CURRENT THERAPY
J Oral Maxillofac Surg
64:317-325, 2006
The Use of Restylane in Cosmetic Facial
Surgery
Joseph Niamtu, III, DMD*
The injection of filler substances is one of the most cations. Although a permanent filler may look fine at
common procedures in cosmetic surgery. In 2003, the time of injection, migration with aging or misin-
the number of nonsurgical procedures increased 22% jection can be very problematic.
from 2002.1 The last 5 years have brought about an
The biggest problem with previous fillers has been
extreme interest in minimally invasive rejuvenation
longevity. The search for a filler that does not require
techniques. The ease and popularity of Botox (Aller- allergy testing and that would last longer than the
gan Inc, Irvine, CA) has popularized and expanded
collagen-based products has brought about the devel-
the use of rejuvenative injections.2-4 This, coupled
opment of hyaluronic acid based substances.
with the introduction of multiple new products, has
Restylane (Medicis Inc, Scottsdale, AZ) is a new
increased the number of treatment options for cos-
filler approved in December 2003 by the US Food and
metic patients. Multiple substances are available to
Drug Administration (FDA) for use in the lips. This
inject into facial wrinkles, folds, lips, traumatic de-
product has been used very successfully for a decade
fects, and depressed scars, and to augment facial form
in Europe, Canada, and Australia.7-13 It is a NASHA
(Table 1).
(non-animal stabilized hyaluronic acid) preparation
Over the last century some substances, such as
synthesized from bacterial cultures and is packaged as
paraffin and silicone, have been used with associated
a clear gel in 1.0-cc syringes with an accompanying
problems.5,6 For over 2 decades the gold standard for
27-gauge needle (Fig 1). Restylane is terminally steril-
injectable facial fillers in the United States has been
ized to prevent bacterial transmission.
bovine-derived collagen (Zyplast; Inamed Inc, Santa
Hyaluronic acid is a naturally occurring substance
Barbara, CA). This product was available in several
found in the skin, eye, and joints. Unstabilized forms
viscosities (particle sizes) to use in different indica-
of hyaluronic acid are not lasting when used as intra-
tions from fine lines and wrinkles to lip plumping.
dermal fillers and are rapidly resorbed. Manufacturers
Various advantages and disadvantages exist with all
use a proprietary process known as cross-linking to
filler substances. One of the biggest disadvantages has
stabilize the hyaluronic acid to increase its longevity.
been the need for allergy testing with the non-human
Hyaluronic acid is thought to be nonimmunogenic,
preparations. In addition to the possible allergic reac-
but trace amounts of bacterial protein from product
tion, cosmetic patients are very impulsive consumers
synthesis can cause inflammatory or granulomatous
and having to wait a month for an allergy test before
reactions. Restylane has a low allergic response of 1 in
treatment is a huge drawback. Many of the newer
26,0008 (data on file, Q Med Inc, Uppsalla, Sweden)
products are non-animal and do not require allergy
compared with bovine collagen, which has a much
testing.
higher allergic response of 3 in 100.14 Several studies
Another problematic situation that can present is
have shown significant inflammatory reactions to hy-
the use of permanent fillers (products such as sili-
aluronic acid fillers, but these appear to be extremely
cone liquid or those containing methylmethacrylate
isolated incidents.15-17 Multiple studies have shown
spheres that are not resorbed by the body). In this
that Restylane can last longer than Zyplast when in-
case, a permanent filler can cause permanent compli-
jected in vivo.12,13 The non-animal composition, low
allergic response, and increased longevity of Resty-
lane have made it an extremely popular product.
*Private Practice, Oral and Maxillofacial and Cosmetic Facial
Because all resorbable fillers are phagocytized by the
Surgery, Richmond, VA.
