Hyaluronic Acid (HA) fillers help aesthetic practitioners achieve a younger look in their patients. Definisse®filler by RELIFE, part of the Menarini Group, is a new portfolio of HA fillers that is changing the course of anti-ageing treatment in India. Aesthetic Medicine brings in subject matter experts to discuss the various facets of the clinical use of Definisse ®Fillers and its XTR Technology.

A ccording to a study by Research and Markets, the Indian Hyaluronic Acid-based dermal fillers market is expected to grow at a CAGR of 8.5 per cent during the forecast period of 2019-2025. Rising disposable income, high proportion of middle-aged people is one of the major factors for the growth of the market, along with increasing awareness of the cosmetic procedures in developed and emerging economies in the region.

Technology is key to the success of HA fillers, and Definisse®filler by RELIFE, part of the Menarini Group, is ahead of the game, thanks to its eXcellent Three-dimensional Reticulation (XTR™) technology, which is based on a controlled three-step process to achieve a stable and long-lasting filler. Its integrated ‘3R approach’ – REsurface, REstore and REshape allows practitioners to deliver natural looking results for patients seeking anti-ageing solutions. The range of products under the Definisse umbrella include Definisse Core Filler, Restore Filler, Touch Filler and Hydrobooster. It is important to know the manufacturing process to better understand the technology, the rheology, and clinical efficacy of the product. According to Giovanni Salti, MD, Aesthetic Surgeon, Italy, a controlled fracturing step is aimed to obtain HA fragments of a broad molecular weight starting from a premium quality raw material. In this process, these long chains are fragmented, thanks to a controlled thermal process allowing it to fragment the original long chain to shorter HA chains. The control of the temperature will enable the manufacturing process to control the length of the HA chains, obtaining two ranges of molecular weight.”

“The objectives of obtaining a stable and elastic matrix are to achieve low extrusion force and better-controlled injection, together with effective filling and more durable volumes. Finally, a highly efficient purification process allows RELIFE to reduce the amount of free BDDE(1,4-butanediol diglycidyl ether),” he adds. The fillers have also been tested for rheology, cross-linking degree and cohesivity.

According to a report in IMCAS, “Having a high G’ is the distinct and important feature of Definisse Filler, since the main volumisation and lifting strategy is based on a deep injection under the SMAS layer, which requires high G’ gels to support the tissues and modulate muscle activity.”

Dermal fillers have also proved to be a good supplement for thread lifts in combination treatments designed specifically to treat anti-ageing concerns. Together, Definisse®fillers and threads are a potent combination that can defer the need for surgery or altogether eliminate it. As per a report in the Journal of Cutaneous and Aesthetic Surgery, the bioabsorbable barbed suspension double-needle threads work as a minimally invasive alternative for skin repositioning. “When compared to surgical face lifting, use of these threads requires reduced procedural and recovery time, no general anaesthesia, confers immediate patient satisfaction, with no cutaneous incisions and no apparent scars, and is more tolerable.”

The Definisse double-needle threads are absorbable, monofilament, suspension barbed threads of synthetic origin with convergent bidirectional spines. When the thread is pulled, an angled path creates a compression of the tissue located between the two sides of the angle that increases the pressure of the barbs on soft-tissue connective fibres.

It is the primary job of the threads to transpose the soft tissue into an elevated position, thereby creating a more youthful look. When this procedure is aided with fillers, there is a drastic improvement in facial contours, resulting in a fuller and more contoured facial structure. Given the rising popularity of HA fillers and the success rate of the combination of fillers and threads, we spoke with key opinion leaders from the aesthetic fraternity to understand this line of treatment better.

“A combination of threads and fillers gives a better aesthetic result than a standalone procedure.”

Dr Monisha Kapoor (MBBS, MS, MCh), Director and Chief Operating Surgeon, Dr Monisha Kapoor Aesthetics, New Delhi.

Many a time the planning for fillers depends upon the choice of patients, because a lot of patients don’t want to undergo surgery. They want something that will make them look fresh, maybe a little better than their current look but certainly not a drastic change. So, threads and fillers are ideal for any client who does not want an aesthetic surgery.

So, how do I go about it? I first see the texture of the skin to decide whether the threads are going to give better results or the filler. It is not a choice between threads and fillers, it is what will give the best aesthetic result for that particular client.

