Nurse Practitioner Pay In New "Medical" Spas

What's a good Nurse Practitioner pay in a new 'medical spa' that wants to offer Botox?

I get lots of individual emails looking for information about pay for PAs, NPs and MDs who are being recruited by a local medical spa. Some of these are just entering aesthetics and others are old hands.

Here's an example email that's typical from a NP who's being solicited by a day spa who's wanting to offer Botox and fillers:

Hello, I am a Nurse Practitioner from Wyoming and I am going to start doing some medical aesthetics for an established spa that up to this point has offered everything except medical aesthetics. The owner of the spa and I are having trouble figuring out a fair pay for me. The products are being ordered under my license and I will also be doing all the injections. Right now we are just starting out with Botox and Fillers. She pays her staff an hourly wage plus commission, but I have also talked with other spas that pay straight commission. Both of us are new to this and we are having a hard time finding out what other medical spas pay. Any insight on this would be helpful.

Sincerely,

Stephanie

Ok, so here's where we're going to drop some knowledge-bombs on you. (For this post I'm not going to go too deep on whether these types of setups are good ideas on their own.)

First, think about what you're asking and how you're thinking about this new business. You're counting your eggs a little before you've got any eggs.

The fact that you're asking how much you should be paid reveals a number of problems with your understaning of how this is going to work and who's going to be responsible. (This isn't uncommon at all and we're going to disucss business models at lenght in future posts.) Since you're the clinician, you're going to be responsible for everthing to do with this business with the probable exceptions of: #1, paying for stuff and #2 supplying the 'patients'.  So let's look at what you're going to be responsible for:

• Purchasing all the Botox, Restylane and Juvederm under your medical license
• Patient care
• Charting and compliance
• Clinic operations and systems
• Malpractice insurance

Since you're going to be practicing medicine, the fulcrum in this relationship is you as the clinician. It's going to be your reputation, medical licence, malpractice insurance, and your ass on the line.

I'm reminded from a line from the science fiction novel Dune in which goes something like, "He who has the ability to destroy a thing, controls that thing." Meaning, that this is effectively going to be your business, not the spas. (Note, I'm not denying that the spa could probably find someone else to do this same deal, just that it's never going to be the spas business.)

The spa will invariably take the tact that this will be an add-on to their existing business and that the 'patients' are their customers etc. This is both wrong in practice and illegal. This will be the practice of medicine and that's pretty cut and dried. You're still going to regulated, HIPPA compliant, etc. and that's it.

You're also going to need to set this up legally in your state. In most states you can't become an employee of or partner directly with a non-physician. (Not sure about how this applies to NPs so if anyone knows, please leave a comment.)

The patients are going to be yours, the responsiblity will be yours, the insurance will be yours etc., and you can't just be paid for performing medical treatments by a non-physician. All that being said, there are ways that this can be done if you're smart, and the spa owner is reasonable.

1. Set up a legal entity for yourself. (Have a real lawyer do this who has knowledge with clinicians.)
2. Make sure that the spa has a legal entity. (Different lawyer there.)
3. The agreement will be between these two entities. (There are different ways to set this up depending on state. In some cases it might be the NP's entity that is 'renting' space from the spa but there are other options. Read through the forum threads on this site for those.) The agreement should also clearly define scopes and responsibilities and what will happen if the business fails. In cases like this, the spa is often 'paid' for rent and/or 'marketing' expenses, not fee splits or referrals. A technicality maybe but an important one.

People always try to overlook the 'business fails' part of the equation but it's a necessity to outline this up front since this business will end at some point in the future, even if both parties are happy.

Since it's illegal in most states to be a clinician who is an employee of a non-physician, that becomes somewhat problematic since you can't be 'paid' in the normal way. I would also suggest that all monies go though your legal entity before being distributed. In effect, you take all payments, not the spa. Headache yes but medicine in the US is the most highly regulated and litigious market there is. Don't sit around on your thumbs with this.

If you look at what you're going to be required to do, the conversation with the spa should be much clearer and should help the negotiations. If the spa owner refuses to understand how this should be set up, don't do any deal. You can't negotiate in good faith with someone who is willing to put you at risk right at the start.