body, the cosmetic effects are transient. One reason
Address correspondence and reprint requests to Dr Niamtu:
that the hyaluronic acid lasts longer than previous
10230 Cherokee Road, Richmond, VA 23235; e-mail:
fillers is that it is a hydrophilic molecule. Normally,
niamtu@niamtu.com
© 2006 American Association of Oral and Maxillofacial Surgeons biodegradable implants shrink gradually upon degra-
0278-2391/06/6402-0024$32.00/0 dation, but Restylane has the unique property of
doi:10.1016/j.joms.2005.10.019 maintaining the initial volume throughout the degra-
317
318 RESTYLANE IN COSMETIC FACIAL SURGERY
Table 1. SOME OF THE NEWER FILLER SUBSTANCES CURRENTLY IN USE AROUND THE WORLD
Product Source Manufacturer
Restylane Non-human hyaluronic acid Medicis Inc, Scottsdale, AZ
Restylane Fine Line Non-human hyaluronic acid Medicis Inc
Perlane Non-human hyaluronic acid Medicis Inc
Cosmoplast Human-derived collagen Inamed Inc, Santa Barbara, CA
Cosmoderm Human-derived collagen Inamed Inc
Radiesse Hydroxyappetite BioForm Medical Inc, San Mateo, CA
Hyalform Hyaluronic acid Inamed Inc
Artecol PMMA beads in hyaluronic acid Artes Medical Inc, San Diego, CA
Artefil PMMA beads in bovine collagen Artes Medical Inc
Silikon Liquid injectable silicone Alcon Labs Inc, Ft. Worth TX
Sculptra Polylactic acid Aventis Pharm Inc, Bridgewater, NJ
Isolagen Cultured autologous fibroblasts Isolagen Inc, Huston, TX
Autologen Autolougous collagen Collagenesis Inc, Beverly, MA
Joseph Niamtu. Restylane in Cosmetic Facial Surgery. J Oral Maxillofac Surg 2006.
dation phase. This is termed isovolemic degrada- the time of submission of this publication only Resty-
tion. As the hyaluronic acid is degraded, water takes lane had FDA approval and discussion will be limited
its place. The less concentrated the gel becomes, the to this product.
more water each molecule is able to bind. The result
is that the same volume can be maintained with less
Cosmetic Indications for Restylane
implant material.18 Finally, the implant is fully de-
graded and reabsorbed, leaving the tissue without any
Like most fillers, Restylane is primarily used for the
fibrosis or implant waste.
treatment of facial lines, wrinkles, folds, and lip en-
The hyaluronic acid products distributed by Medi-
hancement. Unlike some fillers, Restylane has no in-
cis Inc are all NASHA-based, contain 20 mg/mL of
herent local anesthesia or local anesthetic properties,
hyaluronic acid, have a pH of 7.0, and differ only by
and for that reason facial nerve blocks are recom-
particle size. Restylane Fine Line contains 200,000 gel
mended before injection. This is especially true in the
particles per mL and is intended for fine lines and
lips, where filler injection can be very uncomfortable.
wrinkles to be injected in the superficial dermis. Re-
Restylane can usually be injected in facial areas such
stylane contains 100,000 gel particles per mL and is
as nasolabial folds with only topical anesthetic, but
indicated for injection in the middle dermis. Perlane
local anesthetic blocks or infiltrations are necessary
contains 10,000 gel particles per mL and is intended
when treating the lips. A useful anesthetic prepara-
for injection in the deep dermis or subcutis. The
tion for topical cutaneous anesthesia is a compound
larger the particle the deeper it is injected and the
of benzocaine, lidocaine, and tetracaine in a gel base
longer it will last. To obtain optimum clinical results
(BBPharmacy.com) which is applied to the skin 15
and longevity it is imperative to inject the correct
minutes before injecting.
particle size product in the correct tissue plane. At
Patients are also advised when they schedule their
appointment to refrain from aspirin or other medica-
tions 2 weeks before treatment because it may affect
coagulation and therefore increase bruising.
Injection Technique: Lips
Esthetic lips are a result of a pleasing combination
of volume, anatomic definition, pout, and symmetry.
The basic outline of an esthetic upper lip is the shape
of an M and the lower lip is curvilinear or parabolic.
The upper lip contains one third of the total lip
volume and the lower lip adds two thirds of the
volume of the lips (Fig 2).
FIGURE 1. Restylane is an injectable hyaluronic acid packaged as a
A well defined Cupid s Bow, white roll, philtral
clear gel in 1.0-cc syringes and comes with a 27-gauge needle.
columns, and commissures contribute to the esthetic
Joseph Niamtu. Restylane in Cosmetic Facial Surgery. J Oral
Maxillofac Surg 2006. lip and are targets of injectable fillers (Fig 3).
