injections in aesthetic medicine.Mario_Goisis

injections in aesthetic medicine.Mario_Goisis injections in aesthetic medicine.Mario_Goisis injections in aesthetic medicine.Mario_Goisis injections in aesthetic medicine.Mario_Goisis injections in aesthetic medicine.Mario_Goisis injections in aesthetic medicine.Mario_Goisis injections in aesthetic medicine.Mario_Goisis injections in aesthetic medicine.Mario_Goisis injections in aesthetic medicine.Mario_Goisis

Mario Goisis Editor Injections in Aesthetic Medicine Atlas of Full-face and Full-body Treatment Injections in Aesthetic Medicine Mario Goisis Editor Injections in Aesthetic Medicine Atlas of Full-face and Full-body Treatment 123 Editor Mario Goisis Maxillo-Facial and Aesthetic Surgeon Doctor’s Equipe Milan Italy ISBN 978-88-470-5360-1 ISBN 978-88-470-5361-8 DOI 10.1007/978-88-470-5361-8 (eBook) Springer Milan Heidelberg New York Dordrecht London Library of Congress Control Number: 2013953897 Ó Springer-Verlag Italia 2014 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher’s location, in its current version, and permission for use must always be obtained from Springer Permissions for use may be obtained through RightsLink at the Copyright Clearance Center Violations are liable to prosecution under the respective Copyright Law The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made The publisher makes no warranty, express or implied, with respect to the material contained herein Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) Affectionately dedicated to my father Gianandrea Preface The Concept of Beauty Beauty has a key role in human history In ancient times Greeks held regularly beauty contests for both male and female Beauty was greatly admired and competitions were serious Annual contests were held at Lesbos, at Elis and in Arcadia But the first beauty contest in history was described in the Iliad The marriage of Peleus and Thetis was celebrated with a big banquet on Mount Olympus, home of the gods All the gods and goddesses were invited, except one, Eris, the Goddess of Strife and Discord, in order to avoid problems For this offense, Eris placed on the table, in the middle of the banqueting hall, a golden apple with the inscription ‘‘For the Fairest’’ All the three most important goddesses, Hera, Athena and Aphrodite had their eyes on the apple, each wanting it for herself They began to quarrel Paris, the son of Priam, King of Troy, was asked to judge The three goddesses were involved in the final round in what would become known as the World’s First Ever Beauty Contest! Hera promised Paris dominions, wealth and power Athena promised victory in battle Aphrodite promised the most beautiful woman in the world, Helen Paris gave the Golden Apple to Aphrodite, and that was the initial cause of Trojan War The beauty was a key concept in human history In particular, Piero della Francesca was one of the most original men of Italian renaissance Piero had two passions—art and geometry—and he integrated the two in the definition of beauty In fact, renaissance education placed exceptional value on mathematic rule of proportion Luca Bartolomeo Pacioli (c.1445–1517) was tutored in mathematics by Piero Both were born in Borgo San Sepolcro, and Luca even posed for Piero in the mid-1470s for Madonna and Child with Saints and Angels He published the Summa de arithmetica, geometrica, proportioni et proportionalita (1494) a summary of arithmetic, geometry, and algebra It contains the first mention of double-entry book-keeping, for which Luca is now known as the ‘‘Father of Accounting.’’ Accounting has a great importance in management of the aesthetic medicine office, but that’s not the reason of introducing Pacioli In fact, in his De divina Proportione published in 1509 he described the golden ratio ‘‘dal ciel mandata’’—heavensent He was inspired by the Platonic solids, and he related the Platonic solids to the golden ratio: As God created the four solids earth, air, water, and fire … so our sacred proportion gave shape to heaven itself The concept of divine proportion and the concept of perfect beauty was one of the most important concept in art, and it inspired Leonardo, Durer and many others artists The research of ideal proportion and ideal beauty changes over time and in different centuries people have different options for becoming beautiful In Shakespearean times, a woman was considered ideally beautiful if she had pale skin, light hair, intense eyes, and red lips and cheeks [1] Women went to extreme measures to have these vii viii Preface characteristics, plastering their faces with white cream and coloring their cheeks red Shakespeare criticises ‘‘ideal’’ beauty in one of his sonnets, Sonnet 130: My mistress’ eyes are nothing like the sun; Coral is far more red than her lips’ red: If snow be white, why then her breasts are dun; If hairs be wires, black wires grow on her head As creams at time of Shakespeare, aesthetic medicine and aesthetic surgery involves techniques intended for the ‘‘enhancement’’ of beauty In fact, the aim of aesthetic medicine and surgery is to change a part of the face and body through surgical and medical techniques in order to increase beauty Beauty is the key concept: the use of aesthetic surgery and medicine must not be in contrast with this principle, also in case of restoring or to maintaining youth In fact, even though beauty is a complex concept, the standards of attractiveness are similar across different genders and cultures [2, 3] As described by Piero della Francesca and Pacioli, beauty is harmony of form and proportions Injecting an enormous amount of filler in the face of an old patient can result in correction of wrinkles But this correction is associated with an unnatural result: in fact, the ‘‘pillow face’’ that we can obtain has probably a younger appearance, but at the end there is not beauty in our result In this book are described many techniques: these techniques must be the instrument to obtain a natural result Avoiding excess is the key to success in aesthetic medicine Mario Goisis References Barroll JL (1984) Shakespearean tragedy: genre, tradition, and change in Antony and Cleopatra Folger Books, Washington D.C Rhodes G (2006) The evolutionary psychology of facial beauty Annu Rev Psychol 57:199–226 Zecchi S (2007) Le promesse della bellezza Oscar Mondadori Contents Part I General Aspects Fillers in Aesthetic Medicine Mario Goisis, Alessandro Di Petrillo, Claudio Rinna, Chiara Brillante, Magda Guareschi, and Doris Ali Youssef Aesthetic Analysis of the Face: The Maxillofacial Deformity Giada Anna Beltramini, Francesco Laganà, Alessandro Baj, Michele