected, can add volume under the skins surface and on top of bone where appropriate to lift and contour the years away.
Juvéderm Vollure ™ XC – This product is effective on severe nasolabial folds, which are the parentheses lines extending down from each side of the nose to the mouth corner. This fillers added volume can help eliminate a “shadow” that appears as the nasolabial line gets deeper into the face with age.
FROM BKM: I have used and trained others using the Juvéderm Collection. It is a great product family and with the proper technique will give results that keep patients returning to you and looking beautiful.
Radiesse® is a product of Merz Aesthetics®. It is a calcium-based filler that temporarily fills lines and wrinkles and promotes collagen growth. It’s also FDA approved for hand rejuvenation, giving the backs of hands a more refreshed appearance.
FROM BKM: There is one caveat to Radiesse. It can’t be aspirated in the syringe, and antidotally some practitioners won’t use it for that reason.
Restylane® is the family name for filler products from Galderma Laboratories. Right now there are six products in this Restylane family- Restylane, Restylane L, Restylane Silk, Restylane Lyft, Restylane Refyne, Restylane Defyne, and Restylane Kysse.
Breakdown of the Restylane® family:
Restylane® Silk is formulated specifically for lip augmentation and correction of perioral wrinkles. Restylane and Restylane L are also indicated for injection into the lips. Their newest product, Restylane Kysse, is designed specifically to retain the natural lip look and last up to one year.
Restylane, Restylane L, Restylane Lyft, Restylane Defyne, and Restylane Refyne fillers are all “on label” for moderate to severe facial wrinkles and/or nasolabial folds.
All are formulated a bit differently so the Practitioner and the patient can make a decision together, depending on the presentation, which would be the most efficacious for the desired result.
FROM BKM: I use Galderma’s Restylane in my practice often and have trained many practices that use their products. The flexibility and product depth they offer is an advantage and my patients get great results.
The RHA Collection has created a lot of attention because Teoxane, the Swiss company that developed The RHA Collection, was founded by the co-creator of Jevederm®, one of the best know fillers in the world. A partnership with Revance will allow them to market The RHA Collection here in the United States. It’s available in several viscosities designated by the numbers RH2, 3, 4, and 5. RH2 will fill fine lines, and as you move up numerically, the indentations filled can be more robust. The product is said to more closely mimic hyaluronic acid fillers in the skin because their gel remains extremely flexible in areas that are dynamic (move a lot). Naturally, the product consistency (RH2 to RH5) is chosen based on the Practitioner and the area to be treated.
FROM BKM: I’ve used this new product and am very encouraged by the results. I’ll keep you posted as I continue to find patients that will benefit from The RHA Collection.
Sculptra® aesthetic is a product of Galderma Laboratories. Sculptra is technically not a filler in the sense of immediacy but rather a collagen stimulant that allows your patient to grow their own collagen faster using injectable poly-L-Lactic acid particles. It is normally injected in a series of two to three injection sessions over a three or four-month period.
FROM BKM: Keep in mind that what many patients call “sagging” in their face is actually bone, fat, and collagen loss. Sculptra’s poly-L-lactic acid is placed foundationally over bone structure and in areas of lost fat to help stimulate and rebuild that foundation and lost collagen. It lasts longer than most fillers because it is usually injected two or three times over a three or four-month period. During that three or four months the patient will see areas fill in with their own collagen as its growth is stimulated. The results are long-lasting (up to two years) and most patients are highly satisfied. The results will not show immediately, but for long-term improvement, Sculptra is hard to beat. This product is one of my favorites because my patients appreciate the way it makes their faces look more naturally fresh.
OTHER COSMETIC PRODUCTS/TREATMENTS:
Kybella® (deoxycholic acid) is a product of Allergan. Kybella was formerly owned by Kythera Pharmaceuticals and was purchased in October of 2015 by Allergan. On Label use calls for submental fat under the chin, commonly known as “double chin”. The product comes with a template grid that is placed under the chin and then marked to show injection points. Practitioners have found multiple other areas to use Kybella, depending on the presenting patient.
FROM BKM: I’ve had a good experience with this product and trained others in its use. It does work well on other parts of the body, depending on the presenting patient.
POLYDIOXANONE (PDO) THREADS:
Polydioxanone (PDO) threads are quite a bit more complex than most injectables and require specific training. If you search the internet for PDO thread information, you’ll find very mixed reviews. Many of those negative reviews are likely because the Practitioner was not properly trained in PDO techniques.
Although PDO threads are being touted as the latest and greatest in aesthetics, the use of absorbable threads to lift or hold delicate areas in place has been around for decades, most notably in cardiothoracic heart surgery.
PDO threading can be easily explained to the patient- You, as the Practitioner, implant smooth or micro-barbed PDO threads into the subcutaneous layer of the skin using small needles preloaded with the absorbable suture. The threads will then either build a foundation for new collagen or be used to lift sagging skin (or both) depending on the technique and the thread composition.
Threads are inserted in two distinctly different patterns depending on the presenting patient. The most complex technique is a bi-directional (vertical and horizontal) insertion of smooth threads, creating a “hashtag” or mesh foundation that becomes a “net” for new collagen production as the micro-injuries from the insertion heal under the skin.
The other technique, using micro-barbed threads, is more like building a “sling” to lift sagging skin. The Practitioner inserts the thread then it is pulled in one or both directions when the insertion is complete to reposition the sagging skin. The effect is immediate and the thread will generate collagen production as the micro-injuries heal under the skin.
The thread itself will take 4 to 6 months to dissolve and leave no scar tissue, rather just new collagen in its place. Most procedures last 12 to 18 months when a sufficient number of threads are used, and the collagen, as it rebuilds, may enhance the patient’s appearance even longer, depending on the individual.
NovaThreads, based in Miami, Florida, is one of the distribution leaders of aesthetic threads, but many more are now entering the marketplace here in the United States.
FROM BKM: I have used this product with fantastic results, but the learning curve for some Practitioners is challenging.