JOSEPH NIAMTU 319
also be used to show other prospective patients an-
ticipated results and for general cosmetic marketing
purposes. It is also prudent to query the patient on
their expectations of the augmentation. Some pa-
tients may have unrealistic expectations and showing
them average before and after photographs can serve
to close the gap between patient perception and
reality. Another caveat is to explain that a single
syringe only contains 1.0 cc of filler and for most
patients several syringes may be required. Multiple
syringes are usually required to treat older patients or
FIGURE 2. Illustration of the anatomic outlines and relative size
younger patients with deep creases or hypoplastic
components of an esthetic adult female lip.
lips. A single syringe is frequently adequate to aug-
Joseph Niamtu. Restylane in Cosmetic Facial Surgery. J Oral
ment the upper lip and the central portion of the
Maxillofac Surg 2006.
lower lip. A single syringe will also serve to blunt the
average nasolabial fold bilaterally. In patients with
Most younger female patients present for lip aug- deeper nasolabial folds it is not uncommon to use a
mentation to either increase volume, pout, or defini- syringe or more on each side. It may also take several
tion. Older patients desire similar improvement and syringes to augment both lips. For this reason, an
the treatment of vertical lip rhytids (lipstick lines). estimate of the number of syringes required should be
Vertical lip lines are a significant problem in older discussed before injection or the patient may be put
females, especially smokers. Not only are they unes- off when they are told in the middle of the procedure
thetic, but applied lipstick will run into the lines that more filler is required. This problem is mitigated
producing fine, colored vertical lines running from by insisting on a 2-week follow-up appointment to
the lip assess the anticipated augmentation and re-treat if
Other common areas of requested treatment in- desired. Finally, if a patient only desires a single sy-
clude nasolabial folds, glabellar lines, and periorbital
and generalized facial rhytids. In reality, any skin wrin-
kle may be treated.
The media frequently hypes new fillers as a treat-
ment for generalized facial rhytids or a replacement
for Botox. Some patients present with the request to
treat hundreds of facial wrinkles and think that filler
injection is a global treatment. Although this could be
performed, it would generally not be cost effective or
long lasting for the average patient. These patients
must be informed that rhytidectomy or laser resurfac-
ing would be a more appropriate wrinkle treatment;
in addition, they should understand the difference
between a filler and a neurotoxin treatment such as
Botox.2 Although these 2 products have distinctly
different treatment actions, it has been shown that
the concomitant use of fillers and Botox enhance the
longevity of the filler and complement the total es-
thetic result.19
Preinjection Considerations
Clinical photographs are taken on all patients.20
Frequently, patients will not recall their actual prein-
jection anatomy and may later complain about what
they perceive as poor treatment results which may
truly be related to their specific pre-existing anatomic
FIGURE 3. Well-defined anatomic units contribute to optimum lip
situation. In addition, pre- and postinjection photo-
esthetics.
graphs will allow both the surgeon and patient to
Joseph Niamtu. Restylane in Cosmetic Facial Surgery. J Oral
judge the success of augmentation. These images can Maxillofac Surg 2006.
320 RESTYLANE IN COSMETIC FACIAL SURGERY
and can skew the apparent amount of augmentation
delivered. For this reason it is absolutely critical to
remain conservative to avoid overcorrection. Under
correcting a patient is never a problem because more
filler can always be added. Significant overcorrection,
on the other hand, can be quite problematic because
the patient may be disfigured for the greater part of a
year. As new fillers increase clinical longevity, this
process becomes more significant. Ice is applied to
the tissues to be injected before and after augmenta-
tion and allows patients to apply makeup as soon as
any pinpoint puncture bleeding stops. Additionally,
all patients are told to expect 24 to 48 hours of
swelling and erythema in the injected areas. It is rare
that a patient would not be able to return to work the
FIGURE 4. Marking the intended areas of augmentation will assist
next day because of swelling or inflammation. Due to
with the accuracy of the filler substance.
the aforementioned increase in erythema and swell-
Joseph Niamtu. Restylane in Cosmetic Facial Surgery. J Oral
ing, the author feels strongly about not attempting to
Maxillofac Surg 2006.
treat most patients in a single injection session. Pa-
tients are told that Restylane augmentation is a sculpt-
ringe of filler the doctor and assistant must keep a ing process and that it may require several appoint-
close eye on the remaining material in the syringe to ments. Reappointment at 1 to 2 weeks allows the
ensure that enough filler is left for the other nasolabial surgeon not only to assess the level of augmentation,
fold or the other lip. but to add more filler if necessary to correct underfill
It is also prudent to ask all potential lip augmenta- or asymmetry.
tion patients about recurring herpes labialis infection, Marking the areas to be injected with a surgical
especially those patients in which perioral trauma marking pen is highly recommended and will enable
triggers outbreak. In this population the author sug- a more accurate augmentation (Fig 4). This is espe-
gests prophylaxis for these patients with valacyclovir cially true for the novice injector because landmarks
500 mg every 12 hours beginning 48 hours before may change during the injection procedure from such
injection and continuing for 3 days postinjection. factors as swelling and patient position.
