As part of the Let’s Talk Series by Aesthetic Medicine India, Dr Narmada Matang, Dermatologist, Neo Skin Aesthetics answers Dr Divita Bhuraria, Consultant Dermatologist, Bethany Hospital and Disha Skin & Laser Centrequestions about Restylane fillers by Galderma, the technology used in various offerings of the portfolio, particularly Restylane Defyne, and their role in facial rejuvenation, in the light of two case studies.

T he virtual discussion on ‘Personalisation with Restylane Defyne’ began with Dr Narmada Matang going through different Restylane dermal fillers, and NASHA and OBT technologies. She also shared her experience of using fillers in the past visa-vis using them now with better control over the desired effect, longevity and a rejuvenating effect.

“We are going to be touching upon Defyne and I like to use this product in the mid face, when you are looking at the cheek volume loss, and the perioral area, specially in females above 40. We have a very good case, which we will be discussing. For the marionette lines, I like to use the cannula and just do a little bit of subcision before. What is amazing with this product is that with a very little amount, you get such refreshing and good volumising of the tissue that you are dealing with.”

Dr Bhuraria brought up the valid question of how aware are patients today about fillers. Dr Matang replied, “Not only are the patients aware, they are also asking the right questions and the fact that we have so many options now, patients are actually choosing from the various products that are available. They are asking about complications and are open to trying out a new indication.”

She added that in terms of educating the patient, information is available through booklets and on the Internet, even Instagram has details about the entire procedure. It is, however, important to understand the patient’s psychology. Fillers are not an emergency procedure, don’t be in a hurry to use them, she suggested. “Do it only when your patient is fully convinced.”

Speaking about AHA and G,’ Dr Matang said, “‘G’ is defined by its viscosity and the firmness of the gel. Now Restylane has come up with a clear demarcation on NASHA and OBT. Higher the ‘G’, lesser the flexibility and more the firmness. So, suppose I am dealing with thick male skin with a heavy lower face. If I use a robust product on thin skin, it will stand out and the patient will come back. You can instead choose the option of softer ones from the OBT portfolio.”

Case Study 1

Patient profile: 42-year old male with diabetic history

Concerns: Premature ageing - sunken cheeks and mesolectal folds

Dr Matang’s synopsis: Checking if diabetes is under control and understanding his current medication

Diagnosis

• Good thick male skin

• Good amount of oiliness; it is well moisturised

• Mid-cheek volume loss, giving him a sunken kind of look

Course of action

• Volumising the midcheek, which is not common in Indian patients

• My choice of product here is from OBT - either Volyme or Defyne with a cannula

• Go deep into the middle cheek pad

• Just below it, deposit the material, maybe fan it out a little

• To treat the tear trough, I would choose Restylane

• Once you have addressed these two areas, you will see the fold also improving

• You can look at pyriform fossa later

• The nasolabial fold will correct a lot once you have done the cheek and the tear trough

Treating temporal hollowing with fillers

“In this case, I would first do the midface. Males tend to have good temporal muscle, and I would plan that later.”

Treatment

“The beauty of Restylane products is that you can see a good amount of difference with the use of limited products. But we have to consider that it is thick male skin that we are dealing with and a choice that I put forth is OBT. So, about 1 ml on both the cheeks, and 0.5 in the tear trough area with Restylane. In total, I would use 3 ml. I would give him a couple of weeks for the product to integrate with the tissue.”

Effect of comorbidities

“It’s important to clarify during consultation that the duration of the product and the results will be influenced by other medical conditions. Do not commit how long it will last, generally give an arbitrary timeline. You don’t know what the stages of diabetes are, although it is controlled. There are so many factors that will be involved in biodegradation of the product - lifestyle, stress value, hypertension, or thyroid. Generally I would say anywhere between 9-12 months or a follow up in 6-8 months as well as a touch up.”

Case Study 2

Patient profile: A 62-year-old female on medication for epilepsy

Concerns: Trauma scar on the forehead

Dr Matang’s synopsis:

“This is a very interesting and challenging case. She is on anti-epileptic drugs, and our apprehension is about lidocaine. All drugs come with lidocaine. The booklet says 3mg of lidocaine per ml.”

“Lidocaine is a relaxing agent and will actually help relax the patient. However, a large dose, about 15 mg, can trigger epilepsy. You will inject 15 mg if you are using more than 8-10 syringes. Another thing that can trigger an epileptic attack is the pain. If you counsel your patient while you are injecting and use cream or local application anaesthesia, the patient will remain calm. And if you have control over the ml of injections (3 mg per ml of lidocaine), you are in a safe zone. Discuss with your patient and plan your injection in a calm confident manner.”

Treatment

“I would refrain from injecting anything in the glabellar complex. I would counsel her on whether the trauma scar bothers her much. I would look at the heaviness on the cheeks. If we give her a lateral lift, with Restylane Lyft, and use Defyne in the perioral area. This will take the attention away from the scar and will improve the tear trough a little bit as well.”

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