Market and competition Zimmer Aesthetic Division exportzimmer de

Market and competition Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de

The aesthetic medicine market represents all soft procedures aiming at improving patients’ appearance. In terms of procedures, it is all less or non invasive treatments such as filler injections, botox, laser, peelings, mesotherapy, dermabrasions… The top 5 aesthetic medicine treatments in Europe are: - Botox (Global market share of Botulinum toxin = 62%) - Fillers (Global market share of HA fillers = 32%) - Laser hair removal - Micro abrasion (gentle peeling aiming at removing a very fine layer of the skin; it helps removing fine lines, superficial scars, stretch marks, age and sunspots and it can also help with acne) - Resurfacing (laser for a smoother skin, smoothing out imperfections and wrinkles. It destroys the superficial layers of the skin and enduces collagen) In 2009, the worldwide market for dermal injectable products was estimated at 947 million Euro, for 6. 85 billion procedures. Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de

Trends, drivers and limiters Trends: - Less surgery, more medicine - Less one time treatments, more treatment programs - Resorbable vs. permanent fillers - Cross-linking agents: toxic elements - Growing cosmeceutical market Market drivers There is an exponential growth of people demanding aesthetic services thanks to: - The increasing desire to look and feel beautiful in an imageconscious society - an ageing population and a general desire to minimize and prevent the effects of ageing - Medias promoting youth as a standard - Patients awareness - Greater doctors’ adoption - Regular entry of new products on the market Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de Market limiters The economic recession on the last 2 years led to a reduced patients demand. Lower disposable incomes make patients weight the need for aesthetic treatments and seek alternative procedures.

Filler market Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de

Viscosity Filler market Volume Deep wrinkles Z-Fill deep² Medium wrinkles Superficial Z-Fill contour² lines Mesotherap Z-Fill refresh² Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de Elasticity

Target market and customers Our target market includes all doctors providing aesthetic treatments (already working with HA fillers, non permanent fillers excluding HA, permanent fillers, botulinum toxin type A, peelings, mesotherapy, and / or other types of aesthetic treatments such as lasers) and all doctors interested in starting to do filler injections. Our target market includes different doctors’ specialties. They can be classified into 4 categories: - aesthetic doctors - dermatologists - surgeons (plastic and ophthalmologists) - Others (such as GP, gynaecologists, dentists…) These segments have some slight differences in the way they work and different approaches to treatments and products. Nevertheless, we will not talk about customers segmentation here as the differences are only slight and do not require to have different products for the 4 different categories. Their expectations are similar. Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de

Target market and customers Our target market includes all doctors providing aesthetic treatments (already working with HA fillers, non permanent fillers excluding HA, permanent fillers, botulinum toxin type A, peelings, mesotherapy, and / or other types of aesthetic treatments such as lasers) and all doctors interested in starting to do filler injections. Our target market includes different doctors’ specialties. They can be classified into 4 categories: - aesthetic doctors - dermatologists - surgeons (plastic and ophthalmologists) - Others (such as GP, gynaecologists, dentists…) These segments have some slight differences in the way they work and different approaches to treatments and products. Nevertheless, we will not talk about customers segmentation here as the differences are only slight and do not require to have different products for the 4 different categories. Their expectations are similar. Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de

The end users They are mostly women between 35 and 55 years old. It is essential to consider that since medias communicate on aesthetic medicine treatments, patients start undertaking such therapies a lot earlier. They usually belong to upper socio professional categories as these treatments are pricy. Their behaviour, demands and expectations are different depending on the country and environment they live in. In western European countries, they don’t want the treatment to be obvious, they want natural results. In Eastern and Arabian countries, it is a status symbol and they expect the result to be more obvious. The treatments most often requested are: the orbital area, the nasolabial folds and the lips. The end users do not decide which product will be used to treat them, doctors do. Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de