Romano, Antonio Russillo, and Aldo Bruno Giannì 25 Standard Evaluation of the Patient: The Merz Scale Enrica Stella and Alessandro Di Petrillo 33 Part II Face and Body Treatments Temporal Fossa Mario Goisis and Alessandro Di Petrillo 53 Forehead, Glabella, and Crow’s-Feet Alessandro Di Petrillo and Magda Guareschi 61 Malar Area Mario Goisis, Enrica Stella, and Alessandro Di Petrillo 73 Tear Trough Mario Goisis and Enrica Stella 89 Nasolabial Folds Enrica Stella and Magda Guareschi 95 Medical Rhinoplasty Mario Goisis 101 10 Marionette Lines Enrica Stella, Alessandro Di Petrillo, and Mario Goisis 113 11 Lips Magda Guareschi and Enrica Stella 125 12 Chin Magda Guareschi and Mario Goisis 137 ix x Contents 13 Neck and Décolleté Enrica Stella and Mario Goisis 145 14 Arms Enrica Stella and Alessandro Di Petrillo 155 15 Hands Mario Goisis and Alessandro Di Petrillo 159 16 Breast Augmentation Mario Goisis 169 17 Gluteal Augmentation and Remodeling Mario Goisis and Magda Guareschi 185 18 Calf Augmentation and Remodeling Mario Goisis and Enrica Stella 193 19 Scar Revision Mario Goisis and Magda Guareschi 203 20 Full-body and Full-face Treatment Mario Goisis 209 21 Complications in Aesthetic Medicine Enrica Stella, Mario Goisis, and Mariangela Giarda 223 Part III Miscellany 22 Quality Standards in Aesthetic Medicine Mario Goisis and Andrea Goisis 253 23 Complementary Treatments Mario Goisis 261 24 Products Magda Guareschi 263 Contributors Editor Mario Goisis Maxillo-facial and Aesthetic Surgeon, Doctor’s Equipe, Milan, Italy Authors Alessandro Di Petrillo, Maxillo-facial Surgeon, Doctor’s Equipe, Bologna, Italy Bruno Giannì, Maxillo-facial Surgeon, University of Milan, Italy Magda Guareschi, Ophthalmologist and Aesthetic Doctor, Doctor’s Equipe, Milan, Italy Claudio Rinna, Maxillo-facial Surgeon, Doctor’s Equipe, Rome, Italy Enrica Stella, Aesthetic Doctor, Doctor’s Equipe, Genova, Italy Contributors Alessandro Baj Maxillo-facial Surgeon, University of Milan, Italy Giulia Beltrami Aesthetic Doctor, Doctor’s Equipe, Asti, Italy Giada Anna Beltramini Maxillo-facial Surgeon, University of Milan, Italy Gina Bianco Aesthetic Doctor, Doctor’s Equipe, Bologna, Italy Chiara Brillante Ophthalmologist, Sapienza University, Rome, Italy Doris Ali Youssef Maxillo-facial Surgeon, University of Milan, Italy Andrea Goisis Software manager, Milan, Italy Francesco Goisis Lawyer, University of Milan, Italy Valentina Isgro` Aesthetic Doctor, Doctor’s Equipe, Rome, Italy Francesco Lagana` Maxillo-facial Surgeon, University of Milan, Italy Chiara Lumini Aesthetic Doctor, Doctor’s Equipe, Torino, Italy Giorgio Persichetti Aesthetic Doctor, Doctor’s Equipe, Rome, Italy Michele Romano Maxillo-facial Surgeon, University of Milan, Italy Antonio Russillo Maxillo-facial Surgeon, University of Milan, Italy xi 24 Products 24.15 283 Macrolane VRF 20 and Macrolane VRF 30 Trade name Macrolane Company Q-Med, a Galderma Division Volume/Package 10- and 20-ml syringes Certifications CE First commercialization 2008 Description Macrolane Volume Restoration Factor (VRF) gels, Macrolane VRF20 and Macrolane VRF30 are sterile, transparent gels of stabilized hyaluronic acid of non-animal origin The products have a pH of 6.0–7.5 Macrolane VRF20 and VRF30 are designed for deep tissue implantation and differ with respect to the physical structure of the gel Macrolane VRF20 and VRF30 are supplied in plastic syringes with Luer lock Intended use Macrolane VRF20 and Macrolane VRF30 are intended to be used for volume restoration and contouring of body surfaces The products are not intended for facial tissue augmentation In general, deep subcutaneous administration is recommended For both products sufficient tissue cover and support are important parameters to achieve a good aesthetic treatment outcome A minimum of cm skin thickness, including subcutaneous fat, is usually required to attain good results The choice between Macrolane VRF20 and Macrolane VRF30 is based on an assessment of tissue cover as determined by skin fold measures Macrolane VRF30 is intended in areas where skin fold thickness is greater The injection should be made by physicians who have thorough knowledge of the anatomy of the treatment site and are experienced with injection techniques in the relevant area The treatment facility must be suitable for performance of aseptic procedures Duration Macrolane gels act by adding volume to the tissue, thereby restoring and enhancing body contours The product will be degraded over time Cannulas 16-G, or wider, blunt cannula In clinical studies where 20-ml syringes were used, 12-G blunt cannulas were preferred 24.16 NEWESTÒ: Skin Biorevitalization Trade name NEWESTÒ Company MASTELLI SRL Volume/Package Polynucleotides and hyaluronic Acid: 20 mg/ml in 2-ml syringe Certifications CE0373—class III MD First commercialization in Italy 2011 Areas of sales European registration and Russia Description NEWESTÒ is a visco-elastic, non-pyrogenic sterile gel for single use for intradermal implants NEWESTÒ is a medical device containing the original association of polynucleotides (10 mg/ml) and hyaluronic acid (10 mg/ml) Polynucleotides are substances of natural origin, highly purified and re-absorbable that are ubiquitous in our body Besides their moisturizing properties, they play a trophic action on fibroblasts improving both elasticity and tonicity of the skin The hyaluronic acid is also one of the major components of the dermal extra-cellular matrix strengthening both mechanical and elastic properties of the tissues The reduction with age of the hyaluronic acid of endogenous origin alters the epidermal and dermal structures accelerating skin ageing and the onset of wrinkles The two substances mixed together trigger a synergic action consisting in a strong moisturizing effect, induced by both components (hyaluronic acid in particular), combined with the trophic action polynucleotides play on the fibroblasts, these latter recovering and/or improving trophism and tonicity of the skin under these Conditions www.mastelli.com Intended use NEWESTÒ moisturizes the tissues, enhances the trophism of the skin and improves the turgidity, elasticity and tonicity of the skin These effects also foster the re-modelling of striae distensae and depressed scars, in therapeutical protocols customized by the practitioner Duration No published data Needle TWN 30 G‘ (supplied) Suggested cannulas 30 G, 27 G (not supplied) 284 24.17 M Guareschi PLINESTÒ: Skin Biorevitalization Trade name PLINESTÒ Company MASTELLI SRL Volume/Package Polynucleotides: 20 mg/ml in syringes Certifications CE0373—class III MD First commercialization 2005 Areas of sales