Patients presenting for filler injection are asked if An additional critical factor is to inject the patient
they are taking any medications such as aspirin com- in the upright position (Fig 5). If the patient is in the
pounds or certain herbs that may affect coagulation. recumbent position, gravitational forces will distort
Although the intradermal injection of fillers is not the nasolabial folds and lips, potentially affecting ac-
contraindicated in these patients, they certainly may curacy.
experience increased incidence of bruising or swell- As stated earlier in this article, erring on the con-
ing and should be forewarned. In addition, there are servative side is a commandment of fillers. A summary
other distinct differences between Restylane and pre- of pertinent injection reminders is listed in Table 2.
vious bovine collagen fillers. Those doctors with prior
experience using bovine collagen fillers generally
Restylane Injection Technique
over-corrected lips and wrinkles beyond the desired
Two main techniques exist for filler injection (Fig
clinical result. This was in part because these prod-
6). Serial puncture is a technique that involves placing
ucts contained lidocaine and an initial resorption of
the clinical augmentation would result in the first
several days. Restylane does not contain any inherent
local anesthesia and does not need to be overcor-
rected to achieve clinical result. Again, it is important
for the doctor and patient to realize this difference to
avoid overcorrection. Additionally, there is a more
pronounced initial inflammatory response with Resty-
lane than bovine collagen fillers. It must be explained
to patients that they will likely experience somewhat
FIGURE 5. Fillers should be injected with the patient in the upright
more redness and swelling with Restylane than they
position to prevent gravitational anatomic distortion.
did with bovine collagen fillers. This swelling and
Joseph Niamtu. Restylane in Cosmetic Facial Surgery. J Oral
erythema also appear more rapidly with Restylane Maxillofac Surg 2006.
JOSEPH NIAMTU 321
Table 2. PEARLS TO REMEMBER WHEN INJECTING
FILLERS
Assess patient outcome expectations prior to injection.
Take preinjection pictures on all patients.
Explain the possible need for multiple syringes before
injecting.
Explain expected recovery in advance of injection.
Schedule the augmentation as a two appointment
procedure to assess results and correct problems.
Be conservative as more filler can be added but excess
cannot be removed.
Mark all areas of augmentation before injecting.
Utilize appropriate pain control.
Always inject in the upright position.
Remember to conserve 1/2 of the syringe for the other
side or other lip when injecting bilaterally
Ice the treated areas before and after injecting.
FIGURE 7. Augmentation of the M configuration of the Cupid s
Bow in the upper lip and the white roll area of both lips.
Joseph Niamtu. Restylane in Cosmetic Facial Surgery. J Oral
Maxillofac Surg 2006.
Joseph Niamtu. Restylane in Cosmetic Facial Surgery. J Oral
Maxillofac Surg 2006.
a small bolus of filler in a single area and repeating this
the M configuration, which creates a defined white
progressively along the area to be augmented. The
roll and accents the Cupid s Bow (Fig 7). The
other technique is linear threading, which is a tech-
proper plane of injection for this area is at the vermil-
nique where the needle is inserted parallel to the long
ion cutaneous junction in the potential space just
axis of the lip or wrinkle and inserted to the needle
below the skin or mucosa. In the proper plane, the
hub. The filler is injected as the needle is removed,
filler should flow freely without excessive syringe
which forms a liner ridge as opposed to a bolus of
pressure in both an antegrade and retrograde direc-
filler. The filler may also be injected while advancing
tion. The needle is inserted in the potential space
the needle as well. Both techniques are valid and
parallel to the lip and the Restylane is injected while
useful in various applications. They are frequently
the needle is withdrawn (Fig 7).
combined and are the preference of the injector.