Competition The aesthetic market is highly competitive. The panel of treatment solutions is wide: topical creams, botox, fillers, laser, dermabrasion… and for each one of them, many offers compete. The HA-based fillers market is extremely competitive with over 30 different brands (many being manufactured by the same companies). 3 types of companies can be distinguished: -the major companies with long experience, setting the trends (e. g. Q-Med) -the medium producers, following the trends and launching innovations (e. g. Anteis) -the distributors, non producers (e. g. Filorga) Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de

Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de

Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de

Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de

Restylane, Q-Med -Launched in 1996, world’s most widely used product (claim over 10, 000 treatments) - Unique NASHA (Non Animal Stabilized Hyaluronic Acid) technology - FDA approved, over 60 publications proving safety, efficacy, longevity - Their strategy has an impact on the market as they are a reference for most practitioners - Biphasic products as opposed to most of the other monophasic products on the market. - Products are said to be stabilized and not cross-linked: claim that high level of crosslinking (some go up to 50%) render the polymer from being natural to being foreign. Q-Med uses stabilization (<1%) to modify the HA to the lowest possible degree. Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de 2010 launches: - Restylane / Perlane with lidocaine (0. 3%) - Skincare line (hydration, post treatment) - 29 G Thin wall needle (Eur 4. 75 in Poland) - Blunt tip cannulas Pix’L (27 G 40 mm, 23 G 50 mm, 25 G 40 mm, 21 G 60 mm; Eur 6. 50 in Poland)

Restylane, Q-Med Monophasic vs biphasic Biphasic products consist of gel particles of stabilized HA suspended in a less – or even non-stabilized HA fluid. Depending on the clinical demand, the gels are thick or thin, containing big or small gel particles. The advantage is the durability (up to 18 months). The disadvantages are a high injection force, risks of granulomas and infection because of particles. Monophasic products are purely stabilized HA gels. They are more elastic and cohesive. They are smooth and easy to inject. Their advantages compared to biphasic products are biocompatibility and safety. Side effects mentioned by Q-Med: erythema, swelling, pain, itching, bruising, tenderness at injection site. Plus, rare cases of inflammatory reactions, granulomas and necrosis. Reality: “tindle effect” often reported (=bluish tinge when the product is too superficially injected). Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de

Needle Product Concentr ation Syrin ge Restylane 20 mg/ml 1 ml / 0. 5 ml Restylane Lidocaine 20 mg/ml Restylane Touch Indication Depth Duration Price 30 G 1/2 Facial wrinkles, lips Middle dermis 6 -12 months Eur 138/ Eur 92/ 1 ml / 0. 5 ml 30 G 1/2 Facial wrinkles, lips Middle dermis 6 -12 months Eur 87 Eur 144 20 mg/ml 0. 5 ml 30 G 1/2 Fine superficial lines Upper dermis Eur 92 Restylane Vital 12 mg/ml 1 ml 30 G 1/2 Hydration of the skin Dermal layer preferably deeper Eur 115 Restylane Vital Injector 12 mg/ml 2 ml 30 G 1/2 Hydration of the skin Restylane Vital Light 12 mg/ml 1 ml 30 G 1/2 Hydration of the skin (younger skin) Dermal layer preferably deeper Eur 79 Restylane Vital Light injector 12 mg/ml 2 ml 30 G 1/2 Hydration of the skin (younger skin) Dermal layer preferably deeper Eur 121 Restylane Lipp 20 mg/ml 1 ml / 0. 5 ml 27 G 1/2 Lip enhancement Deep dermis/superficial layer sub cutis 6 months Eur 125 Eur 210 Perlane 20 mg/ml 1 ml / 0. 5 ml 27 G 1/2 Deep wrinkles and folds. Lip sculpting Middle to deep dermis 6 -12 months Eur 168 Eur 130 Perlane Lidocaine 20 mg/ml 1 ml / 0. 5 ml 27 G 1/2 Deep wrinkles and folds. Lip sculpting Middle to deep dermis 6 -12 months Eur 170 Eur 130 Sub. Q 20 mg/ml 2 ml 16 G, 18 G 21 G Chin and cheek augmentation Deep subcutaneously or supraperiostal Macrolane VRF 20 20 mg/ml 10 ml/2 0 ml 16 G Body shaping and contouring Deep subcutaneously Zimmer Aesthetic. Division export@zimmer. de Macrolane VRF 30 www. zimmer. de Dermal layer preferably deeper Eur 163 Eur 315