European registration, Russia and other country ongoing Description PLINESTÒ is a polynucleotide gel for intradermal implants, visco-elastic, non-pyrogenic, sterile for single use only PLINESTÒ is a medical device containing polynucleotides (20 mg/ml) Polynucleotides are substances of natural origin, highly purified and re-absorbable that are ubiquitous in our body Besides their moisturizing properties, they play a trophic action on fibroblasts improving both elasticity and tonicity of the skin Intended use Thanks to its biochemical, visco-elastic and moisturizing properties, PLINESTÒ improves the turgidity, elasticity and tonicity of the skin It is also effective on highly fibrous areas, such as striae and scars PLINEST is the ultimate for mature skin, photo ageing, intensive treatments Duration Needle TWN 30 G‘ (supplied) Suggested cannulas 30 G, 27 G (not supplied) 24.18 PLINESTÒ fast: Skin Biorevitalization Trade name PLINESTÒ fast Company MASTELLI SRL Volume/Package Polynucleotides: 7, mg/ml syringes Certifications CE0373—class III MD First commercialization 2008 Areas of sales European registration, Russia and other country ongoing Description PLINESTÒ fast is a polynucleotide gel for intradermal implants, visco-elastic, non-pyrogenic, sterile for single use only PLINESTÒ fast is a medical device containing polynucleotides (7, mg/ml) Polynucleotides are substances of natural origin, highly purified and re-absorbable that are ubiquitous in our body Besides their moisturizing properties, they play a trophic action on fibroblasts improving both elasticity and tonicity of the skin Intended use PLINESTÒ fast thanks to its biochemical, moisturizing and trophic properties and improves the turgidity, elasticity and tonicity of the skin It also helps remodelling striae and depressed scars and is included in integrated biorestructuring protocols PLINESTÒ fast is the ultimate for fine and delicate skin areas, particular areas like scalp, eye contour, young skin and as maintenance Duration No published data Needle TWN 30 G‘ (supplied) Suggested cannulas 30 G, 27 G (not supplied) 24 Products 24.19 285 IALESTÒ: Skin Biorevitalization Trade name IALESTÒ Company MASTELLI SRL Volume/Package Hyaluronic Acid: 20 mg/ml in ml syringe Certifications CE0373—class III MD First commercialization 2008 Areas of sales European registration, Russia and other country ongoing Description IALESTÒ is a medical device based on sodium hyaluronate It is a sterile, non-pyrogenic, viscoelastic and transparent solution packaged in 2-ml syringes for single use only Hyaluronic acid is one of the main components of the extracellular matrix Besides giving tissue mechanical and elastic properties, it takes part in the attraction of fibroblasts, macrophages and endothelial cells and has a scavenger effect against certain free radical Endogenous hyaluronic acid dramatically decreases with age and this lower concentration contributes to altering epidermal and dermal structures thereby accelerating skin ageing and the onset of wrinkles Intended use Thanks to its natural moisturizing function, IALEST remarkably improves skin trophism and texture, considerably increasing skin turgidity and elasticity Duration Needle TWN 30 G‘ (supplied) Suggested cannulas 30 G; 27 G (not supplied) Reference Cavallini M, Papagni M (2007) Long chain polynucleotides gel and skin biorevitalization Int J Plastic Dermatol ISPLAD 3(3):27–32 286 24.20 M Guareschi Radiesse 24.20.1 Radiesse Filler Trade name RADIESSE Company Merz Pharma Certifications CE, FDA First commercialization 2008 Market Europe (Austria, Belgium, Bulgaria, Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Ireland, Italy, latvia, Lithuania, Luxemburg, Malta, Netherlands, Norway, Poland, Portugal, Romania, Russia, Slovakia, Spain, Sweden, Switzerland, Turkey, Uk and Ukraine), Asia/South Pacific (Australia, Hong Kong, Korea, Malaysia and Taiwan), Africa (Egypt, South Africa and Tunisia), Latin America (Argentina, Brazil, Colombia, Panama and Chile), Middle Est (Iran, Israel, Jordan, KSA, Kuwait, Lebanon, Oman, Qatar and UAE) and North America (Canada, Dominician Rep., Mexico and US) Description Radiesse injectable implant is a steam-sterilized, latex-free, non-pyrogenic, semi-solid, cohesive completely biodegradable deep- and sub-dermal implant The principle components are synthetic calcium hydroxylapatite, a biomaterial with over twenty years of use in orthopedics, neurosurgery, dentistry, otolaryngology and ophthalmology Calcium hydroxylapatite is the primary mineral constituent of bone and teeth The semi-solid nature of the implant is created by suspending calcium hydroxylapatite in a gel carrier that consists primarily of water and glycerine The gel structure is formed by the addition of a small amount of sodium carboxymethylcellulose The gel is dissipated in vivo and replaced with soft tissue growth, while the calcium hydroxylapatite remains at the site of injection Intended use RadiesseTM is approved in the United States (FDA) for the correction of moderate to severe facial folds and wrinkles, including nasolabial folds and for restoration of the signs of facial fat loss (lipoatrophy) in HIV patients In Europe, RadiesseTM is approved for plastic and reconstructive surgery, including deep-dermal and sub-dermal soft tissue augmentation of the facial area Duration The result is long-term yet non-permanent restoration and augmentation Reported cosmetic improvement until 9–12 months Needle TWN 27 G 1 or 28 G’ (supplied) Suggested cannulas 27 G inch; 27 G 1‘ inch; 25 G 1‘ inch; 25 G inch (not supplied) Radiesse Filler: Reference (2007) Minimizing discomfort during the injection of radiesse with the use of either local anesthetic or ice Dermatol Online J 13(3):5 (2007) Hand augmentation with radiesse (calcium hydroxylapatite) Dermatol Ther (20):385–387 (2007) Calcium hydroxylapatite (Radiesse) for correction of the mid- and lower face: consensus recommendations Plast Reconstruct Surg 120(6 Suppl):55–66 (2007) Injectable calcium hydroxylapatite for orbital volume augmentation Arch Facial Plast Surg 9(6): 439–442 (2007) A multicenter, randomized trial comparing calcium hydroxylapatite to two hyaluronic acids for treatment of nasolabial folds Dermatol Surg 33:S144–S151 (2008) Calcium hydroxylapatite versus nonanimal stabilized hyaluronic acid for the correction of nasolabial folds: a 12-month, multicenter, prospective, randomized, controlled, split-face trial Dermatol Surg 34:210–215 (2008) Use of calcium hydroxylapatite (Radiesse) for facial augmentation Clin intervent Aging 3(1): 161–174 (2008) Aesthetic 338e–339e (2008) Neocollagenesis after injection of