Selphyl: a filler you make yourself

Selphyl is a new facial filler that's getting a lot of buzz. It's made on site at the doctor's office, using a few vials of your own blood. Twenty minutes later, after processing, an amber-colored liquid is ready to inject into facial wrinkles. While it's not a filler itself, the liquid contains platelets and platelet-derived growth factors, which stimulate your tissues to produce more collagen. At least, that's the theory.

This technology has been around for a while, but previously was limited to reconstructive applications. The Selphyl people have come up with an easy system to make it a convenient, standardized, in-office technique, and have taken it through the FDA approval process. The product is designed to be used in the correction of facial lines and wrinkles.

This stuff, however, isn't for someone looking for a bargain. A typical Selphyl treatment costs about $2000, about 3-4 times the cost of our typical fillers. The company claims the duration of the treatment effect is 2 years - and so that makes it cheaper in the long run, compared to Restylane or Juvederm.

It also works differently than many other fillers. Restylane or Juvederm directly fill the area with their gel. Instant gratification. Selphyl, on the other hand, fools the body into making extra collagen by means of growth factors. It's the new collagen which then gradually fills the area. Because of the lag time in collagen production, it takes 2 -3 weeks to see the desired results. If your body doesn't make much collagen, you won't see much effect. Selphyl is not recommended for patients over age 65 for this very reason.

So far, I've only seen 3 papers on Selphyl, all by the same author. So much of the data is still preliminary. We don't yet know how long the effect lasts; the longest duration data I've seen on Selphyl is only out to 12 weeks.

Many practices are promoting it as a facelift-replacement, which as you can see is a patently silly claim. Selphyl will help to volumize an area, and the platelet-derived growth factors may have some other, as yet unknown, rejuvenative effects on the quality of the skin - but that's it. There's absolutely no reason to expect tightening of loose necks, lifting of jowls, or the other typical effects that we get with a surgical facelift.

Bottom line: interesting product, but need to see more data before I start using it.
Pros: autologous filler;
Cons: Pricey. About 10% of people get no significant benefit from it, even if they are under age 65.

Non-surgical rejuvenation of the eye area

While our surgical operations for the upper and lower eyelid can yield some pretty impressive improvements, not everybody wants to jump directly to surgery right away. Many patients want to know, "Doctor, what can you do for me without getting invasive?"

the answer: quite a lot, actually. The secret is to combine several non-invasive techniques in an artistic way.

For example, when we look at the eye area, we commonly see the combination of:
a) crow's feet,
b) texture changes in the lower eyelid skin,
c) lowering of the brow position, and
d) the "tear-trough" groove, running diagonally downward from the inside corner of the eye, around onto the top of the cheek.

We can use non-surgical methods to address each of these concerns. The combination is synergistic - working together nicely better than any one treatment by itself.

Crow's feet can be significantly reduced with the use of Botox or Dysport. A small dose of Botox (or Dysport) just beneath a low lateral eyebrow can elevate it in a subtle way. Filler injections, such as Prevelle Silk, can be used to fill in the valley of the tear trough area, making it much less prominent. Finally, a light chemical peel or laser can be used to resurface the lower eyelid skin, improving the texture.

Naturally, these options may not be as powerful as their surgical counterparts, but for many thirty and forty-somethings, it's really all they need at the moment.

And none of these options requires a trip to the operating room under anesthesia!

One week only: botox & filler discounts galore

Here's an incredible deal for our loyal readers and friends: 25% off of your next Injectable service for you and your friends. But act fast - this fantastic special is good from now only until August 20, 2010!

This special may not be combined with any other specials or discounts. The minimum purchase is for 25 units of BOTOX Cosmetic, an equivalent amount of Dysport, or one full syringe of the filler of your choice.

Please call to set up your appointment (407) 339-3222, or email us at: theteam@drfiala.com.

It's like a Back-to-School sale on beauty!

Fun: Juvederm simulator

Ever wonder how you might look with a Juvederm treatment?

Now you can, with a web-based photo manipulation tool from Allergan, the makers of Juvederm. You can even upload your own photo!

While the simulation is not 100% perfectly realistic, it's certainly fun to move the sliders around on the screen, and watch wrinkles come and go!

Click here for the link.

Johnson & Johnson pulls the plug on "Evolence"

Johnson & Johnson has announced this week that it has decided to stop making and selling Evolence, an injectable soft-tissue filler.

Although Evolence has a good track record of safety and effectiveness, product sales apparently did not meet corporate expectations.

The facial filler gained approval from the FDA in June 2008, but its market introduction coincided with a rough time in the market for cosmetic medical products, due to the recession.

It's too bad - we liked this product and used it here. Evolence was useful for nasolabial creases and marionette lines, and was a good alternative to the hyaluronic acid family of fillers.

The return of Artefill

Artefill, the permanent injectable filler, is returning to the U.S. market.

