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    Fillers 101: Foundations for success

    Take-home message: The foundations for success in using fillers during oculofacial surgery include understanding the characteristics of these products, which influences outcomes, and learning techniques to avoid and treat complications.


    Injectable fillers are growing in popularity, with an increase in use of neurotoxins and fillers of 20% or more reported in 2015. To achieve success with these fillers, it’s essential to understand their characteristics, interactions, and risks, said Julie A. Woodward, MD, associate professor of ophthalmology and dermatology, and chief, oculofacial surgery, Duke University School of Medicine.

    The American Society for Aesthetic Plastic Surgery claims that use of neurotoxins grew 19.9% and fillers 26.6% in 2015, and as their use becomes more widespread one of the most important characteristics to understand about fillers is the G prime or stiffness, Dr. Woodward said.

    “All of these fillers have different characteristics, and it makes them behave differently in the tissue,” she said, citing a 2013 study by Sundaram and Casuto that analyzed the G prime of a series of fillers. “What they found was that certain fillers are very, very stiff, which gives them certain characteristics which are good for lifting cheekbones, and other fillers are very soft, which makes them good for fine lines in the perioral or periocular areas.”

    Having a bit of background on how fillers are produced is also helpful. All but one of the hyaluronic acid fillers are crosslinked with a chemical called BDDE (1,4-butanediol diglycidyl ether). If the filler goes through a sieving technology, as do products in the NASHA family (Restylane, Restylane Lyft, Restylane Silk by Galderma), it’s called a biphasic filler, and the tissue will conform around the filler. These products are well suited to structure and lifting. Monophonic fillers include technologies including Hylacross (Juvederm Ultra and UltraPlus by Allerga), Vycross (Voluma, Vollure, Volbella by Allergan)  and Cohesive Polydensified Matrix (Belotero by Merz Aesthetics). These technologies have various levels of tissue integration. The newest technology is the XpressHAn (Restylane Refyne, Restyland Defyne)  technology that results in fillers with increased flexibility to move naturally with facial expression.

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