Restylane skincare range (no indication of price yet Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de Product Indication Facial cleanser Mild cleanser/hydration Day cream Hydration/cell repair Night cream Skin repair/antiinflammatory Night serum Regenerative/wrinkles/pig mentation Recover cream After treatments Hand cream Hydration/nails Price

Juvederm, Allergan -Allergan bought Juvederm and Surgiderm to Laboratoires Corneal in 2006, both references on the market (even though there is no communication for Surgiderm) - FDA approved - Their strategy has an impact on the market: they were the first ones to integrate lidocaine in their products. Their marketing also impacts the market: they advertise in public magazines, directly to patients who get these products as their reference - Juvederm = monophasic products, with 0. 3% lidocaine; duration is generally >12 months 2010 launches: Juvederm Hydrate (HA+0. 9% mannitol, no Lidocaine) Juvederm Ultra Smile (claim a year duration) Allergan also offers botox Vistabel (interesting offers for doctors to buy both HA and botox: prevent their customers from buying to any competitor) Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de

Product Concentra tion Syringe Needle Indication Depth Duration Price 12 months Eur 68 Juvederm Hydrate 1 ml 30 G 1/6 Improvement of skin hydration and elasticity Superficially Juvederm Ultra 2 2 x 0. 55 ml 30 G 1/2 Medium skin depressions Upper dermis Juvederm Ultra 3 2 x 0. 8 ml 27 G 1/2 Medium and deep skin depressions Mid dermis Juvederm Ultra Smile 2 x 0. 55 ml 27 G 1/2 Lip contour and augmentation, medium to deep wrinkles (oral commissures, peri-oral lines) Mid dermis Juvederm Ultra 4 2 x 0. 8 ml 27 G 1/2 Deep skin depressions Deep dermis Eur 115 Juvederm Voluma 2 ml 23 G 1+ 18 G 70 mm canula Restoration of facial volume Sub dermis Eur 336 2 x 0. 8 ml 30 G 1/2 Fine lines Superficially 6 months Eur 87 30 G 1/2 Medium skin depressions, lip contouring Superficial to mid dermis 9 months Eur 178 27 G 1/2 Medium and deep skin depressions, volume augmentation and lip contouring Mid to deep dermis 12 months Eur 198 1 x 0. 8 ml 30 G 1/2 Lip contouring and volume 1 x 1 ml 30 G 1/2 Improvement of skin hydration Surgiderm 18 18 mg Surgiderm 24 XP 24 mg Surgiderm 30 XP 24 mg Surgilips Surgilift Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de 13. 5 mg 2 x 0. 8 ml 12 months Eur 75 12 months Eur 105 Superficially Eur 59

Teosyal, Teoxane -Teoxane laboratories were set in 2003 - Teosyal is a very wide range of products (often judged too wide by some doctors: leads to a big stock and high cost for them) - They are going for the FDA - Teoxane spends a lot in marketing and communication - They were the first ones to launch a line of cosmeceuticals 2010 launches A line of injectable including 0. 3% lidocaine: Teosyal Pure. Sense A post procedure kit Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de Product Indication Advanced filler (normal to combination skin) Anti-wrinkle, anti-aging skincare Advanced filler (dry to very dry skin) Correct imperfections Covering repair Skin repair/anti-inflammatory Pre-post injection Prepares, soothes and regenerates skin after treatment Kit post procedure Sample quantity of above mentioned products Price