Yesterday, I had the opportunity to speak with the CEO of the new company, Suneva Medical, that has purchased all the production facilities and intellectual property of Artes Medical, the now-defunct owners of the Artefill brand.

Suneva Medical has now had their manufacturing facilities inspected and certified as GMP, and are ready to re-launch Artefill in selected physician practices. Artefill is a possible treatment for patients who have been using standard fillers for quite some time to improve their naso-labial creases, and who want a more long lasting (i.e. semi-permanent) option. Studies show that Artefill has a five-year proven duration.

The use of permanent fillers is debated amongst plastic surgeons. Injection technique has to be more exact, in terms of the amount and placement of the filler. This is not a product for physicians who are just starting their injection practices. Unlike the HA fillers which can be dissolved with an "antidote", Artefill injections are not easily reversible. Skin testing is required before the use of Artefill, to check for reactions to the product prior to use. People who have prior reactions to collagen should not have Artefill. Rare reactions, known as granulomas, are still possible, even with this newest formulation.

Save Money! Look Great! - New Internet Discounts

I'm pleased to announce two new specials for our Botox and filler (Juvederm, Restylane, Sculptra, etc.) patients.

Special #1: Bring a Friend and Save.

Book a filler or Botox appointment for yourself and a good friend at the same time. If the friend is a new patient to our practice, we'll give you a credit of 15% of the value of your friend's first completed treatment, which can be used for your own botox or filler treatment, or used in our medi-spa, either on the same day, or sometime in the future.

One small restriction: The credit can not be applied to surgical procedures.


Special #2: Internet special for loyal patients

Have you had three or more treatments with Botox in the past 15 months with us? Or three or more treatments with injectable fillers in the past 15 months in our office? Then you are a loyal patient and we'd like to give you a reward. Just mention the internet-only password of "PSB" when you come in, and we'll give you 50% off your next maintenance treatment with botox or fillers, up to the average dose that you usually get.

This is only for our loyal patients, as defined above.

See, it pays to read PSB - the plastic surgery blog!

Fillers, the Liquid facelift and "Puffy Face" Syndrome

Everything evolves. When cosmetic fillers were first used, we applied them to the problems of wrinkles - and they worked pretty well. Then we used them to enhance lips, and then to enhance cheekbones, and to smooth out jawlines...and the list of uses kept on growing.

This ever-increasing use of fillers has directly led to the concept of the "liquid facelift", which is simply the use of a significant volume of injectable filler agents to add volume to the face. When done appropriately, and done well - the technique can look good, restoring the lost contours of youth, at least for a time, until the costly products are absorbed by the body. But like anything, it can be overdone. And quite expensive.

Hype alert: the liquid facelift technique is not really "just like a regular facelift", despite the marketing hype of some websites. The two methods work totally differently. Let's review some of the basic differences:

- In a surgical facelift, you remove excess neck and cheek skin. Not possible with the liquid facelift technique, which works by inflation.

- In a surgical facelift, you can tighten the neck muscles and re-suspend the SMAS layer (the fibro-fatty anatomic layer between the skin and the muscles). Not possible with the liquid technique.

- Traditional facelifts (with the exception of those that use fat grafting techniques) work by tightening tissue planes. This can sometimes cause a flattening effect on soft-tissue facial curvature.

- The liquid techniques work by inflation or "re-volumizing", and can add fullness to areas that would otherwise be difficult to correct. Traditional facelifts can sometimes shift soft tissue fullness by re-distributing or lifting tissues, but they don't add new volume.

- Surgical facelifts typically have an effect of 8 to 10 years, on average. Injectable products, even the newer, longer-lasting ones, last 1-2 years at most.

So, the two procedures are not directly comparable. Don't be fooled - choose the right procedure for your particular needs. If you have a lot of lax skin, get a surgical facelift. If you have loss of facial volume issues with minimal skin laxity, then you might be a candidate for re-volumizing with fillers. Your plastic surgeon can advise you.

I'm also starting to see patients who have been over-treated with the facial fillers. It used to be just the lip area - but now it's the entire face that is involved. Since there isn't an official name for this, I'll call it "puffy-face syndrome". Features of "Puffy face syndrome" that I've seen include:
- generalized swollen or bloated look to the face, due to the over-injection of filler agents, which is out of keeping with the pre-procedure appearance;
- excessive fullness in some or all of the injected areas: brow, cheekbones, paranasal and perioral areas;
- obliteration of normal naso-labial creases.

Interestingly, many of the patients that I feel are over-injected seem to be somewhat addicted to their filler treatments. When I tell them "no, you really don't need any more volume" - they react with shock and disbelief!

So, while I think that facial fillers are useful, they are but one option among many for the treatment of facial aging. Too much filler can lead to Puffy Face Syndrome! This is another example of how aesthetic judgement is important.

New service: Same Day Botox

We're pleased to announce a new service for our patients. We call it "Same Day Botox" - and just like the name implies, we're opening up a limited number of appointments each day for people that want to have their treatment with Botox or any of the injectable fillers that same day. Just call early in the day to set this up.