calcium hydroxylapatite composition in a canine model Derm Surg 34:S53–S55 10 (2008) A 52-month summary of results using calcium hydroxylapatite for facial soft tissue augmentation Derm Surg 34:S9–S15 11 (2008) Adverse cutaneous reactions to soft tissue fillers—a review of the histological features.J Cutan Pathol 35(6):536–548 12 (2008) Evaluation of injectable calcium hydroxylapatite for the treatment of facial lipoatrophy associated with human immunodeficiency virus Derm Surg 34(11):1486–1499 24 Products 287 13 (2009) Hand recontouring with calcium hydroxylapatite (Radiesse) J Cosmet Dermatol, 8(1):44–51 14 (2009) Injectable calcium hydroxylapatite microspheres (radiesse) Facial Plast Surg 25(2):100–5 15 (2010) Controlled, randomized study of pain levels in subjects treated with calcium hydroxylapatite premixed with lidocaine for correction of nasolabial folds Dermatol Surg 36(3):309–315 16 (2010) Calcium hydroxylapatite (Radiesse) for treatment of nasolabial folds: long-term safety and efficacy results Aesthetic Surg J 30(2):235–238 17 (2010) Multinational, multipatient study of calcium hydroxylapatite for treatment of the aging hand: European cosmetic physician group on hand augmentation Dermatol Surg 36 (S1):782–789 24.21 18 (2010) Multicenter, randomized trial assessing the effectiveness and safety of calcium hydroxylapatite for hand rejuvenation Dermatol Surg 36(S1):790–797 19 (2010) Hand rejuvenation using radiesse Plast Reconstr Surg 125(6):259e–260e 20 (2010) Ocular ischemia and ischemic oculomotor nerve palsy after vascular emobilation of injectable calcium hydroxylapatite filler Opthal Plast Reconstr Surg 26(4):289–291 21 (2010) Facial shaping: beyond lines and folds with fillers J Drugs Dermatol,9(8S):s129–s137 22 (2010) A review of dermal fillers in facial plastic surgery Curr Opin Otolaryngol Head Neck Surg 18(4):295–302 Restylane Range: Q-Med, A Galderma Division 24.21.1 Restylane Filler Trade name Restylane Company Q-Med, a Galderma Division Volume/Package 1, 0.5 ml Certifications CE, FDA First commercialization 1997 Description Restylane is a sterile, transparent gel of stabilized hyaluronic acid of non-animal origin (20 mg/ml) supplied in a glass syringe with a Luer lock fitting Disposable sterile needles are provided with each syringe Restylane is a filler that acts by adding volume to the tissue, thereby supporting the overlying (dermal) tissue to restore the skin contours or enhancing the lips to the desired level of correction The manufacturing process is based on the patented NASHATM technology, that allows to obtain an gel through a very low degree of synthetic cross-linking (BDDE) while keeping the natural three-dimensional structure of the native HA molecule by preserving its natural entanglements Higher strength of the HA gel (i.e a higher resistance to deformation) and superior capacity to lift the tissue are the most important features of the NASHA manufacturing process Restylane will in time undergo isovolemic degradation, which means that the product maintains its volume even during degradation [1–6] Intended use Facial tissue augmentation It is recommended to be used for the correction of wrinkles and lip enhancement [7] It should be injected into the middle part of the dermis layer Duration The degree and duration of the correction depend on the character of the defect treated, the tissue stress at the implant site, the depth of the implant into the tissue and the injection technique Documented to last from to 12 months after one treatment according to different clinical studies [1–3] Documented persistence of the aesthetic results until 18 months after one re-treatment session and until 36 months after two re-treatment sessions [8, 9] In vivo stimulation of de-novo production of collagen has been shown after injection of Restylane [10] Needle TWN 29 G ‘ (supplied) Suggested cannulas Pix’L 27 G or pix’L 28G reinforced (not supplied) 288 M Guareschi Trade name Restylane Lidocaine Company Q-Med, a Galderma Division Volume/Package 1, 0.5 ml Certifications CE, FDA First commercialization 2009 Description The same chemical composition such as Restylane with the addition of lidocaine hydrochloride mg/ml The Restylane formulation with lidocaine has the same chemical and physical characteristics (gel content, particle size, pH and degree of modification) as NASHA-based gel without lidocaine The addition of lidocaine provides a painrelieving effect during treatment In a controlled study, Restylane lidocaine was shown to have comparable efficacy and safety profile as Restylane without lidocaine [11] Intended use See Restylane Duration See Restylane Needle TWN 29G ‘ (supplied) Suggested cannulas Pix’L 27 G or pix’L 28G reinforced (not supplied) Trade name Restylane Perlane Company Q-Med, a Galderma Division Volume/Package 1, 0.5 ml Certifications CE, FDA First commercialization in Italy 2000 Description Stabilized hyaluronic acid of non-animal origin (20 mg/ml) supplied in a glass syringe with a Luer lock fitting The volume and the lifting capacity originate from the ability of hyaluronic acid to attract high amount of water, which is further increased by the stabilization process Restylane Perlane will in time undergo isovolumic degradation, which means that the product maintains its volume even during degradation Intended use Restylane Perlane is intended to be used for facial tissue augmentation It is recommended to be used for shaping the contours of the face, the correction of folds and for lip enhancement It should be injected into the deep layer of the dermis and/or the surface layer of the subcutis For facial areas with limited soft tissue support and soft tissue cover, e.g., the periorbital region, injection into the subcutaneous fatty tissue or supraperiostal administration is recommended Duration Restylane Perlane for the correction of nasolabial folds, 75 % of the subjects maintained a clinically significant improvement months after treatment [11] Needle TWN 29G ‘ (supplied) Suggested cannulas Pix’L 23 G or 25G or pix’L 28 G reinforced (not supplied) Trade name Restylane Perlane Lidocaine Company Q-Med, a Galderma Division Volume/Package 1, 0.5 ml Certifications CE, FDA First commercialization in Italy 2009 Description The same chemical and physical composition such as Restylane Perlane with the addition of lidocaine hydrochloride mg/ml The addition of lidocaine provides a pain-relieving effect during the treatment Intended use See Restylane Perlane Duration In a randomized controlled 12 months follow-up study, Restylane Perlane with lidocaine was comparable to Restylane Perlane alone in terms of aesthetic efficacy [13] Needle