If significant syringe pressure is required or if the
Cosmetic lip injection is performed after makeup is
filler does not flow forward, then the needle is in the
removed, the lips anesthetized, and the area is
incorrect plane and must be redirected. Injection in
prepped with an alcohol wipe. Each patient exhibits
the incorrect plane will cause a clump of filler as
different anatomy and treatment expectations. Injec-
opposed to a flowing ridge (Fig 8).
tion is begun in the upper lip to enhance or reform
Keeping the lip stretched will also assist the flow-
ing of the filler. A perimeter of filler is placed on the
borders of both lips to define the white roll. De-
pending on the amount of aging and the patient s
desires, the filler can be carried all the way to the
commissure area. Some lips look esthetic with only
the central two thirds augmented, while other pa-
FIGURE 8. A shows a flowing ridge of filler when injected in the
FIGURE 6. Linear threading (LT) and serial puncture (SP) techniques correct plane; B shows clumping of filler from injecting in an improper
are most commonly used in filler injection. plane.
Joseph Niamtu. Restylane in Cosmetic Facial Surgery. J Oral Joseph Niamtu. Restylane in Cosmetic Facial Surgery. J Oral
Maxillofac Surg 2006. Maxillofac Surg 2006.
322 RESTYLANE IN COSMETIC FACIAL SURGERY
To further define or accent esthetic lip anatomy,
augmentation of the philtral columns may be per-
formed. The philtral columns are shaped like a mega-
phone where the apex is subalar and the base is at the
vermilion cutaneous junction. To augment this area,
the skin is pinched between the thumb and index
finger of the noninjecting hand. This defines the area
to be injected and assists in containing the flowing
filler to this area. This area is injected in the deep
dermal layer.
Injecting the Nasolabial Folds
Second to the lips, the nasolabial folds are the most
requested area to be augmented in the author s prac-
FIGURE 9. For volumetric vermilion augmentation, deeper submuco- tice. Many patients do not understand that these folds
sal injection is performed.
cannot be eliminated. It is explained to them that an
Joseph Niamtu. Restylane in Cosmetic Facial Surgery. J Oral
adult would look unnatural without any nasolabial
Maxillofac Surg 2006.
folds; the goal is to blunt these folds. As previously
mentioned, an upright injecting position is preferred
tients appreciate augmentation all the way to the as gravitational effect will distort the true nasolabial
commissure, especially in the senescent lip where the anatomy when the patient is reclined or supine. The
corners turn downward. There exists some artistry in correct tissue plane for Restylane injection in the
this aspect, and asking the patient what they want or nasolabial fold is intradermal. Because the skin is
asking them to bring a picture can give the surgeon a
blueprint for treatment, assuming the request is
realistic. After outlining the Cupid s Bow area, the
surgeon may choose to inject the vermilion substance
of the lip. Augmenting the white roll area is all that
is required for some patients, while others desire
more volumetric vermilion augmentation. This can be
performed in the deep and superficial plane. In the
superficial plane the filler is injected in the submuco-
sal plane several millimeters inferior to the vermilion
cutaneous area. It is important to stay superficial in
this area to ensure optimum planar flow and to avoid
hematoma (Fig 9). Again, the potential space beneath
the mucosa is the correct plane.
To inject in the deep substance of the lip, the
needle is injected midway into the lip and aspiration
is used to prevent both intravascular injection and
hematoma formation. The labial artery traverses the
posterior third of the lip at the level of the lower
central incisor edge and also corresponds with the
level of the vermilion cutaneous junction and is rarely
encountered with filler injection. Many patients do
not need deep tissue injection as Restylane augmen-
tation of the white roll area and or vermilion area is
sufficient.
Older patients frequently have rhytids in the cor-
ners of the mouth from overclosure, resulting from
reduced vertical dimension. Restylane is injected in
this area in a radiating pattern to plump this area.
FIGURE 10. Illustration of plumping of the vertical lip rhytids with
Finally, if significant vertical rhytids still exist, these
Restylane.
are treated with a very superficial intradermal injec-
Joseph Niamtu. Restylane in Cosmetic Facial Surgery. J Oral
tion parallel to the long axis of the wrinkle (Fig 10). Maxillofac Surg 2006.
JOSEPH NIAMTU 323
relatively thick in this area, the needle is placed just
deep enough in the skin so that the injection pro-
duces augmentation without visibly producing lumps
that are lighter in color than the skin; this indicates
too superficial of an injection plane. This is especially
true when injecting pigmented skin with light col-
ored fillers.
A caveat is to not make the nasolabial fold bigger.