Needle Product Concentr ation Syringe Teosyal Meso 15 mg/ml 2 x 1 ml 30 G 1/6 Rehydration of dermis Teosyal First lines 20 mg/ml 2 x 0. 7 ml 30 G 1/2 Superficial lines and wrinkles Teosyal Global action 25 mg/ml 2 x 1 ml 30 G 1/2 2 x 0. 5 ml Teosyal Touch up Teosyal Deep lines Teosyal Kiss Teosyal Ultra Deep 25 mg/ml Teosyal Ultimate 22 mg T. Pure. Sense Ultra deep 25 mg/ml T. Pure. Sense Kiss 25 mg/ml T. Pure. Sense Deep lines 25 mg/ml T. Pure. Sense Global Action 25 mg/ml T. Pure. Sense First lines 20 mg/m Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de Duration Price 2/3 month s Eur 130 Superficial dermis 6 months Eur 142 Moderate wrinkles Mid dermis 6/9 months Eur 216 30 G 1/2 Moderate wrinkles / touch ups Mid dermis 6/9 months 2 x 1 ml 27 G 1/2 Highly pronounced wrinkles Deep dermis 6/9 months Eur 223 2 x 1 ml 27 G 1/2 Lip contour and volume Deep dermis 6/9 months Eur 250 2 x 1 ml 26 G 5/8 Creates and restores volumes, very deep wrinkles Subcutaneous tissue 9/12 months Eur 250 1 x 3 ml 23 G 1 Chin, cheeks, face contour Subcutaneous tissue 12/18 mon ths 25 G 1 Creates and restores volumes, very deep wrinkles 2 x 1 ml 27 G 1/2 2 x 1 ml 2 x 0. 7 ml 30 G 1/2 Indication Depth Subcutaneous tissue 12 months Lip contour and volume Deep dermis 6/9 month s Highly pronounced wrinkles Deep dermis 9 months Moderate wrinkles Mid dermis 6 months Superficial lines and wrinkles Superficial dermis 6 months

Esthelis / Fortelis / Mesolis, Anteis -Anteis was set in 2003 - Just like CROMA, Anteis is active in ophthalmology, orthopedics and aesthetics - Anteis manufactures several products: Jolidermis and Belotero (license for Merz) - They are said to be going for the FDA - Anteis created their Inject Now Academy for plastic surgeons, dermatologists and aesthetic doctors. They provide information and trainings for injection techniques… - The products have the same BD syringe as Croma products - CPM technology including 2 cross-linking steps Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de 2010 / 2011 launches - Injection system: device including a syringe part, pedal, and central unit. It is compatible to all products available on the market (from all brands) and can be used for all types of treatments. - Esthelis (Soft and Basic) + glycerol: the aim of these products is to fill wrinkles and improve the quality of the skin at the same time. - Modelis: real volumetric product

Product Concentr ation Syringe Mesolis 14 mg/ml 1 ml Mesolis 14 mg/ml Mesolis + Needle Indication Depth 30 G 1/2 Rehydration of dermis, skin elasticity… Superficially 3 x 1 ml 30 G 1/2 Rehydration of dermis, skin elasticity… Superficially 18 mg/ml 1 ml 30 G 1/2 Hydration of dermis, skin elasticity… Superficially Mesolis + 18 mg/ml 3 x 1 ml 30 G 1/2 Hydration of dermis, skin elasticity… Superficially Esthelis soft 20 mg/ml 1 ml 30 G 1/2 Fine lines Superficial dermis Eur 100 ESthelis Soft 20 mg/ml 0. 6 ml 30 G 1/2 Fine lines Superficial dermis Eur 75 Esthelis basic 22. 5 mg/m l 1 ml 30 G 1/2 Medium to deep wrinkles, volume enhancement, lip volume Superficial to mid dermis Esthelis basic 22. 5 mg/m l 0. 6 ml 30 G 1/2 Medium to deep wrinkles, volume enhancement, lip volume Superficial to mid dermis Fortelis 25. 5 mg/m l 1 ml 27 G 1/2 Deep folds and wrinkles, contour of the face, lip volume Deep dermis Esthelis soft glycerol 20 mg/ml 1 ml 30 G 1/2 Fine lines + hydration Superficial dermis 1 ml 30 G 1/2 Medium to deep wrinkles, volume enhancement, lip volume + hydration Esthelis basic glycerol Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de 22. 5 mg/m l Superficial to mid dermis Duration Price Eur 125