Patients who have scheduled appointments for these treatments will still be seen at their usual times.

Talk about "instant gratification"! Call us for details: (407) 339-3222

FDA approves "12 month" indication for Evolence

This week, the FDA approved a labelling change for the collagen-based filler Evolence, permitting what is known as a "12 month indication". In simple terms, this means the FDA was satisfied that the product has a significant effect on correcting moderate to deep facial wrinkles or nasolabial folds for 12 months. The original label indication was for six-month duration.

Evolence is the first collagen-based filler to get this "12 month indication", and you can bet that it will be featured extensively in future marketing.

What is not yet clear to me, however, is whether Evolence really performs significantly better than some of the other available filler agents (which currently have the older "6 month" label from the FDA) at 12 months after injection. There is data, for example, that Restylane also has significantly lasting effects well beyond their 6 month label.

I expect Allergan and Medicis (makers of Juvederm and Restylane respectively) will be submitting their data to the FDA, hoping for a similar 12-month approval, if only for competitive marketing purposes.

Q-Med announces Restylane with lidocaine

This week, Q-Med, the Swedish pharmceutical company that is the home to Restylane and Perlane, announced Restylane® Lidocaine and Restylane Perlane™ Lidocaine as the latest additions to their Restylane family of dermal fillers. These products have the familiar Restylane and Perlane hyaluronic gel fillers, together with a small amount (0.3 %) of lidocaine, a commonly used local anesthetic, to help minimize the discomfort of the procedure.

According to the studies, the fill effect of the products is unchanged, but 90% of the patients tested said the new products made the treatments more comfortable than the standard formulation.

This allows the company to catch up with Allergan's Juvederm Ultra with Lidocaine product, which has been available in Canada and Europe for several months.

Availability of these products in the USA has not been announced. Hopefully, we'll see these later in 2009. It should be a pretty straightforward approval path with the FDA.

Here in the USA, Prevelle Silk has the combination of lidocaine and HA gel filler - but it is a much less concentrated product than either Restylane or Juvederm. I don't use Prevelle Silk often, as I don't find it is as long lasting around the mouth or smile lines.

Special offers on injectables

Good news for those patients who are fans of Juvederm, Restylane, Evolence and Botox: the manufacturers seem to be trying to out-do each other with special offers, rebates and coupons. That means savings for you.

Here's some of the current special offers:

Botox cosmetic
- Schedule your initial botox treatment before February 28, 2009 and receive a $50 rebate coupon from Allergan. Make your follow-up treatment between May 1 and July 1, 2009 and receive a second $50 rebate.


Juvederm Ultra and Juvederm Ultra Plus injectable gel
- Schedule your Juvederm treatment before February 28, 2009, and receive a $100 rebate coupon from Allergan with your second syringe of Juvederm.


Evolence collagen dermal filler
- Schedule your Evolence treatment before December 31, 2009 and receive a $50 rebate coupon for each syringe used, up to $150.


Restylane and Perlane injectable gel
- Schedule your Restylane or Perlane treatments before February 28, 2009, and get the "buy-one, get the second half-off" special.

It seems like the time to get those wrinkles treated, doesn't it!

Hello, Evolence!

Here's a new twist on an "old friend" - collagen is back, in a new & improved way. Known as Evolence - and don't ask me how they come up with these names - it's an FDA-approved filler with a good track record for wrinkle correction after being on the market several years in Europe. It's now available in the USA.

Compared to the old collagen products (Zyderm & Zyplast), Evolence offers several advantages:

1) no need for a skin test prior to treatment to check for sensitivities or allergies, which happened in about 1% of people with the old product;

2) much longer-lasting correction. European studies show a duration of about 12 months; and

3) minimal bruising from the injection.

Overall, it looks promising, and we're now going to offer it in my practice, adding another option to the many other FDA-approved fillers we have.

What will be really interesting is a head-to-head comparison study comparing Evolence to some of the better hyaluronic gel fillers. This study is underway. "Which filler will reign supreme?"...we'll have to wait and see!

The non-surgical rhinoplasty

With the advances in the world of injectable fillers, a concept known as the non-surgical rhinoplasty is beginning to become popular. Initially performed to disguise minor contour problems after a standard rhinoplasty, this technique uses Restylane or Juvederm to fill in divots or build up contours selected areas of the nose. When this is carefully done, it can sometimes save the patient from having to undergo a difficult secondary rhinoplasty procedure.

In addition, adding a small dose of Botox to reduce the activity of the small depressor septi nasi muscle can reduce the "plunging tip" effect that we sometimes see when people smile.

I've recently seen some pretty interesting results published by a group of cosmetic dermatologists, where they disguised a prominent nasal hump by building up the parts of the nasal profile immediately adjacent to the bump with fillers. While I applaud their skill with fillers, in my opinion, it makes more sense to actually perform a rhinoplasty in these cases, as reducing a prominent nasal hump surgically usually works out pretty well.