TWN 29G ‘ (supplied) Suggested cannulas Pix’L 23 G or 25G or pix’L 28 G reinforced (not supplied) 24 Products 289 Trade name Restylane SubQ Company Q-Med, a Galderma Division Volume/Package ml Certifications CE First commercialization in Italy 2004 Description Restylane SubQ is a sterile, transparent gel of 20 mg/ml stabilized hyaluronic acid of non-animal origin It is supplied in a glass syringe with a Luer lock fitting The mode of action into the tissue is comparable to the other NASHA formulations Intended use Intended to be used for facial tissue augmentation It is recommended to be used for shaping the contours of the face, e.g., more pronounced cheeks or chin [14–16] The depth of injection may vary from injection into the subcutaneous fatty tissue to supraperiostal administration depending on the treatment site Restylane SubQ shall only be injected by practitioners with expertise in the correction of volume defects in the facial area Duration Reported cosmetic improvement until 9–12 months in the studies [14, 15] Suggested Needle 21G (not supplied) Suggested cannulas 16–21 G (pix’L 21 G)(not supplied) Trade name Restylane SubQ Lidocaine Company Q-Med, a Galderma Division Volume/Package ml Certifications CE First commercialization in Italy 2012 Description Restylane SubQ is a sterile, transparent gel of 20 mg/ml stabilized hyaluronic acid of non-animal origin with the addition of 0.3 % lidocaine hydrochloride It is supplied in a glass syringe with a Luer lock fitting The mode of action into the tissue is comparable to the other NASHA formulations Intended use See Restylane SubQ Duration No published data on the formulation with lidocaine Supposed to be as long-lasting as Restylane SubQ without lidocaine Suggested Needle 21G (not supplied) Suggested cannulas 16–21 G (pix’L 21 G) (not supplied) Trade name Restylane Lip Volume Company Q-Med, a Galderma Division Volume/Package ml Certifications CE First commercialization in Italy 2012 Description Restylane Lip Volume is a sterile, transparent, biodegradable gel of 20 mg/ml stabilized hyaluronic acid of nonanimal origin with the addition of 0.3 % lidocaine hydrochloride Intended use Intended for lip enhancement It should be administered by submucosal injection Duration No published data Supposed to be up to months Needle TWN 29G ‘ (supplied) Suggested cannulas Pix’L 25 G or 27G (not supplied) 290 M Guareschi Trade name Restylane Lip Refresh Company Q-Med, a Galderma Division Volume/Package ml Certifications CE First commercialization in Italy 2012 Description Restylane Lip Refresh is a sterile, transparent, biodegradable gel of stabilized hyaluronic acid of non-animal origin with the addition of 0.3 % lidocaine hydrochloride It is supplied in a glass syringe It is naturally integrated into the tissue where it helps to restore hydro balance and improve skin structure of the lips This is accomplished by the water associated with the stabilized hyaluronic acid in the gel Intended use Restylane Lip Refresh is intended to restore hydro balance and improve skin structure of the lips It should be administered by submucosal injection Duration No published data Supposed to be up to months Needle TWN 30G ‘ (supplied) Suggested cannulas Pix’L 27 G (not supplied) Restylane Filler: Reference Olenius M (1998) The first clinical study using a new biodegradable implant for the treatment of lips, wrinkles and folds Aesth Plast Surg 22:97–101 Duranti F, Salti G, Bovani B, Calandra M, Rosati ML (1998) Injectable hyaluronic acid gel for soft tissue augmentation A clinical and histological study Dermatol Surg 24(12):1317–1325 Narins RS, Brandt F, Leyden J, et al (2003) A randomized, double-blind,multicenter comparison of the efficacy and tolerability of Restylane versus Zyplasts for the correction of nasolabial folds Dermatol Surg 29 (6):588–595 Edsman K,Lars I, Nord LI, Öhrlund A et al (2012) Gel properties of hyaluronic acid dermal fillers Dermatol Surg 38:1170–1179 Friedman PM, Mafong EA, Kauvar ANB, et al (2002) Safety data of injectable nonanimal stabilized hyaluronic acid gel for soft tissue augmentation Dermatol Surg 28:491–494 Hamilton RGH, ABMLI D, Strobos J, Adkinson F (2007) Immunogenicity studies of cosmetically administered nonanimal-stabilized hyaluronic acid particles Dermatol Surg 33:S176–S185 Matarasso SL, Carruthers JD, Jewell ML (2006) Consensus recommendations for soft tissue augmentation with nonanimal stabilized hyaluronic acid (Restylane).Plast Reconstr Surg 117:3S-34S; discussion 5S–43S Narins RS, Dayan SH, Brandt FS e Baldwin EK (2008) Persistence and improvement of nasolabial fold correction with nonanimal-stabilized hyaluronic acid 100,000 gel particles/ml filler on two retreatment schedules: results up to 18 months on two retreatment schedules Dermatol Surg 34:S2–S8 Narins RS, Brandt FS, Dayan SH, Hornfeldt CS (2011) Persistence of naso-labial fold correction with a hyaluronic acid dermal filler with retreatment: results of an 18-month extension study Dermatol Surg 37:1–7 10 Wang F, Garza LA, Kang S et al (2007) In vivo stimulation of de novo collagen production caused by crosslinked hyaluronic acid dermal filler injections in photodamaged human skin Arch Dermatol 143:155–163 11 Weiss R, Bank D, Brandt F (2010) Randomized, double-blind, split-face study of small gel particle hyaluronic acid with and without lidocaine during correction of nasolabial folds Dermatol Surg 36:750–759 12 Lindqvist C, Tveten S, Bondevik BE, Fagrell D (2005) A randomized, evaluator-blind, multicenter comparison of the efficacy and tolerability of Perlane versus Zyplast in the correction of nasolabial folds Plast Reconstr Surg 115(1):282–289 13 Heden P, Fagrell D, Jernbeck J et al (2010) Injection of stabilized hyaluronic acid-based gel of non-animal origin for the correction of naso-labial folds: comparison with and without lidocaine Dermatol Surg 36:775–781 14 Wu W, Carlisle I, Huang P, Ribé N, Russo R, Schaar C, Verpaele A, Strand A 2009 Novel Administration Technique for Large-Particle Stabilized Hyaluronic Acid-Based Gel of Nonanimal Origin in Facial Tissue Augmentation Aesthetic Plast Surg Nov 19 (Epub ahead of print) 15 De Lorenzi C, Weinberg M, Solish N, Sweift A (2009) The long-term efficacy and safety of a subcutaneously injected large-particle stabilized hyaluronic acid-based gel of nonanimal origin in esthetic facial contouring Dermatol Surg 2009 35:313–321 16 Lowe NJ, Grover R (2006) Injectable hyaluronic acid implant for malar and mental enhancement Dermatol Surg 32:881–885 24 Products 24.22 291 Range Restylane Vital Trade names Restylane Vital/Restylane Vital Injector/ Restylane Vital Lidocaine/Restylane Vital