About your Pay?

The real question is, "how much money are you going to make?". 

Business 'partners' always run into personal conflict when; they don't make any money, or.. they make a lot of money. I would suggest that you make sure that you go into this with your eyes open and the spa owner does the same. If you can't resolve the above issues then the money won't matter.

Comments welcome.

Top 5 Medical Spa Treatments In 2011

The top nonsurgical treatments in 2011?

1. Botox: 5.7 million treatments (up 5% from 2010)
2. Filler Injections (Juvederm, Restylane, Perlane, etc) 1.9 million treatments (up 5% from 2010)
3. Laser Hair Removal: 1.1 million (up 15% from 2010)
4. Chemical Peels: 1.1 million (down 3% from 2010)
5. Microderm: 900,000 (up 9% from 2010)

Source: American Society of Plastic Surgeons

Can Nurse Practitioners Offer Botox?

Guest Post By Carolyn Buppert, NP, JD

Can Nurse Practitioners offer Botox, Restylane, Juvederm and other cosmetic treatments on their own?

The answer to this question is going to be state-specific. Here are the steps to follow:

1. Read your state's Nurse Practice Act section on scope of practice for nurse practitioners to answer these questions: What acts require physician collaboration or supervision? How is collaboration or supervision defined? (Boards of Nursing in the United States: State-by-State Web Links)
    
2. Go to your state's Board of Medicine Websites and search for any policies on provision of botulinum toxin (Botox®). Note that botulinum toxin is a prescription medication, so a prescription or order for the medication must be written and someone must administer the drug. If your state has policies on botulinum toxin, note the requirements for prescription and administration. Some states consider administration of botulinum toxin a medical act, and some states consider it to be within the scope of a registered nurse. Prescribing is always a medical act.
    
3. If you live in a state that requires no physician collaboration when nurse practitioners prescribe, then as long as the Board of Medicine has no requirements with respect to botulinum toxin, you are free to proceed with your practice idea. If your state requires physician collaboration in order for nurse practitioners to prescribe, then you'll need to line up a collaborator. In most states, the collaborator does not need be on site, but in some states, the collaborator must practice at the site with specified frequency. Follow the rules as they relate to any prescribing.

About: Carolyn Buppert, NP, JD is an attorney practicing in Bethesda, Maryland.

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Medical Spa MD: Filler Injection Tips (Restylane, Juvederm)

Restylane, Juvederm and filler injections tips for physicians running medical spas and laser clinics.

The following is from a string of emails that were circulating among some of Medical Spa MDs Members. I've edited this somewhat to make it readable and get rid of all the extraneous copies. I'm also not displaying the identity or email addresses of the physicians in this thread.

Please leave your thoughts below as a comment.

Note: Some of the comments below might be out of order from the original thread. Emails' somewhat difficult to follow as a thread but you'll get the gist.

Filler Injection Discussion & Tips: Restylane | Juevederm | Evolence

1.  When I use the "push ahead" technique, I feel that I get better "plumping" per cc of filler.  I learned this from Kevin (thanks Kevin).

 

2.  When I use the "push ahead" technique, the filler fills a few millimeters in front of the needle tip.  You need to realize this to be able to put the material exactly where you want it.  Sometimes you have to "feel" the injection because you can't "see" the plumping.

 

3.  I mix 0.1 cc of lidocaine with epinephrine with my Juvederm.  This helps with bruising (epinephrine) and when the lidocaine goes away and the Juvederm attracts water, the two effects cancel each other and there is not as much enhancement after the injection due to the hydrophilic nature of the Juvederm.

 

4.  I use Juvederm Ultra under the eye and above the lip.  I use Juvederm UltraPlus everywhere else.

 

5.  I constantly complain to my Juvederm Rep about the 0.8 cc syringes.  I use lots of Radiesse because you get almost twice as much material for the same price.  Volume, volume, volume.  Please complain to your rep, maybe we can get them to change. 

