In spite of a stalling economy and declining revenues from aesthetic practices, new dermal fillers are still entering the market at a heightened pace.

Aesthetic practitioners are faced with the challenge of marketing repetitive treatments to their existing patients, as well as seeking out new patients who desire dermal fillers.

We asked four leading aesthetic practitioners from different specialties who practice in major markets in the United States to share their thoughts on this changing area of cosmetic medicine.

What shifts do you predict occurring in the US market as new fillers arise and more products get FDA approval?

Steven Fagien, MD, FACS: The current trend is more of a duplication rather than innovation. Due in a large part to the huge success of Restylane and then with Juvéderm, most companies are looking for other hyaluronic acid products to add to their product portfolios.

Yet, the hyaluronic acid market is slowly saturating. And unless products can prove equivalence or superiority to the existing leaders, it will be an uphill battle for these newer introductions—despite an exploding market for fillers, as well as the growth of noncore injectors.

The addition of agents, such as lidocaine, to improve patient comfort will have some advantage. Eventually, most of the agents will offer this option. Many clinicians already add this agent to products.

I think everyone is looking in the same direction, and what will be one of the triumphs in the filler market in the US—and even worldwide—is a product that is safe and effective in the superficial dermis. Hyaluronic acid has not been a large success here and it will be more likely a collagen-type substance with improved longevity.

Haideh Hirmand, ME, FACS: We are seeing more choice in the market, but also more consumer confusion. There is increased competition, but I am not sure this will affect prices of products.

Mark G. Rubin, MD: With more products coming out, we are able to offer better results to our patients. In addition, with longer-lasting products, we are seeing more new “filler naïve” patients who are now interested in being treated.

I think that for every patient we see who is willing to be treated every

6 months with a filler, there must be at least 10 more patients who would be willing to be treated if they could have their results last 2 years.

Ira Papel, MD, FACS: As the market matures with various new products, we will likely see groups of products with different applications.

For example, we will have products designed for 6- to 9-month duration in superficial tissues (Restylane/Juvéderm Ultra), thicker materials for deeper implantation and intermediate duration (Radiesse/Perlane/Juvéderm Ultra Plus), and deep fillers for wider soft-tissue augmentation (Sculptra).

The role of permanent fillers (ArteFill) will slowly expand as safety becomes documented. Patients and physicians will choose what fits their needs, and combinations of fillers may be used.

How do you evaluate each new filler as it gets introduced? What are the three key criteria you look for?

Steven Fagien, MD, FACS, is an oculoplastic surgeon in private practice in Boca Raton, Fla. He is an expert in aesthetic eyelid plastic surgery and has been recognized for his work with injectable, soft-tissue augmentation agents. Fagien serves as a member of Allergan’s National Education Faculty and is co-director of the International Plastic Surgery Education Initiative.

Fagien: Safety and efficacy is always of primary importance. A main [criterion] also has to be the patient experience. Patients are looking for results without downtime, so minimal pain, bruising, and swelling become key factors. Finally, there is the value proposition—cost and persistence are the other key ingredients.

Hirmand Efficacy, safety, longevity are most important to me. I also consider where they fit into my practice and for my patients; and, finally, price point.

Rubin: The three most important criteria for all new fillers in my experience are safety, longevity, and efficacy.

Papel: As fillers are introduced, they must demonstrate safety, efficacy, and value for the patient, or they will fail in the marketplace. Each physician must review the scientific/clinical data and decide if the risk/reward ratio makes sense for [their] patients. I always ask myself if the new product will help me provide a better service for my patients. If not, then there is no need to proceed further.

How important to your practice and your patients is direct-to-consumer marketing? Is it driving more patients into your practice?

Fagien: I think that direct-to-consumer is driving patients to practices and is making these products “household names” that they are familiar with and become more comfortable with. I don’t find them necessarily a large driver to my personal practice, and this often depends on the sophistication of the consumer. Most of my patients have already made up their mind, and the direct-to-consumer hasn’t influenced them a great deal, except for education and giving them a greater comfort and familiarity with different products.

Hirmand I am not a fan of direct-to-consumer marketing, but we will wait and see how this trend will impact the market.

Rubin: Direct-to-consumer marketing has been fairly unimpressive in driving patients into my office, but I do think it has raised awareness among consumers that there are new products out there that they should look into.

Papel: It is hard to measure the effects of direct-to-consumer marketing by the filler manufacturers. Certainly, it does raise awareness about the products, and creates interest by patients in comparing products. Overall, this is a healthy process, as it encourages patients to ask us about safety and efficacy issues.

How long are patients willing to wait to get in for a filler treatment in your practice?

Fagien: My patients make their appointment for their next visit before they leave the office. Many have budgeted for particular treatments annually, and most have basically figured out how long their treatments last, depending on what (including volumes) they have had.

New patients can usually get into the office within a couple of months for an appointment for fillers. Understandably, some will not wait this long.

Haideh Hirmand, MD, FACS, is a clinical assistant professor of surgery at the Cornell-Weill Medical College/ New York-Presbyterian Hospital in New York City. Her practice focuses on aesthetic surgery with a special interest in eyelid/facial surgery and breast and body contouring. She conducts clinical research and has published and presented numerous scientific articles, the latest on eyelid surgery and the surgical management of the prominent eye.

Hirmand In New York, we try to get patients into the office within a month. We have found that up to 1 month is what they are willing to wait in general, but not more than that.

Rubin: Some patients will happily wait weeks to get in, whereas others will go elsewhere if they can’t be treated right away. You have to know your patients.