X-HA 3 / X-HA Volume, Laboratoire Filorga -Laboratoires Filorga were started in the 70 s by French Dr Michel Tordjman. - The aim was to understand the process of skin ageing and find a way to prevent/fight it. They started with mesotherapy and peelings in the 90 s. - The initial group separated and Didier Tabary became the president - They are specialized in cosmetics with a very wide range, sold in pharmacies - They started a range of fillers (Isogel) in the past which wasn’t successful. X-HA 3 was launched in 2009. - Filorga does not manufacture any of the product they sell. Product Concentr ation Syringe X-HA 3 23 mg/ml 1 ml X-HA Volume 23 mg/ml 1 ml Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de Needle Indication Depth Duration 27 G 1/2 Medium and deep wrinkles, lip contour and volume All depth 9/12 months 27 G 1/2 Facial volumes Deep dermis Product Indication NCTF 135 Preventing first signs of aging NCTF 135 HA Treating existing signs of skin aging Price

Product Indication Glykopeel Treating wrinkles, elasticity, glow Glykopeel 70%Max Deeper than Gleekopeel, but remains superficial peeling Glykopeel Max Not as superficial as the 2 above (can induce secondary effects for a few days) Glykopeel 70% Tolerant skins (used to such treatments) Glykopeel 50% Sensitive skins Glykopeel 20% Highly sensitive skins Product Indication Iso-Age / Iso-Structure 1 st signs of aging / Anti-wrinkles and firming Sleep and Peel Anti-aging night cream Meso-Mask Hydrating mask Meso-C Rejuvenating treatment course, with vitamins Meso-Peel Kit associating the benefits of peeling and mesotherapy Deep-fill Filling cream Optim-eyes Eye contour cream Neocica Skin repair cream Meso-white Whitening treatment Meso + Antu-aging serum Eau anti-age Refreshing and renerating mist Zimmer Aesthetic. Division Liss export@zimmer. de www. zimmer. de and go Immediate lifting solution Price

Stylage, Vivacy -Vivacy was created in France by people from Corneal after it was purchased by Allergan - They only manufacture HA-based products, with their range Stylage. - Technology IPN-like: they put together 2 cross-linked HA gel to create Stylage products - The syringe is the same as Croma products - All Stylage products include HA and an antioxidant (mannitol). Mannitol helps fighting against free radicals, cause of skin ageing. A few cases of swelling after injection on the lips or around the eyes, maybe because of the mannitol. 2010 launches 2 products including 0. 3% lidocaine: Stylage special lips and Stylage M Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de

Needle Product Concentr ation Syringe Stylage Hydro 14 mg/ml 1 ml 30 G 1/2 Mesotherapy Stylage S 16 mg/ml 2 x 0. 7 ml 30 G 1/2 Fine to medium wrinkles, lips Stylage M 20 mg/ml 30 G 1/2 Medium to deep wrinkles 12 months Eur 213 Stylage L 24 mg/ml 27 G 1/2 Deep to very deep wrinkles 12 months Eur 246 Stylage XL 26 mg/ml 26 G 1/2 Enhancement 12 Months + Eur 300 Stylage 16 mg/ml Lips 6/9 months Stylage lidocaine special lips 18. 5 mg/ ml Lip contour and volume 6/9 months Stylage lidocaine M 20 mg/ml Medium to deep wrinkles 12 months Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de 2 x 1 ml 30 G 1/2 0. 8 ml 30 G 1/2 2 x 1 ml 30 G 1/2 Indication Depth Duration Price Eur 58 9 months Eur 171