FIGURE 11. Before and after injection of facial atrophy secondary to
Because multiple tissue planes come together at the
HIV antiviral medication.
nasolabial area, any injected substance can easily fol-
Joseph Niamtu. Restylane in Cosmetic Facial Surgery. J Oral
low the natural tissue plane laterally instead of re-
Maxillofac Surg 2006.
maining at the depth of the fold. It is especially easy
to have filler flow lateral to the nasolabial fold. If this
happens, it actually increases the lateral margin of the
provement that is superior to what each technique
fold and makes the valley deeper, thereby worsening
could provide by itself.
the appearance of the fold. This is not an uncommon
When injecting very superficial cheek or lip wrin-
mistake with the novice injector. To prevent this, the
kles it is imperative not to overcorrect, as the patient
injector must pay close attention to where the filler is
will go from a noticeable wrinkle to a noticeable
flowing and most importantly err on the medial side
ridge. Again, being conservative and having the pa-
of the nasolabial fold. Liner threading and serial punc-
tient follow up in 2 weeks for possible re-treatment
ture are frequently used in combination to fill in this
can prevent overtreatment misadventures. At the time
area (Fig 6). Using the serial puncture technique and
of submission of this article only Restylane has FDA
aiming just medial to the valley of the fold is a pre-
approval in the United States. A similar product called
dictable manner of injecting this area. When using the
Restylane Fine Line (Medicis Inc) has smaller size
serial puncture technique, the surgeon is laying down
particles and is specifically designed for fine lines.
small boluses of filler and the area may appear bumpy.
This is analogous to Zyderm (Inamed Inc) being indi-
By placing the thumb inside the mouth and the index
cated for superficial injection as compared with Zy-
finger on the skin, these bumps may be smoothed by
plast (Inamed Inc). When injecting lips and folds
compression and massage. The actual injection tech-
some practitioners will layer the augmentation. Resty-
nique is less important. It is the final result of a
lane or Perlane is injected deeper and Restylane Fine
blunted or less noticeable nasolabial fold that is the
Line is injected more superficially.
desired endpoint. It generally takes an entire syringe
to bilaterally blunt shallow nasolabial folds and multi-
ple syringes to bilaterally blunt deeper folds.
Augmenting Facial Anatomy
Restylane may also be used to enhance existing
Injecting Facial Rhytids
anatomy. Perlane is actually better indicated for this
Extreme care must be used when injecting any because of its larger particle size, but is not FDA
substances in the periorbital areas because permanent approved in the United States at the time of submis-
blindness has been described with collagen and fat sion of this article. The author has augmented the
from intravascular injection and retinal artery occlu- malar areas, chin, and the lateral eyebrows by inject-
sion.21-23 Any injection in these areas must be ex- ing Restylane over the prominence of the area to be
tremely superficial and intradermal. augmented. It has been noted that only small amounts
The linear threading technique works well with of Restylane are required to produce a visible augmen-
these superficial rhytids. The rhytid is first marked tation over a prominent area.
with a surgical marker and the skin is stretched. The Another indication for facial augmentation is HIV
needle is inserted in the mid or superficial dermis and patients that have severe facial atrophy from lipodys-
the filler is injected directly in the valley of the rhytid trophy from antiretroviral therapy.24 The antiretrovi-
while withdrawing the needle. The area is then mas- ral medications cause extreme hollowing of the
saged to smooth any lumpy areas. cheeks, temples, and zygomatic areas, calling atten-
Deep glabellar or lateral canthal lines are best tion to the tell-tale stigmata of this disease. Restylane
treated with a combination of Botox and Restylane has been successfully used to treat antiretroviral lip-
and can truly create a synergistic result that will en- odystrophy. It may take 5 to 10 syringes to augment
hance the longevity of the filler because of the de- severe facial atrophy. Figure 11 shows a before and
crease in local muscle movement.19 In addition, the after photograph of an HIV patient with lipodystro-
combination of Botox and Restylane provides an im- phy from antiretroviral medications.
324 RESTYLANE IN COSMETIC FACIAL SURGERY
better and want more filler free of charge. Other
patients may feel that the fillers did not address the
original problem they presented with. This after the
fact discourse can be uncomfortable and awkward for
the patient and the doctor s office. It is best avoided
by having a sound preinjection informed consent, as
well as taking time to provide a realistic expectation
of treatment outcome to the patient. Showing the
prospective patient actual pre- and postinjection pic-
tures can improve expectations and decrease patient
FIGURE 12. Before and after injection of a single syringe of Resty-
lane divided between both lips. unhappiness. It is best to show a full range of results
from average to best, and is important to show pic-
Joseph Niamtu. Restylane in Cosmetic Facial Surgery. J Oral
Maxillofac Surg 2006.
tures of older patients as well. Showing only the best
treatment results can lead to disappointed patients.