Injector Lidocaine Company Q-med a galderma division Volume/Package Syringe: ml; Injector: ml Certifications CE First commercialization 2004 (Restylane Vital); 2009 (Restylane Vital Injector) Description Sterile, transparent gel of stabilized hyaluronic acid of non-animal origin 20 mg/ml supplied in a 1-ml glass syringe or a 2-ml pre-filled injector, both with a Luer lock fitting Restylane Vital is naturally integrated into the skin where it helps to restore skin hydro balance and improve skin structure and the elasticity of the skin This is accomplished by the water associated with the stabilized hyaluronic acid in the gel The unique characteristics of the gel help maintain the effect for a long period of time The addition of 0.3 % lidocaine hydrochloride in Restylane Vital lidocaine and Restylane Vital lidocaine Injector provides increased overall treatment comfort Intended use Restylane Vital is intended to restore skin hydro balance and improve skin structure and the elasticity of the skin It should be injected in the dermal layer of the skin, preferably in the deeper part of dermis A treatment plan for Restylane Vital is recommended with three treatments weeks apart Generally, it is recommended to repeat the treatment plan every months, but results and patient preferences may vary Duration In clinical studies with Restylane Vital, patients experienced significant improvement in dermal elasticity and skin morphology up to months after initial treatment [1–4] Needle Syringe: 30G 1/2; Injector: TWN 29G ‘ (supplied) Suggested cannula Pix’L 27 G or 30G (with syringe) 2011 (Restylane Vital lidocaine); 2011 (Restylane Vital lidocaine Injector) Cost Trade names Restylane Vital Light/Restylane Vital Light Injector/ Restylane Vital Light Lidocaine/Restylane Vital Light Injector Lidocaine Volume/Package Syringe: ml; Injector : ml Certifications CE First commercialization 2008 (Restylane Vital Light); 2008 (Restylane Vital Light Injector) Description Sterile, transparent gel of stabilized hyaluronic acid of non-animal origin 12 mg/ml, supplied in a 1-ml glass syringe or a 2-ml pre-filled injector, both with a Luer lock fitting Restylane Vital is naturally integrated into the skin where it helps to restore skin hydro balance and improve skin structure and the elasticity of the skin This is accomplished by the water associated with the stabilized hyaluronic acid in the gel The unique characteristics of the gel help maintain the effect for a long period of time The addition of 0.3 % lidocaine hydrochloride in Restylane Vital lidocaine and Restylane Vital lidocaine Injector provides increased overall treatment comfort Intended use Restylane Vital is intended to restore skin hydro balance and improve skin structure and the elasticity of the skin It should be injected in the dermal layer of the skin A treatment plan for Restylane Vital is recommended with three treatments weeks apart Generally, it is recommended to repeat the treatment plan every months, but results and patient preferences may vary Duration In clinical studies with Restylane Vital, patients experienced significant improvement in dermal elasticity and skin morphology up to months after initial treatment [1–5] Needle Syringe: 30G ‘ Injector: TWN 29G ‘ (supplied) 2011 (Restylane Vital Light lidocaine); 2011 (Restylane Vital Light Injector lidocaine) 292 M Guareschi Range Restylane Vital: Reference Kerscher M, Bayrhammer J, Reuther T (2008) Rejuvenating influence of a stabilised hyaluronic acid-based gel of nonanimal origin on facial skin aging Dermatol Surg 34:1–7 Williams S, Tamburic S, Stensvik H, Weber M (2009) Changes in skin physiology and clinical appearance after microdroplet placement of hyaluronic acid in aging hands J Cosm Dermatol 8:216–225 Distante F, Pagani V, Bonfigli A (2009) Stabilized Hyaluronic Acid of Non-animal origin for rejuvenating the skin of the upper arm Dermatol Surg 35:389–394 Reuther T, Bayrhammer J, Kerscher M (2010) Effects of a three-session skin rejuvenation treatment using stabilized hyaluronic acid-based gel of non-animal origin on skin elasticity: a pilot study Arch Dermatol Res 302(1):37–45 Ribé NA & Ribé N (2011) Neck skin rejuvenation: Histological and clinical changes after combined therapy with a fractional non-ablative laser and stabilized hyaluronic acid-based gel of non-animal origin J Cosmet Laser Ther 13(4):154–61 24.23 SurgidermÒ Range 24.22.1 SurgidermÒ18 24.22.2 SurgidermÒ 24XP 24.22.3 SurgidermÒ 30XP 24.23 SurgidermÒ Range 24.22.4 SurgidermÒ 30 24.23.1 SurgidermÒ18 Trade name SurgidermÒ18 Company ALLERGAN Certification CE Mark Year CE mark receipt 2005 Volume/package One syringe contains 0.8 ml of SurgidermÒ 18 Each box contains two 0.8-ml syringes, four single-use 30G1/200 sterile needles, an instruction leaflet and a set of labels to ensure traceability [1] Intended use SurgidermÒ 18 is an Injectable implant indicated for filling superficial skin depressions by injection in the superficial dermis It can be also used in Mesolift applications [1] Description SurgidermÒ18 is a sterile pyrogenic-free, physiological solution of cross-linked hyaluronic acid which is not of animal origin The gel is presented in a graduated pre-filled disposable syringe [1] Composition Hyaluronic acid gel 18 mg and phosphate buffer pH 7.2 q.s ml [1] Sterilization The contents of the SurgidermÒ 18 syringes are sterilized by moist heat The 30G1/2needles are sterilized by radiation [1] Method of use This product is designed to be injected into the dermis by an authorized medical practitioner in accordance with local applicable regulation As precision is essential to a successful treatment, the product must be used by medical practitioners who have undertaken specific training in injection techniques for filling [1] Duration Not reported in DFU 24 Products 293 24.23.2 SurgidermÒ 24XP Trade name SurgidermÒ 24XP Company ALLERGAN Certification CE Mark Year CE mark receipt 2005 Volume/package One syringe contains 0.8 ml of SurgidermÒ 24XP Each box contains two 0.8-ml syringes, four single-use 30G1/200 sterile needles, an instruction leaflet and a set of labels to ensure traceability [1] Intended use SurgidermÒ 24XP is an Injectable implant used for filling any medium depression of the skin via mid-dermis injection, as well as for definition and pouting of the lips [1] Description SurgidermÒ 24XP is a sterile pyrogenic-free, physiological solutions of cross-linked hyaluronic acid which is not of animal origin The gel is presented in a graduated pre-filled disposable syringe [1] Composition Hyaluronic acid gel 24 mg and phosphate buffer pH 7.2 q.s ml [1] Sterilization The contents of the