 

6.  I hear the Evolence is very good.  We will be getting trained and start using it next month.

Thanks for the filler tips.Can you explain how you get the Lido with epi mixed into the Juvederm syringe? --PD

Fluid Dispensing Connector from Braun Medical Inc (you can get from PSS)

BD 1 ml Luer-Lok Syringe

 

This syringe allows you to get very precise amount of lidocaine (swish back and forth 20 times).

 

I use this syringe to put exaclty 1 cc of saline in my Botox Bottle. When I reconstitute the Botox (this gives it full strength per unit). The chances of intravascular injection might be lower with push ahead because the material will push the vessels out of the way as you advance --  Jeff

Hi Jeff,--I agree w/ #6.  I seem to get good augmentation, less redness, swelling and bruising with Evolence.  I use it for deeper fills in cheeks, NLF, etc.  Don't use it for lips or under eyes.  I do same with Lido w/ epi.  I tend to use Juvederm in lips.  Perlane / Restylane for other areas.  I agree w/ why Allergan uses 0.8 cc syringes. I've moved away from Radiesse.  I feel that the duration is not that much longer than a good correction with the HA's.  Besides, I believe a fair amount of the volume of Radiesse is a gel carrier, thus needing touch-ups at 2-3 months.  Perhaps that's why the went to the larger syringes? -- Don

The push ahead technique also moves small blood vessels out of the way, so you may notice less ecchymosis is overall pts. -- Greg

Jeff: --"Push ahead" has a higher risk of vessel cannulation & potential for vascular effects - skin necrosis in glabella, even potential for retro-grade flow to eye (causing visual loss).  I wouldn't recommend that technique for the periorbital area.

Restylane is recommended for the tear troughs;  it's less hydrophilic than juvederm - which means less post-treatment swelling.--Tom  --  [note from Jeff:  Tom is a plastic surgeon]

I would not use push ahead around the eye, I agree with Tom's comments. It works great for NLF. I was actually taught this by a PS -- Greg

Thanks Jeff for your kind comments. However I must make a few points in regards to fillers:

1) There are some areas that one has to still do the retrograde injection either b/c the purpose was to make a straight line (eyebrow lift and vermillion border and the bow-tie (the vertical lines connecting the base of nose and the upper lip border) AND when injecting the most inner 1/3 of the tear-trough to avoid risk of filler getting into the orbital space due to its close proximity to the orbital rim.

2) On the glabellar injection, it is best to first push and pull the needle thru the space underneath to break up the tissue before actually injecting the filler both in an anterograde and retrograde pattern

3) I ONLY use the 1/2 inch needles in all my injections

4) One can inject even Radiesse and/or Perlane via an 1/2 inch 30 gage needle. Why is this noteworthy to mention?? When I work on the lips and Marrionette's lines, I ususally first build the Vermillion border with Radiesse or Perlane (I get the best "lifting outcome" with heavier filler). I push the 1/2inch needle all the way forward then slowly and steadily inject while withdrawing (retrograde method). Then I re-evaluate how much of a correction I already get of the Marrionette' line and lifting up of the lip body. My next step is to inject into the most lateral lip section (about 1 cm distance) starting at the corner (using Perlane or Restylane or Juverderm). This time I inject slowly as I push forward (anterograde). Often I ended up correcting about 50% of the marrionette's line by going after the lip's border and most lateral body. Besides, the patient loveto see that they now could see their lip body all the way to the corner and more "smiley shape". The last step is the trickiest one, I use either Radiesse or Perlane on an 1/2 inch 27 gage needle. First placing my left thumb at the patient's lower half NLF's I retract the skin upward (about 2-3cm upward) then I approach my needle in an upward (vertical) position at about one centimeter lateral and one cm below the mouth corner of that same side. Then I aim diagonally toward the corner and start injecting anterograde just 1-2 mm below the imaginary horizontal line of the mouth corner (about 0.2 cc), then I withdraw the needle and reaim straight up and inject just below the horizonal line (0.2cc) then I do it one more time aiming diagonally outward (0.2cc). What was I attempting to do?? I was laying down a new flooring along the imaginary horizontal line. After the injection, release the left thumb. You will be surprised to see the retracted portion just rest right along this new floor, thus the Marrionette'line has been corrected. This is different from the common fanning technique of using the filler to "blow up" around the Marrionette's line. If you look carefully at those company's issued photos, the area around the Marrionette's line now appeared very swollen and puffed up. It is aesthetically unpleasant. It looked like the patient was beat up below the mouth. It reduced the profile of the chin.