As the science of tissue fillers advances, prolonged
Postinjection Protocol
clinical effects are being seen. The increased duration
After injecting any area, bimanual massage is used of the augmentation is generally looked upon as pos-
to smooth any lumps or irregularities. This is done by itive by the doctor and patient. If an area is over
placing the thumb intraorally and the index finger on corrected, however, the product longevity can be-
the skin and massaging and stretching the lips or come a liability. The longer lasting the filler, the
nasolabial fold to compress the injection sites. For longer lasting the potential complication and this
areas remote to the mouth, a finger compresses the should be kept in mind. The best weapon against over
injected area against the hard tissue. The injected augmentation is to be conservative and make filler
areas are iced immediately after injection and the augmentation a multi appointment procedure. This is
patient is encouraged to continue this for several imperative for the novice injector.
hours. The patient is forewarned to expect erythema Inflammatory and granulomatous reaction can re-
and swelling for 24 to 48 hours. The patient is given sult from product allergy as detailed earlier in this
a follow-up appointment at 1 to 2 weeks and advised article. Tissue necrosis can result from intravascular
in advance that further treatment may be required at injection with blockage of blood flow or with ex-
the follow-up appointment if asymmetry exists. tremely superficial tissue injection causing localized
Figures 12 and 13 show before and after photo- vascular congestion.25 Close attention to proper tis-
graphs of Restylane lip enhancement. Figure 11 sue injection planes and syringe pressure can prevent
shows a pre- and post-treatment photograph of an vascular occlusion problems.
HIV patient augmented with Restylane for facial fat Hematoma and bruising are relatively common
atrophy from antiretroviral medical therapy. problems with filler injection and usually pose no
significant problems. Even the most experienced in-
jectors will, from time to time, cause bruising or
Complications
hematoma from unrecognized vasculature. This must
Asymmetry, overcorrection, and under correction be explained to the patient in the preinjection in-
are the most common complaints and generally im- formed consent. Immediate bruising, hematoma, or
prove with the experience of the injector. Because swelling is treated with ice and elevation. It is ex-
the facial tissues (especially the lips) may begin to
swell during the injection it is sometimes difficult to
judge what is edema and what is filler. For this reason,
the patient and doctor may not have an accurate
perception of the final result. As the degree of intra
injection swelling differs from patient to patient, it is
best to remain conservative with injection and have
the patient return for follow-up at 1 to 2 weeks. At the
follow-up appointment undercorrection or asymme-
try may be addressed with reinjection. One caveat is
to have an understanding before this appointment as
to who will be responsible for the cost of the filler and
FIGURE 13. Before and after injection of 2 syringes of Restylane
what that cost will be. Some patients will feel that
divided between both lips.
they should have had a larger augmentation for their
Joseph Niamtu. Restylane in Cosmetic Facial Surgery. J Oral
investment or that the product should have worked Maxillofac Surg 2006.
JOSEPH NIAMTU 325
6. Palkhivala A: Injected silicone risks. Dermatology Times, June
plained to the patient that 24 to 48 hours may be
2003, p 69
required before they are socially presentable. In rare
7. Olenius M: The first clinical study using a new biodegradable
cases patients may experience extended swelling that
implant for the treatment of lips, wrinkles, and folds. Aesthetic
Plast Surg 22:97, 1998
can last up to a week. These patients are treated with
8. Friedman PM, Mafong EA, Kauvar AN, et al: Safety data of
a dose of tapering steroids in addition to the afore-
injectable nonanimal stabilized hyaluronic acid gel for soft
mentioned therapies. As mentioned earlier in this
tissue augmentation. Dermatol Surg 28:491, 2002
9. Lowe NJ, Maxwell CA, Lowe P, et al: Hyaluronic acid skin
article, medications that affect coagulation can in-
fillers: Adverse reactions and skin testing. J Am Acad Dermatol
crease the incidence of bruising and, like all surgeries,
45:930, 2001
patients should be screened and informed of this.
10. Duranti F, Salti G, Bovani B, et al: Injectable hyaluronic acid gel
for soft tissue augmentation. A clinical and histological study.