SurgidermÒ 24XP syringes are sterilized by moist heat The 30G1/2needles are sterilized by radiation [1] Method of use This product is designed to be injected into the dermis by an authorized medical practitioner in accordance with local applicable regulation As precision is essential to a successful treatment, the product must be used by medical practitioners who have undertaken specific training in injection techniques for filling [1] Duration Not reported in DFU 24.23.3 SurgidermÒ 30XP Trade name SurgidermÒ 30XP Company ALLERGAN Certification CE Mark Year ce mark receipt 2005 Volume/package One syringe contains 0.8 ml of SurgidermÒ 30XP Each box contains two 0.8-ml syringes, four single-use 27G1/200 sterile needles, an instruction leaflet and a set of labels to ensure traceability [1] Intended use SurgidermÒ 30XP is an Injectable implant used for filling mid- and/or deep depression of the skin via mid- and/or deep dermis injection, as well as for volume increase, definition and pouting of the lips [1] Description SurgidermÒ 30XP is a sterile pyrogenic-free, physiological solution of cross-linked hyaluronic acid which is not of animal origin The gel is presented in a graduated pre-filled disposable syringe [1] Composition Hyaluronic acid gel 24 mg and phosphate buffer pH 7.2 q.s ml [1] Sterilization The contents of the SurgidermÒ 30XP syringes are sterilized by moist heat The 27G1/2needles are sterilized by radiation [1] Method of use This product is designed to be injected into the dermis by an authorized medical practitioner in accordance with local applicable regulation As precision is essential to a successful treatment, the product must be used by medical practitioners who have undertaken specific training in injection techniques for filling [1] Duration Not reported in DFU 294 M Guareschi 24.23.4 SurgidermÒ 30 Trade name SurgidermÒ 30 Company ALLERGAN Certification CE Mark Year ce mark receipt 2005 Volume/package One syringe contains 0.8 ml of SurgidermÒ 30 Each box contains two 0.8-ml syringes, four single-use 27G1/200 sterile needles, an instruction leaflet and a set of labels to ensure traceability [1] Intended use SurgidermÒ 30 is an injectable implant used for filling any deep depression of the skin via deep dermis injection, as well as for lip enhancement and cheekbone augmentation [1] Description SurgidermÒ 30 is a sterile pyrogenic-free, physiological solution of cross-linked hyaluronic acid which is not of animal origin The gel is presented in a graduated pre-filled disposable syringe [1] Composition Hyaluronic acid gel 24 mg and phosphate buffer pH 7.2 q.s ml [1] Sterilization The contents of the SurgidermÒ 30 syringes are sterilized by moist heat The 27G1/2needles are sterilized by radiation [1] Method of use This product is designed to be injected into the dermis by an authorized medical practitioner in accordance with local applicable regulation As precision is essential to a successful treatment, the product must be used by medical practitioners who have undertaken specific training in injection techniques for filling [1] Duration Not reported in DFU 24.24 VistabexÒ VISTABEX Ò Company ALLERGAN Trade Name Vistabex, allergan units/0.1 ml, powder for solution for injection Intended Use Vistabex is indicated for the temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown, in adults\65 years old, when the severity of these lines has an important psychological impact for the patient (1) Description Qualitative and quantitative composition (1) Botulinum toxin type A1—4 allergan units per 0.1 ml of reconstituted solution of Clostridium botulinum Allergan units are not interchangeable with other preparations of botulinum toxin Vial of 50 units Pharmaceutical Form Powder for solution for injection White Powder Posology Reconstituted Vistabex (50 U/1.25 ml) is injected using a sterile 30-gauge needle 0.1 ml (4 U) is administered in each of the injection sites: injections in each corrugator muscle and injection in the procerus muscle for a total dose of 20 U (continued) 24 Products 295 (continued) VISTABEX Ò Clinical Data As stated in the SPC, 537 patients with moderate to severe vertical lines between the eyebrows (glabellar lines) at maximum frown have been included in clinical studies Vistabex injections significantly reduced the severity of glabellar lines for up to months, as measured by the investigator assessment of glabellar line severity at maximum frown and by subject’s global assessment of change in appearance of his/her vertical lines between the eyebrows (glabellar lines) None of the clinical endpoints included an objective evaluation of the psychological impact Thirty days after injection, 80 % (325/405) of Vistabex-treated patients were considered by investigators as treatment responders (none or mild severity at maximum frown), compared to % (4/132) of placebo-treated patients At this same time point, 89 % (362/405) of Vistabel-treated patients felt that they had a moderate or better improvement, compared to % (9/132) of placebo-treated patients Vistabex injections also significantly reduced the severity of glabellar lines at rest Of the 537 patients enrolled, 39 % (210/537) had moderate to severe glabellar lines at rest (15 % had no lines at rest) Of these, 74 % (119/161) of Vistabex-treated patients were considered treatment responders (none or mild severity) thirty days after injection, compared with 20 % (10/49) of placebo-treated patients Safety and efficacy of Vistabex have been demonstrated in several studies reported in literature [2–9] Onset of Response and Duration Improvement of severity of vertical lines between the eyebrows (glabellar lines) generally occurs within one week after treatment The effect was demonstrated for up to months after injection Treatment intervals should not be more frequent than every three months (1) Package Powder in a vial (type I glass) fitted with a stopper (chlorobutyl rubber) and a seal (aluminium); Vial of 50 allergan Units of Botulinum toxin type A—pack of one of two It is possible that not all registered pack sizes are marketed (1) Shelf Life years (1) Vistabex: Reference Carruthers et al (2002) Vistabex summary of product characteristics A multicenter, double-blind, randomized, placebo-controlled study of the efficacy and safety of botulinum toxin type A in the treatment of glabellar lines J Am Acad Dermatol 46:840–649 Carruthers et al (2003) Double-blind, placebo-controlled study of the safety and efficacy of botulinum toxin type A for patients with glabellar lines Plast Reconstr Surg 112:1089 Fagien et al (2007) Patient-reported outcomes with botulinum toxin type A treatment of glabellar