Papel: Patients generally wait until their fillers or Botox effects are fading before calling for an appointment. Therefore, more than a week wait will disturb them. We try to avoid this by scheduling routine filler appointments months in advance, at regular intervals. After a few injections, we can determine how long specific fillers will last for an individual patient so we can schedule them accordingly.

Can you identify any trends that you are seeing among your filler patients? Are they coming in less frequently? Are they turning to fillers in an effort to postpone facial surgery? Are they asking for fillers by brand name? Are they hopping from doctor to doctor?

Fagien: I see all of the above, yet in different proportions. Many filler patients are coming in less frequently, as the treatments seem to last longer with each additional session.

Some, on the other hand, are actually coming in more frequently, as they get used to the youthful, “full” look (lips, cheeks, lower face) and return far before the “tank is empty”—also another interesting trend/phenomenon.

Yes, many come for a nonsurgical alternative to facial rejuvenation, and I believe this has been a large part of [any product’s success]. Many come in asking for a “brand”; yet, if I believe another is more appropriate, I will tell them this, and they usually trust the recommendation.

There are always those patients that hop from doctor to doctor. I get this usually when they try to make an earlier appointment unsuccessfully, and then just try someone that “their friend goes to.”

I actually find this quite amusing at times and redeeming in some ways, as many of them come back saying they should have just waited.

Hirmand I definitely see patients who are trying different doctors at a time. Some have seen their faces change shape too much from too much filler use. They are now coming back to surgery.

At times, I think some noncore practitioners—and even some patients—push fillers too much to the detriment of facial aesthetics.

Patients are also definitely using fillers to postpone surgery, which can be very effective when it is done appropriately.

Mark G. Rubin, MD, specializes in facial plastic surgery with particular expertise in rhinoplasty and nasal surgery. This includes aesthetic and reconstructive problems of the face, nose, head, and neck. He also is an associate professor at Johns Hopkins University in Baltimore.

Rubin: Patients are definitely trying to stall longer with Botox and fillers before moving on to surgery. I think they have less of that fatalistic attitude that, “I just have to suck it up and go have surgery.” I think they are expecting better technology and less invasive surgical options in the near future, and that, until then, they want to try and hold out longer with nonsurgical options.

Papel: Patients are certainly delaying traditional surgery by using fillers in a judicious manner. Many are able to preserve a younger look for several extra years. Combined with good skin care, the effects can be impressive. In the end, though, fillers cannot replace the role of surgery to reverse the chronic signs of aging and gravity.

What is the average number of syringes you use in a single session? Has the number of syringes/products you use on each individual patient increased/decreased in the past 3 years?

Fagien: Most patients get two or more syringes, on average. Few of my patients just get one, and many get three syringes.

Many times, the products are used in combination, and it is not unusual for a patient to have two or three different fillers plus botulinum toxin. I believe the trend has been that patients have been getting a greater number of syringes per treatment over the past 3 years.

Hirmand My average treatment is two syringes, and that has increased slightly in my practice, based on patient demand and the superior results I can achieve by using more material.

Rubin: I don’t think I have an average patient, so I will use anywhere from 0.1 cc to 3 cc in a single sitting. I do think patients are using more products per visit than they did in the past. This is true because of [our] ability to correct more areas since we have different products to use (that is, thinner product for fine lines, hyaluronic acid or Radiesse for deep folds, and some facial contouring and Sculptra as well).

It is common for me to use two or three types of fillers on a single patient in one session. In doing so, I can give them a much better result than I could several years ago when we had fewer products to choose from.

Ira Papel, MD, FACS, is a board-certified dermatologist who currently practices at the Lasky Clinic in Beverly Hills, Calif. In addition, Rubin is an assistant clinical professor of dermatology at the University of California, San Diego. He is a specialist in skin resurfacing and has written multiple papers, book chapters, and a textbook on skin rejuvenation.

Papel: In an initial filler appointment, we may use two to three syringes to address nasolabial folds, tear troughs, or marionette lines. Lips are also commonly treated. At 6 months later, one or two syringes may be necessary.

As the patient becomes familiar with the results, they realize that a single syringe may not meet their goals. I believe the number of syringes used by each patient has slowly increased over the past few years.

In your geographical area, is price becoming a greater factor in a patient’s decision to choose a practice for their injectable treatments?

Fagien: Price is an issue and is becoming more so with more noncore MDs and physician extenders coming into the fold, and may be influenced by some of the next-generation products.

This less affects the higher-end, reputable practices, as their patients are less concerned with cost and more concerned with excellent [or] top-level results—not just average [or] acceptable results.

I believe that with the introduction of volumizing agents that may require several syringes, at the very least, to approach rejuvenative reflation, pricing will have to [reflect] this, and it won’t simply be “charging by the syringe,” which has been the current concept of pricing that needs another look.

Hirmand I have not seen this yet, but am sure it will become a more important factor in the future if the economy continues as it has been and more injectors enter the market.

See also “The New Therapy Landscape” by Wendy Lewis in the April 2007 issue of PSP.

Rubin: Thankfully, price hasn’t been a big factor in our area. Patients are not currently making their decisions based on price alone. Several years ago, we decided to make the price of most competitive filler products fairly similar, so there isn’t an incentive to choose one brand over another. This practice has worked well.

Papel: We have not seen a significant concern by patients that the price influences their choice of a physician’s practice. These materials are fairly expensive, and the price range in doctor’s offices does not seem to be very wide. I believe that the patients choose their physician injector by their feelings of confidence in the doctor, comfortable and convenient setting, and predictable results from each session.

Wendy Lewis is a consultant based in New York and London. She is the author of 10 books, including Plastic Makes Perfect: The Complete Cosmetic Beauty Guide (Orion, 2008). She can be reached at or