Voluma: FDA Approved

The newest filler in the US is Voluma and it is different than other fillers. Its arrival means that injectors have one more way to address facial aging and that they need to understand how to use this new product.

Voluma is a highly crosslinked hyaluronic acid used to treat mid facial volume loss. The fact that it is a hyaluronic acid means that it is transparent and that it can be digested in the event that placement is less than optimal.  Because it is highly cross linked, it is possible to attain long term corrections that last for up to two years.

Knowing where to inject the product is a little more complicated than other products because Voluma is intended to reside in the periosteal region according to the package insert. In reality, it is reasonable to fill concave defects in the deep dermis in an effort to get the skin to have a more rounded appearance.

When I inject the lower mid face, I tend to fill the defects while everting the skin with my non dominant hand. My goal is to try to achieve the volumetric correction that restores the skin to a more round, youthful appearance. It is great when a patient is able to bring a photo from when they were younger and I can see what they looked like.

When I train people to inject Voluma, I divide the face into three regions that span the lower eyelid region, the zygomatic arch and the lower malar region. When injecting from the lateral aspect of the lateral canthus, I drop a line down and this is the initiation point for my zygomatic arch injections. This region should be injected just above the periosteal plane in a vector that moves both superior and posterior. For the infraorbital region, I would recommend also injecting on the periosteal plane and to use small eg 0.5 mL per side of filler so that the person does not have a big, disproportionate anterior face.  The submalar region is the area that I tend to inject in the deep dermal plane to inflate this area back to youthful proportions.  Each of these zones is defined in the training video mandated by the company before one can inject the product.  In general, volumes of between 2-4 mL will help provide a great correction for most patients.


During the clinical trials, changes were noted in both the nasalabial creases as well as the tear trough despite the fact that neither was injected. Significant changes in the nasalabial crease occurred because the lifting provided by this highly cohesive gel raised and inflated the crease.  This makes intuitive sense because the crease does not occur due to volume loss in that linear area but rather because the skin has sagged as the area has descended and adjacent structures have lost volume.  The inflation seen in the tear trough region is also easy to understand when considering the anatomy of the region. Inflating the malar region will help to lift the infraorbital crease up and out. 
As with all new products, the ultimate use and areas that are amenable to treatment remain to be defined by clinical experience and phase IV trials. Voluma has the potential to open new areas to treatment in the correct patients. When injecting this product (or any new product) proceed gradually and revisit the anatomy of the region. Since the product has a longer duration than most, it is important to obtain proper placement and volumetric correction when injecting.

Kenneth Beer MD
Beer Dermatology

Voluntary Associate Clinical Professor in Dermatology, University of Miami
1500 North Dixie Hwy
West Palm Beach, Fl
33401
561-655-9055
www.palmbeachcosmetic.com


Injectables

According to ClinicalTrials.gov, Revance has recently completed a trial of a Botox based gel. This gel has been used in several centers to treat Crow's Feet. One obvious benefit of delivering a botulinum toxin with a gel is that it can get into the areas to be treated without a needle. This is a huge boon for people that fear needles and would otherwise like to be treated. Another possible benefit is that a gel may enable large parts of the body to be treated for sweating without multiple injections.

It is not clear from reports that are presently available how the gel will be used. Based upon what is known, it is likely that a patient will need to visit a physician and be evaluated. Following the consultation, it is possible that they will have the gel applied and wait while it is absorbed. It is not likely that the company would develop an "at home" version of this because of the need to have the product applied to precise areas.

For the gel to be commercially viable, the pricing would need to be comparable to injections. Although patients will likely pay extra for the comfort of a gel, if it is too much more expensive, they may stick with the existing delivery platforms.

The Revance product is not likely to be a threat to the injectable market. In fact, some have made the argument that it will increase the injectable market for Botox, Dysport and Xeomin because patients who otherwise might not have been interested in these products will be treated with a gel and want to see what the injectable type of product can do. As with Dysport, I think that the more discussions there are about the safety and efficacy of these proteins, the better off and the more people will understand how much research goes into them. People still come in to dermatology and plastic surgery offices afraid of these molecules because they erroneously think they are "Poison". Having another safe and effective treatment available will likely increase public knowledge and bring patients to the plastic surgeons and dermatologists who have the skill to inject or apply them.

Kenneth Beer MD
Beer Dermatology

Voluntary Associate Clinical Professor in Dermatology, University of Miami
1500 North Dixie Hwy
West Palm Beach, Fl
33401
561-655-9055
www.palmbeachcosmetic.com