rhytids: a double-blind, randomized, placebo-controlled study Dermatol Surg 33:S2–S9 Harii et al (2008) A double-blind, randomized, placebocontrolled, two-dose comparative study of botulinum toxin type A for treating glabellar lines in Japanese subjects Aesth Plast Surg 32:724–730 Wu et al (2010) Botulinum toxin type A for the treatment of glabellar lines in Chinese: a double- blind, randomized, placebo-controlled study Dermatol Surg Dailey et al (2011) Long-term treatment of glabellar rhytides using onabotulinumtoxinA Dermatol Surg 37:918–928 Stotland et al (2007) Patient-reported benefit and satisfaction with botulinum toxin type A treatment of moderate to severe glabellar rhytides: results from a prospective open-label study Plast Reconstr Surg 120:1386 Carruthers et al (2004) One-year, randomised, multicenter, two-period study of the safety and efficacy of repeated treatments with botulinum toxin type A in patients with glabellar lines J Clin Res 7:1–20 24.25 Summary An overview of the products described in the previous paragraphs is given in Table 24.1, with information about class, association with lidocaine, company, and areas where they are commercialized 296 M Guareschi Table 24.1 Overview of the most common materials used in aesthetic medicine Commercial name Class Lidocaine Company Commercialization Chapter Azzalure (dysport) Botulinum toxin No Galderma Europe 24.1 Belotero basic Medium viscosity HA No Merz Pharma Austria, Germany, Italy, Russia, Switzerland, UK and USA 24.2 Belotero soft Low viscosity HA No Merz Austria, Germany, Italy, Russia, Switzerland, UK and USA 24.2 Belotero intense Medium viscosity HA No Merz Austria, Germany, Italy, Russia, Switzerland, UK and USA 24.2 Bocouture (Xeomin, Xeemin) Botulinum toxin No Merz Argentina, Austria, Belgium, France Germany, Italy, Mexico, Netherlands, Portugal, Russia, Spain, Sweden, UK and USA 24.3 Botox (Vistabex Vistabel) Botulinum toxin No Allergan Europe, USA, Asia 24.23 Emervel touch Low viscosity HA No Galderma Europe 24.4 Emervel classic Medium viscosity HA With and without Galderma Europe 24.4 Emervel deep Medium viscosity HA With and without Galderma Europe 24.4 Emervel volume High viscosity HA With and without Galderma Europe 24.4 Emervel lips Medium viscosity HA With and without Galderma Europe 24.4 Dysport Botulinum toxin No Medicis USA 24.1 Glytone filler Low viscosity HA No Merz Pharma France, Italy, Netherlands, Belgium, Luxembourg, Spain and Portugal 24.5 Glytone filler Low viscosity HA No Merz Pharma France, Italy, Netherlands, Belgium, Luxembourg , Spain and Portugal 24.5 Glytone filler Medium viscosity HA No Merz Pharma France, Italy, Netherlands, Belgium, Luxembourg, Spain and Portugal 24.5 Glytone filler Medium viscosity HA No Merz Pharma France, Italy, Netherlands, Belgium, Luxembourg, Spain and Portugal 24.5 Hyacorp H 1000 Macrofiller No Bioscience GmbH Europe, Japan and Middle East 24.6 Hyacorp H/S 500 High viscosity HA No Bioscience GmbH Europe, Japan and Middle East 24.6 Hyacorp L Hight viscosity HA No Bioscience GmbH Europe, Japan and Middle East 24.6 Hyacorp face Medium viscosity HA No Bioscience GmbH Europe, Japan and Middle East 24.6 Hyacorp lips Medium viscosity HA No Bioscience GmbH Europe, Japan and Middle East 24.6 Hyacorp fine Low viscosity HA No Bioscience GmbH Europe, Japan and Middle East 24.6 Ephyal Low viscosity HA No Bioscience GmbH Italy, Russia, Ukraine 24.6 Juvederm Hydrate Low viscosity HA No ALLERGAN Europe 24.7 Juvederm ULTRA Medium viscosity HA Yes ALLERGAN Europe 24.8 Juvederm ULTRA Medium viscosity HA Yes ALLERGAN Europe 24.8 Juvederm ULTRA Medium viscosity HA Yes ALLERGAN Europe 24.8 Juvederm ULTRA SMILE Medium viscosity HA Yes ALLERGAN Europe 24.8 Juvederm VOLBELLA Medium viscosity HA Yes ALLERGAN Europe 24.9 Juvederm VOLUMA Hight viscosity HA With and without ALLERGAN Europe 24.10– 24.12 (continued) 24 Products 297 Table 24.1 (continued) Commercial name Class Lidocaine Company Commercialization Chapter Juvederm VOLIFT Medium viscosity HA Yes ALLERGAN Europe 24.13 Haequo Medium viscosity HA No Genethia Europe 24.13 Haequo plus Medium viscosity HA No Genethia Europe 24.13 Macrolane VRF 20 and VRF30 Macrofiller No Q-med a Galderma division Europe 24.14 NEWEST Low viscosity HA No MASTELLI SRL Europe and Russia 24.15 PLINEST Polynucleotides No MASTELLI SRL Europe and Russia 24.16 PLINEST fast Polynucleotides No MASTELLI SRL Europe and Russia 24.17 IALEST Low viscosity HA No MASTELLI SRL Europe and Russia 24.18 RADIESSE Calcium Hydroxylapatite No Merz Pharma Europe (Austria, Belgium, Bulgaria, Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxemburg, Malta, Netherlands, Norway, Poland, Portugal, Romania, Russia, Slovakia, Spain, Sweden, Switzerland, Turkey, UK and Ukraine), Asia/South Pacific (Australia, Hong Kong, Korea, Malaysia and Taiwan), Africa (Egypt, South Africa and Tunisia), Latin America (Argentina, Brazil, Colombia, Panama and Chile), Middle Est (Iran, Israel, Jordan, KSA, Kuwait, Lebanon, Oman, Qatar and UAE) and North America (Canada, Dominician Rep., Mexico and US) 24.19 Restylane Medium viscosity HA With and without Q-med a Galderma division Europe and USA 24.20 Restylane Perlane Medium viscosity HA With and without Q-med a Galderma division Europe and USA 24.20 Restylane SubQ Hight viscosity HA With and without Q-med a Galderma division Europe and USA 24.20 Restylane lip Volume Medium viscosity HA Yes Q-med a Galderma division Europe and USA 24.20 Restylane Refresh Medium viscosity HA Yes Q-med a Galderma division Europe and USA 24.20 Restylane Vital and Vital Light Low viscosity HA Yes Q-med a Galderma division Europe 24.21 Surgiderm 18XP Low viscosity HA No Allergan Europe 24.22.1 Surgiderm 24XP Medium viscosity HA No Allergan Europe 24.22.2 Surgiderm 30XP Medium viscosity HA No Allergan Europe 24.22.3 Vistabex Vistabel (Botox) Botulinum toxin No Allergan Europe, USA, Asia 24.23 Xeomin, Xeemin (Bocouture) Botulinum toxin No Merz Argentina,Austria, Belgium, France Germany, Italy, Mexico, Netherlands, Portugal, Russia, Spain, Sweden, UK and USA 24.3 .. .Injections in Aesthetic Medicine Mario Goisis Editor Injections in Aesthetic Medicine Atlas of Full-face and Full-body Treatment 123 Editor Mario Goisis Maxillo-Facial and Aesthetic. .. techniques in order to increase beauty Beauty is the key concept: the use of aesthetic surgery and medicine must not be in contrast with this principle, also in case of restoring or to maintaining youth... with paraffin injections were outlined in 1911 by Kolle [4], who described inflammation, infection, embolism, and yellowish skin plaques at the site of the injection In the following years, the