Cosmetic surgery has become very popular in our
Dermatol Surg 24:1317, 1998
society and technologic advances and patients de-
11. Bosniak S, Cantisano-Zilkha M: Restylane and Perlane: A six-
sires are making minimally invasive cosmetic proce-
year clinical experience. Operat Tech Oculoplast Orbital Re-
construct Surg 4:89, 2001
dures more popular than ever. The injection of facial
12. Lemperle G, Morhenn VV, Charrier U: Human histology and
fillers is a commonly requested and performed proce-
persistence of various injectable filler substances for soft tissue
dure for cosmetic facial surgery. Technologic ad-
augmentation. Aesthetic Plast Surg 27:354, 2003
13. Narins RS, Brandt F, Leyden J, et al: A randomized, double-
vances have increased the longevity and decreased
blind, multicenter comparison of the efficacy and tolerability of
the allergenicity of facial fillers, making them more
Restylane versus Zyplast for the correction of nasolabial folds.
predictable and safer for the patient.
Dermatol Surg 29:588, 2003
14. Keefe J, Wauk L, Chu S, et al: Clinical use of injectable bovine
Restylane is a filler new to this country that can be
collagen: A decade of experience. Clin Mater 9:155, 1992
used in the practice of cosmetic facial surgery to
15. Lupton JR, Alster TS: Cutaneous hypersensitivity reaction to
augment lips and improve facial rhytids and folds.
injectable hyaluronic acid gel. Dermatol Surg 26:135, 2000
16. Fernandez-Acenero MJ, Zamora E, Borbujo J: Granulomatous
Restylane has notable advantages over previous ani-
foreign body reaction against hyaluronic acid: Report of a case
mal-derived fillers. Because Restylane is a non animal
after lip augmentation. Dermatol Surg 29:1225, 2003
product, preinjection allergy testing is not required
17. Honig JF, Brink U, Korabiowska M: Severe granulomatous al-
lergic tissue reaction after hyaluronic acid injection in the
and the incidence of allergic reaction is greatly re-
treatment of facial lines and its surgical correction. J Craniofac
duced. In addition, Restylane lasts longer than the
Surg 14:197, 2003
bovine collagen products. This product has been used
18. Q-Med Inc, Annual Report 2003. Available at: http://www.
q-med.com/pdf/ar2003eng.pdf. Accessed May 5, 2004
safely and effectively in other countries for a decade.
19. Carruthers A, Carruthers J: A prospective, randomized, parallel
The author has injected over 450 syringes in the 24
group study analyzing the effect of BTX-A (Botox) and nonani-
months since FDA approval and submission of this
mal sourced hyaluronic acid (NASHA, Restylane) in combina-
tion compared with NASHA (Restylane) alone in severe glabel-
article. A high degree of patient and doctor satisfac-
lar rhytides in adult female subjects: treatment of severe
tion was observed and no significant complications
glabellar rhytides with a hyaluronic acid derivative compared
occurred or were reported.
with the derivative and BTX-A. Dermatol Surg 29:802, 2003
20. Niamtu J: Image is everything: Pearls and pitfalls of digital
photography and PowerPoint presentations for the cosmetic
surgeon. Dermatol Surg 30:81, 2004
References
21. Egido JA, Arroyo R, Marcos A, et al: Middle cerebral artery
1. American Society for Aesthetic Plastic Surgery. Available at: embolism and unilateral visual loss after autologous fat injec-
http://www.surgery.org/press/statistics-2003.php. Accessed tion into the glabellar area. Stroke 24:615, 1993
March 28, 2004 22. Teimourian B: Blindness following fat injections. Plast Reconstr
2. Niamtu J: Botulinum Toxin A: A review of 1,085 oral and Surg 82:361, 1988
maxillofacial patient treatments. J Oral Maxillofac Surg 61:317, 23. Castillo GD: Management of blindness in the practice of cos-
2003 metic surgery. Otolaryngol Head Neck Surg 100:559, 1989
3. Niamtu J: The use of botulinum toxin in cosmetic facial sur- 24. Strauch B, Baum T, Robbins N: Treatment of human immuno-
gery. Oral Maxillofac Surg Clin North Am 12:596, 2000 deficiency virus-associated lipodystrophy with dermafat graft
4. Niamtu J: Aesthetic uses of botulinum toxin A. Oral Maxillofac transfer to the malar area. Plast Reconstr Surg 113:363, 2004
Surg 57:1228, 1999 25. Hanke CW, Higley HR, Jolivette DM et al: Abscess formation
5. Klein AW: Paraffinomas of the scalp. Arch Dermatol 121:382, and local necrosis after treatment with Zyderm or Zyplast
1985 collagen implant. J Am Acad Dermatol 25:319, 1991
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