Sometimes I use both fillers and threads to give a certain kind of result for the client. I believe a practitioner should not be fixed in using either of these.

You can also recommend both of these to create the desired look. The goal is to give an aesthetic result to the client that he or she can appreciate when they look into the mirror. According to me, a combination of threads and fillers gives a better aesthetic result than a standalone procedure.

Regarding the choice of the patient - how do I choose my patient for threads? The skin has to be flexible, flexible and ageing. However, it doesn’t have to be to a grade where threads cannot give a good aesthetic result. My clients for threads are between the age group 40 to 60 with good quality skin with a slight tightness that is required to give nice contours to the face, and a little bit of jawline that can be lifted with the threads.

“A person who needs repositioning of the facial fat pads in the jawline and midface, is a potential candidate for threads as well as fillers.”

Dr Rasya Dixit MBBS, MD -Dermatology, Dr Dixit Cosmetic Dermatology Clinic, Bangalore

How to identify patients for threads and fillers?

Most of the time, especially when it comes to injectives like fillers or threads, patients may not present or understand that they need this procedure. They come to us a lot of times saying ‘I look dull’ or ‘my skin looks dull’ or ‘my friends tell me I look tired’ or ‘I look sad’. So, this is a very important thing for a dermatologist to understand what they are trying to tell you is an emotion but you need to understand it in the types of facial features.

Usually a volume loss, which is very commonly seen after 25 years of age in the facial features of a woman or a man, is the facial fat loss in the under eye area. This is a normal sign of ageing. It is more common for Indians who lose weight and lose fat in this area, which makes the under eye hollow or the under eye darkness more prominent. This in turn makes the patient come to you for dark circle treatment, or they say they look like they haven’t slept well or they look ill. So, instead of trying to correct it with chemicals or facials, aesthetic practitioners should educate the patient that they have a volume loss, which is actually contributing to the appearance of the dark circle or the tired look. In such situation, Hyaluronic Acid fillers are very good option to address the volume loss.

Another thing that is common and is a big fad now is the rapid loss or gain of weight, because of various fad diets that people are doing. When they put themselves on any of these diets, the patients start to see facial sagging, which appears as more pronounced marionette lines around the mouth and the prominence of jowls as well as an ill-defined jawline. The significance of the lower half of the face is that it is a signature of the youth - atight lower half of the face. A person who needs repositioning of the facial fat pads in the jawline and midface, is a potential candidate for threads as well as fillers.

“Combination of Definisse threads and fillers have proved useful in symbiotically treating the mild to moderate signs of ageing.”

Dr Shrilata Trasi MD, DVD, DDV and FCPS (Mumbai), Dermatologist, Dermatosurgeon, Cosmetologist and Laser Specialist at Dr Trasi clinic and La Piel Skin Clinic

How does the combination treatment of Definisse Threads and Fillers work?

When a potter moulds a pot from clay, he gives it a shape first. Then he paints it with various colours to define the pot into a beautiful piece. Similarly, anti-ageing treatments or face rejuvenation treatments are like art. No single rule persists in this and every patient’s face is unique to mould by the aesthetic physician. Also, different colours of treatments help them a create a beautiful face.

Face tightening treatments involve treating multiple layers of the skin. The epidermis and dermis determine the texture of the skin. The fat pads determine the contouring of the face. While the skeletal system supports the overlying layers of the skin. Thus, while rejuvenating the face adequate attention must be paid to all these layers. Successful rejuvenation requires a combination of minimally invasive modalities to fill dents and hollows, resurface the lines and wrinkles and lift the sagging fat pads.

Definisse threads are absorbable, monofilament barbed, double needle threads meant for repositioning of the sagging skin. The thread contains poly L-lactide-co-ecaprolactone, which is used when tissue support is required. These threads intend to lift the skin to support and reposition the tissues with their mechanical action. They also help in revitalising the skin with the help of the fibrosis along the thread.

These fillers not only help in volumising the irregularities on the face but also help in lifting the soft tissue, giving a more natural looking results on the skin. As a person ages, some fat pads atrophy leading to flattening of the facial contours. Fillers are an excellent alternative for such deflation.

The combination of Definisse threads and fillers have proved useful in symbiotically treating the mild to moderate signs of ageing. The threads help in lifting the sagging skin while fillers help in contouring the skin.

Hyaluronic Acid fillers, over the period of time, have become the treatment of choice for soft tissue dermal corrections.

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