When discussing how natural the volume appears on your cheek area, depends more on the location and quantity of where the filler is injected, and not dependent on the brand of the filler.

If I have a brand X paint and brand Y paint, if the painter paints a beautiful landscape with either brand of paint, the painting will be just as beautiful with either brand X or Y. Let's say that Brand X has UV protection built into the paint so the color doesn't fade when exposed to UV rays from the sunlight. Even though both paints start off equally beautiful, if both paints are hung on a wall exposed to direct sunlight Brand X's color will stay more vivid and colorful, while Brand Y's colors may fade without the extra UV protection added to the paint.

You can think of this analogy when discussing fillers. If you search before and after photos on the internet for cheek filling, you will find good and bad results for any brand of filler. This should dispell any myth that the results are linked to any particular brand of filler. If you would look good with 1-2 cc's of Voluma, but the injector injected you with 4-5 cc's of Voluma (which would make you look weird and puffy) would you look better with 1-2 cc's of Restylane or Perlane or 4-5 cc's of Voluma?

Location and Amount

When it comes to injecting fillers for anything other than filling lines, it is really a type of live sculpting. When injecting fillers to the tear troughs, for example, patients do not only look straight, but also up and down. I will take my time to fill my patient at different eye positions or for the cheeks smiling and not smiling to see how the volume moves. I also will fill in increments. Between each increment of filler, the patient and I will check how the filler looks and moves with the face, and look for any spots which may be missing. With Juvederm Voluma, Restylane-L or Perlane-L, there is lidocaine (a numbing agent) added to the filler, so after the first increment of filler is added, the patient is numbed in the areas to be volumized without any additional injection of lidocaine which may distort of artificially make the cheeks or tear troughs more filled than it actually is. Additional increments of filler do not hurt since the lidocaine has kicked in and it allows the patient to focus on communicating with me on the results that they want. One good result for one patient may be an overfilled appearance for another patient. I don't assume that I know exactly what the patient wants, but I will guide them during the filling process to avoid any pitfalls or inject areas which may look weird or bad. But in general, I feel most of my patients have a very good feel for where they want the filler and when we are finished I see the result that they were going for in their mind's eye, which is not 100% clear in my mind before we start, but may be only 80% clear.

This type of filling take much longer than filling a simply smile line wrinkle, and is a process. However, the patient satisfaction is high, since the patient and I as a team fill the areas of concern to the patient's liking while constantly checking to make sure the filler is smooth and moves naturally with each increment. Typically filling sessions can take at least 30-60 minutes or longer depending on how much filler is used. My patients who have had fillers with other doctors often comment how the filler session seems to be a completely different method than the one's that they have had in the past.

Brand of Fillers

Juvederm Voluma is the newest filler on the market which uses Hyaluronic acid and is FDA approved specifically for Cheek augmentation. Restylane and Perlane are FDA approved for smile lines or Nasolabial folds. Restylane is marketed for smile lines to only last 4-6 months, before additional filler is added. Perlane is the big brother version of Restylane. The hyaluronic acid filler particles are bigger but the concentration of the hyaluronic acid is the same. Juvederm Ultra and Juvederm Ultra Plus would be analogous to Restylane and Perlane, except they kept the same name Juvederm Ultra and added a Plus to the thicker version. For Restylane, they changed the name to Perlane even though they are the same filler with bigger particles.

Perlane is designed to be injected deeper for deeper smile lines, with some Restylane injected closer to the surface of the skin directly into the wrinkle (intradermal injection). Since Perlane is has bigger particles of hyaluronic acid and is firmer than Restylane, it is also good for cheek augmentation. However, there are no FDA studies to show how long Perlane lasts in the cheeks as compared to Voluma. The Voluma marketing states that it lasts up to 2 years and in their study, ~60% is still left at the 2 year mark in their study subjects.

For Restylane, in the marketing material it states Restylane only lasts 4-6 months, but if used off-label in the lower eyelid area, it seems to be lasting 12-18 months. I suspect that Restylane may actually still be in the smile lines vicinity at the 6 month mark, but may have been pushed above and below the line after repeated smiling. Other patients report that their Restylane in the smile lines also lasted about a year, before it dissipated. Without side by side comparison of Perlane versus Voluma, or at least a 2-3 year study for cheek augmentation using Perlane, we cannot say how long it lasts in the cheeks, but I think it lasts at least 12 months. If we were to quantitatively measure how much is left after 2 years, I suspect it would compare favorably to Voluma.

Cost

Juvederm Voluma's MSRP as suggested to us by our Juvederm Reps is $1100 to $1600 per 1cc syringe. In the study the amount of Voluma used was 1.2 mL to 13.9 mL, with a median volume of 6.6 mL. This means the typical patient was using 7 syringes of Voluma to get optimal results. In comparison, tear troughs typically only need 1 cc of Restylane to look good +/- 0.5 cc's.

Although I love the fact that the FDA study and the approval for cheek augmentation, I worry that many of my patients may not be willing to spend that much money per cc of volume in the cheeks. Even rounding the price down to $1000 per cc of Voluma will cost the patient $6-7000 to get an optimal result, and most likely they may stop before they reach the optimal result. On the high end, the same 6-7 cc's would cost $9600 to $11,200. The selling point is that the Voluma may not need to be refilled for about 2 years, but if 60% is left at 2 years, I suspect patients may be returning at around 18 months as the optimal results begin to fade. The touch ups would end up being a fraction of the original session. If 60% of 6.6 cc's is left after 2 years, then the patient still has 4 cc's to start and would be add back another 2.6 cc's plus any facial fat loss from natural aging over the 2 years.

In comparison, Perlane costs $750 in our office and $1300 for a 2 cc syringe for patients who are more hollow and clearly need more filler. 6 cc's of Perlane would cost significantly less than Voluma. If the average patient would need 6 cc's for an optimal result, I would prefer to us Perlane and be able to add a full 6 cc's instead of stopping after 3-4 cc's using Voluma if their budget does not allow it.

Great question, I hope this covers the topic with great depth.

Good luck on your upcoming filler session.

Best,

Dr. Yang

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