Glytone, Pierre Fabre / Merz Pharma -Glytone is Pierre Fabre’s full range of aesthetic dermatology - The range includes pre and post treatments for professional as well as home use. They also offer peelings - All intradermal products (Glytone 2, 3 and 4) are made of HA and mannitol 2010 launches Glytone 4 for very deep lines and volume treatments was launched Product Concentr ation Syringe Glytone 2 20 mg/ml 1 ml 30 G 1/2 and 27 G 1/2 Superficial wrinkles Glytone 3 23 mg/ml 1 ml 27 G 1/2 Medium to deep wrinkles, and facial volume Glytone 4 24 mg/ml 1 ml 23 G 1 and 25 G 5/8 Facial volume and contour Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de Needle Indication Depth Duration Price

Product Indication Exfoliating cleanser Cleanse the skin Exfoliating day cream Exfoliating and moisturizing Exfoliating and cellular renewal stimulating night cream Stimulating cellular renewal Soothing cream for stressed skin Soothing and nourishing Price Very high protection sun cream spf 50+ Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de Product Indication Preparation cleanser Skin cleansing Medical Peel 30% Wipes / gel Medical Peel 40% Wipes / gel Medical Peel 50% Wipes / gel Medical Peel 60% Wipes / gel Medical Peel 70% Wipes / gel Post-peel neutralizer Soothe skin and neutralize effect of peeling Price

Belotero, Merz / Anteis /Glytone -Aesthetic department of Merz group is still quite small but fast growing - There is not so much information about Belotero, other than the brochures - Belotero range is manufactured by Anteis (only available in German speaking countries) Belotero Soft = Esthelis Soft Belotero Basic = Esthelis Basic Belotero Intense = Fortelis 2010 launches Launch of their own botulinum toxin type A (Bocouture) Needle Product Concen tration Syringe Belotero Soft 20 mg/m l 1 ml 30 G 1/2 Superficial wrinkles 22. 5 mg/ ml 1 ml 27 G 1/2 Shallow lines and lip contour 23 G 1 and 25 G 5/8 Deep lines and lip volume Belotero Basic Zimmer Aesthetic. Division Belotero export@zimmer. de www. zimmer. de Intense 25. 5 mg/ ml 1 ml Indication Depth Duratio n Price

Z-Fill contour²: Z-Fill deep²: - Juvederm Ultra 3 - Juvederm Ultra 4 - Princess Filler - Princess Volume - Restylane - Perlane - Teosyal Global Action - Teosyal Deep lines / Ultra Deep - Esthélis Basic - Fortélis Extra - Stylage M and L - Stylage XL - Glytone 2 - Glytone 3 Z-Fill refresh²: - Restylane Vital - Princess Rich - Teosyal Méso - Mesolis + and Mesolis Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de - Stylage Hydro

Other anti-ageing treatments • Topical treatments: anti-ageing creams. . . • Botulinum toxin: blocks neuromuscular transmission when injected in tiny amount into muscles to treat lines associated with facial expression. Mostly effective on frown lines and crow‘s feet. The longterm risks aren‘t known. But if injected incorrectly, it can cause droopy eyelid or immobile face. Effects last about 4 months. • Chemical peeling: peels away signs of ageing on the face, hands, neck and chest. Removes damages on the top and middle layers of the skin for less wrinkles and better texture. For fine lines, discoloration. . . • Laser skin rejuvenation: many types: non ablative laser rejuvenation, intense pulsed light, photodynamic therapy, fractional laser rejuvenation, ablative laser resurfacing (needs recovery time). Laser can‘t treat alone wrinkles caused by constant muscle movements. For fine to deep lines. Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de

Other anti-ageing treatments • Dermabrasion: sands away damaged skin; as the wound heals, new skin appears smoother, radiant and toner. For scars, and wrinkles. The area is temporarily red, sore and swollen. • Microdermabrasion: exfoliates the skin for smoother and toner skin. A serie of treatments is needed; it causes the skin to produce collagen, but the effects are modest. It causes bruising, burning and stinging. • Skin tightening: different from facelift, produces mild tightening by sending heat deep into the skin. This causes immediate tightening and signals the body to start making collagen. Reduces wrinkles but modest results. • Fillers: collagen, HA, fat, PMMA, hydroxylapatite, poly-l-lactic acid. Immediate results, different lasting. Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de

