The Steering Committee
Alastair Carruthers, MD, FRCP(C)
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Ask the Expert
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Q. |
Manufacturer instructions pertaining to fillers recommend storing the product at 77ºF. At what point do fillers lose their integrity if stored in temperatures >77ºF? Along those same lines, is integrity compromised when the product is used for a previous occasion (ie, 6 months prior) and saved for touch-ups?
Response by
Kevin C. Smith, MD,
FRCP(C) |
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A. |
I am not aware of any filler for which it is suggested that the product be stored “at 77ºF. Which filler are you referring to?
In general, manufacturers advise storing fillers within a specified temperature range, or (outside the United States) simply give common sense advice to store the product at “room temperature.” As a practical matter, storing a filler at a temperature higher than body temperature (say, 98ºF) might accelerate decomposition or dehydration of the filler. The upper limit on safe storage temperature will be different for each filler, and will also vary as a function of the length of time that the product is stored at a given temperature. (For example, product that might tolerate 30 minutes at 50ºC in the trunk of your car might break down completely if stored at that temperature for 2 weeks if you left your car in an airport parking lot.) Freezing a filler is also a bad idea, because freezing and thawing might cause disruption of the filler or its vehicle system, or even rupture the syringe.
ArteFill®/Artecoll®/ArteSense™* (polymethylmethacrylate microspheres) are to be stored at 2 to 8º C and brought to “room temperature” before use. Most other commonly used fillers (eg, Juvéderm™ Ultra [hyaluronic acid], Restylane® (non–animal-stabilized hyaluronic acid], Radiesse® [calcium hydroxylapatite microspheres]) should be stored at “room temperature.” What is “room temperature”? This has variously been defined as “the temperature at which red wine should be served (60–65ºF), or more commonly as “68 to 72ºF” or “around 20ºC.” (http://www.answers.com/topic/room-temperature?cat=technology. Accessed July 13, 2008).
Storing part of a syringe for future use on a patient has a number of risks:
1. The product could become contaminated during first use or during storage, and pathogenic organisms could interfere with the properties of the product or cause infection or inflammation when injected.
2. If the manufacturer specifies that the product should be stored at something like “18 to 24ºC” but you consider it prudent to refrigerate partially used syringes, you will be in a bind. What will you do, and how will you explain your decision if (when) something goes wrong?
3. If you are storing syringes for several patients and there is a mix-up, it is possible that a patient could be exposed to pathogens, including but not limited to, human immunodeficiency virus, herpes simplex virus, or hepatitis. How do you propose to explain this small but real risk to your patients?
*Not available for use in the United States
Response peer reviewed by Christopher B. Zachary, MBBS, FRCP
Response date: July 2008
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Q. |
What is the appropriate dose of hyaluronidase injected to dissolve excess hyaluronic acid (HA; eg, Restylane® or Juvéderm™ Ultra)?
Response by
Kevin C. Smith, MD,
FRCP(C) |
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A. |
Assuming that you are using a commercial preparation like Vitrase® (hyaluronidase for injection) and that you want to completely eradicate the deposit of HA, a reasonable rule of thumb would be to inject 1 unit of hyaluronidase for every 0.01 ml of HA you are trying to eliminate. (So, if you estimate that there is about 0.1 ml of HA in the target area, injecting 10 units of hyaluronidase should do the trick.) This can be repeated in 1 week if necessary. I find it best to inject hyaluronidase using a BD-II, 0.3-ml syringe with 31-gauge needle, as this is very fine and causes the least possible amount of discomfort. The 2-mm barrel diameter of this syringe also provides exquisitely fine control of the flow rate when injecting.
Response peer reviewed by Christopher B. Zachary, MBBS, FRCP
Response date: July 2008
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Q. |
Is it safe to combine a light chemical peel after performing a light intense-pulsed light (IPL) treatment for photorejuvenation during the same visit?
Response by
Kevin C. Smith, MD,
FRCP(C) |
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A. |
Without knowing the details of what you are proposing, I can’t give you safe, useful advice. What equipment and parameters are you proposing to use for “a light IPL treatment for photorejuvenation”?
What kind of “light chemical peel” are you proposing to do? (What skin prep, peeling agent, duration of application, and post-procedure care?)
Finally (I am not trying to be pedantic here), it is never “safe” to do anything—it is more accurate to think and speak in terms of “various degrees of risk.” The level of risk is a function of many things, including the technology being used and the skill of the operator.
Both IPL and chemical peels can cause similar problems (eg, blistering, swelling, reactivation of herpes simplex).
Response peer reviewed by Christopher B. Zachary, MBBS, FRCP
Response date: July 2008 |
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Q. |
What are your thoughts regarding the addition of 0.2 cc of lidocaine to thin Radiesse® (calcium hydroxylapatite microsphere implant) before injecting?
Response by
Kevin C. Smith, MD,
FRCP(C) |
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A. |
If all you want to do is thin the product out, why use lidocaine? Why not just use normal saline?
In fact, what most people use lidocaine for is not to thin the product but to provide anesthesia to reduce patient discomfort.
Issues to consider when adding lidocaine to fillers include:
1. Strict sterile procedures must be followed to prevent contamination of the filler.
2. Proper record keeping must be done so that you will know how long the product has been stored after lidocaine has been added.
3. How do you intend to mix the lidocaine with the filler? You can’t just add lidocaine to the filler syringe—once it is in there, you have to make sure it is adequately mixed throughout the filler material. You have to find a way to do this that will not degrade the vehicle system or the filler itself. Each filler has its own properties, and these have to be taken into account to avoid trouble.
A number of dermatologists, plastic surgeons, and some others appear to have found ways to achieve the above objectives with Radiesse and other fillers, but detailed descriptions of the procedures, their rationale, and long-term patient follow-up have not been published.
Response peer reviewed by Christopher B. Zachary, MBBS, FRCP
Response date: July 2008
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Q. |
Approximately 4 years ago, my patient was injected with a filler (possibly polymethylmethacrylate microspheres [PMMA] implants [ArteFill®]) in Venezuela and is unhappy with the results; the contour is smooth, but the patient’s lips are quite large and unsightly. Is there any nonsurgical technique that can be done to improve her lips or to remove the injected product?
Response by
Kevin C. Smith, MD,
FRCP(C) |
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A. |
To begin with, your patient is unlikely to have been injected with ArteFill, for the simple reason that the product was not on the market 4 years ago. Moreover, ArteFill is not marketed for use outside of the United States.
Before discussing treatment with such a patient, I would insist on knowing what I was treating. This means a small biopsy, both to identify the product and to rule out inflammatory processes. There are a variety of PMMA-based products (some of them quite crude) on the market outside of the United States and, in addition to that, there are myriad other non-PMMA fillers. Routine histology, polarized microscopy, and perhaps also electron microscopy should help to give you some idea of what you are treating.
After obtaining the biopsy results, you might consider injecting very small amounts of Kenalog® (triamcinolone acetonide) 10 mg/ml (perhaps 0.02-ml aliquots, using a BD-II, 0.3-ml syringe with 31-gauge needle.) These injections could be perhaps 1 cm apart and repeated at 4- to 8-week intervals several times, with careful standardized photography to monitor the patient’s progress. The injection sites should be marked and photographed, and subsequent injections should be made between the previous set of injections, so as to evenly distribute the atrophic effect of the Kenalog.
Response peer reviewed by Christopher B. Zachary MBBS, FRCP
Response Date: July 2008
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