Restylane and Perlane and Hyaluronic Acid fillers that are pretty much the gold
standard for soft tissue augmentation in the lips and lines around the mouth.
Hyaluronic acid was first isolated from the bovine vitreous in the 1930b�s. It is found in
the extracelluar space in humans and animals. It is known to create volume, lubricate
and support tissues. It is also highly hydrophilic which means it has a high waterbinding
Hyaluronic acid is comprised of repeating disaccharide units or sugar molecules. The
majority of HA occurs in the skin (56%). This production decreases with age. Less HA
produces a decreased ability to bind water which leads to loss of volume, more
wrinkles, less firmness and a drier skin.
Figure 1. Chemical structure of hyaluronic acid.
The half-life of HA or how quickly it turns over. It is usually less than 24 hrs. This is
avery quick! In order to clinically use HA to augment soft tissue it has to be stabilized.
Figure 2. Diagram of the half-life of HA.
My favorite of the HAb�s are Restylane and Perlane. In 1996 Restylane was the first HA
to be stabilized by non-animal sources. NASHA (TM) stands for stabilized non-animal
hyaluronic acid which was patented and and developed by Q-Med AB in Uppsala,
Sweden. They modified the HA by less than 1% which makes this product highly
compatible with a patientb�s own natural HA. There is less risk of inflammation and not
being of an animal source it is less immunologic and hence more pure. Since it is not
reactive and sensitizing we donb�t need to do skin testing like was necessary with
collagen. Another interesting fact about the NASHA gel is that as it is degraded with
time it will hold more water. This means that the volume is maintained longer and the
skin will continue to appear moist.
An important concept to understand about fillerb�s is itb�s elastic modulus or Gb�.(1) The
degree of cross-linking and the HA concentration of a filler determines itb�s Gb�. The
higher the Gb� the thicker and firmer the filler will be and it provides more tissue lift and it
will not spread as much. These are usually injected in the mid-dermis or deep dermis.
A low Gb� means the filler is soft and has more tissue spreading and will move with facial
movement. These are less palpable and I like to inject these into fine lines around the
mouth and under the eyes. These are usually injected in the papillary dermis or just
underneath the epidermis. Restylane and Perlane have a Gb� of 514 and 549
Hence a lower Gb� filler is injected more superficially and a higher Gb� is injected deeper
in the dermis or subcutaneous plane. Some can also be injected under muscle or on
top of bone.
Figure 3. Diagram of skin with an example of tissue tailoring.
Tissue tailoring means to place the filler in the correct location so as produce the best
filling effect that is going to last the longest.
My filler of choice for lip augmentation is Restylane and sometimes Perlane. It has
been shown to be present in tissue up to 1 yr. after injection. It does not form nodules
that you see with more permanent fillers and it can look natural. The vermillion border
is usually filled but not too much as to make the patient look like one has duck lips. I
usually inject it into the muscle itself and in the philtrum to produce a nice looking
Cupidb�s bow which turns up the lips in the midline. Lines around the mouth can also be
softened with Restylane. Lip augmentation can be painful so I perform blocks for
Kablik J et al. Dermatol Surg. 2009;35:302-312.
VALENTINES SPECIAL: BUY 1 SYRINGE OF ANY FILLER AT REGULAR PRICE AND
RECEIVE SECOND SYRINGE AT 50% OFF. THAT IS A $275-$300 SAVINGS.
RESTRICTIONS APPLY AND OFFER ENDS 2/14/2014