Collagen-based fillers To a large degree, a wrinkle is a localized loss of collagen: to restore the lost collagen it can be injected back. It lasts 3 to 6 months and there is a risk of allergic reaction. Different origins: Bovine/porcine collagen (Zyderm, Evolence, which is off the market since november 2009): cheaper, but causes allergies because of structural differences between bovine and human collagene Human (Cosmoderm, Autologen): lower risk of allergy, but more expensive. Sources: human tissue culture, cadaver tissue obtained at time of death, patient‘s own excess of skin Injections of fibroblasts (Isolagen): collagen-producing cells from donor. This is an alternative to injecting collagen as the enzymes will break the collagen up in 2 to 4 months. Risk of rejection, but own culture can be used. If the injected fibroblasts take hold in the skin, they can keep producing collagen for a long time. Autologous fibroblasts injection is a bit complicated since it requires a large skin graft to obtain enough fibroblasts, or can be grown in culture. It is expensive, too new and needs some more research. Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de

Hydroxylapatite-based fillers It is long-lasting, nontoxic, biocompatible It‘s a mineral naturally found in human teeth and bones. Chemically, it is a calcium phosphate based mineral with characteristic hexagional crystalline structure. Mostly used: Radiesse, which consists of small hydroxylapatite microspheres suspended in a gel-like solution. Advantages: biocompatible and doesn‘t require allergy testing prior to use, lasts 12 to 18 months and appears to stimulate the production of body‘s own collagen at the injection site, needs less quantity than other biodegradable fillers Disadvantages: expensive and painful. Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de

Autologous transplants The idea to transplant the patient‘s own tissue to correct cosmetic imperfections is not new. The benefits are obvious. The implant should survive permanently, cause no allergy, no risk of disease transmission Reality: expensive, inconsistent results, transplant-based fillers survive partially. Re-treatment often required. 2 options: autologous fibroblasts (see collagen) and autologous fat Autologous fat: patient‘s own fat is harvested (by suction), then it is purified, homogenized and treated, and finally injected. It will add extra volume to depressed areas. Only a percentage (10 – 50%) of the injected fat takes hold in the treated area. What takes hold, stays at least a year. Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de

Synthetic polymer fillers Poly-l-lactic acid: a slow-biodegradable polymer made of l-lactic acid (nontoxic and natural by-product of anaerobic metabolism of glucose). Mostly used: Sculptra. It lasts 2 years (for deep wrinkles and facial contours). It is well tolerated, requires no allergy test. It may cause tenderness, redness, bruising for 3 to 15 days. The results aren‘t immediate: 6 to 8 weeks as the effect is more due to the reactive synthesis of new collagen. Polyacrylamide (Aquamid) and Polyalkylimide (Bio-Alcamid) gel: can hold a large amount of water, forming a gel with mechanical properties resembling some human tissues. The gel is injectable, non-biodegradable, the results are permanent, but can apparently be removed by aspiration. It integrates into the skin matrix, and rarely migrates away from the treatment site. For deep lines and fat loss due to ageing. Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de

Synthetic polymer fillers Polymethylmethacrylate (PMMA): also used in bone cement, dentures, pacemaker covers. . . It is nonbiodegradable, relatively nontoxic and chemically inert. Mostly used: Arte. Fill = PMMA microspheres suspended in bovine collagen solution (to provide a smoother suspension and aid in skin matrix integration). The collagen is degraded over 2 -3 months and PMMA gets encased in the patients‘s own collagen produced in response to foreign material and bovine collagen. Results: good integration, durable results, low risk of filler migration. Allergy test is required because of bovine collagen. Reports of reactions. Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de

Thank you very much for your attention! Zimmer Aesthetic. Division export@zimmer. de www. zimmer. de