5) For those of you that use fillers on the highly vascularized and shallow areas such as the temporal, crow's feet, undereye area lateral to the submalar area and along the lateral border of the cheek prominence (especially in those older skinny Caucasian ladies with much excessive very thin skin) I now emulate the same technique used in the hand. I would pinch to levitate the skin itself above the bony structure, then I bolus Restylane into the empty space. Then I massage it down. This elimates the risks of injecting into the vessels and nodules.

Interesting discussion.  So Kevin, how do you account for the difference in that anterograde injection you need less filler than in retrograde injections, assuming all else being equal?

Second, I am understanding one group claims anterograde injection carries a higher risk of vessel cannulation and possible intravascular injection, while another group claims that anterograde injection "pushes away" blood vessels, thus decreasing the risk. Not sure how anterograde increases risk of intravascular injection any more than retrograde.  If you push the needle ahead, transfixing a vessel, then begin injection, you can still conceivably deposit some material intravascularly, can you not?  Am I missing something here?

I also found an interesting idea of sub q bolus technique in areas of thin skin, ie crowsfeet, etc.  Anyone else try this method? ~ Don

Tom:

I do agree with you about those risks with anterograde injection. The key is always the skills in doing it, be it retrograde or anterograde. One always has to be very carefully doing anything around the eyes. However, the anterograde techinique has been advocated some of the best known experts such as Arnold Klein, MD and Kent Remington, MD. I also believed that the filler amount used was critical. It takes much more amount to get the same result with the often taught retrograde technique compared with the anterograde one. For example, I almost never required more than one full syringe in correcting bilateral NLF's vs what was typically used ( 2 syringes) by most others. I attached the before and after of a case wherein I used Readiesse to correct her NLF's and Marrionette's lines with anterograde technique. The after photo was taken right after. You can still see some of needle marks. I used one full 1.3 cc syringe, 1/2inch 30g for the Vermillion border and 1/2inch for NLF's and Marrionette's line. Notice also there was no "puffy/swollen look" medial to the Marrionette's line often seen with retrograde and fanning technique used by most others. ~ Kevin

All interesting comments.  The only place, I use “push ahead” is in the cheeks when doing them via the intra-oral route. (Apparently Radiesse is no longer teaching this method because may practitioners couldn’t get the hang of it but it works for me.)  I might try it in the “safe” areas such as NL folds.  We use only Radiesse and Juvederm and  I find that neither filler lasts as long as advertised in “first-timers”.  I’ve also had disappointing longevity in my older patients (>65) with both types fillers despite using numerous syringes.  I’m sure this has to do with their inability to generate collagen around the filler once the carrier gel is gone.  Does anyone know the age range of patients done in the filler studies? ~ SD

I came across this old thread way down in my inbox and read it again.  I’m not sure who wrote #4 below.  It sounds interesting but I’m having a hard time visualizing it.  Do you steadily move the needle forward  toward the lip edge as you are injecting or do you hold it in place while the area fills?  I’d love to see a drawing on where you start.  ~ SD

SD: I wrote those threads. The techniques that I described were similar to what you could see watching the video instruction on www.thederm.org by Kent Remington and his colleagues (lower face injection portion) THe only thing new from my thread was when fixing the Marrionette's line, his doctor (Nowell Solish) injection upward and anterograde from the lower part toward the lip corner only one time vs what I now do is I do the same thing but with a fanning pattern where (with the skin lifted about 1-2cm upward with the other thumb) I laid down "three such "anchoring points" along an imaginary horizontal floor starting from the lip corner going laterally for about 3-5cm long. Here I used something firmer such as Radiesse or Perlane. Having done this, you would release the thumb letting the skin go back down. Often you will see the Marrionetter's line is much improved because "part of that Marrionette's line" now is positioned along the horizontal flooring that you just created. ~ Kevin

PS: It is hard for me to send over some graphic illustration but I will attempt to do this in the future

Do it yourself Botox? ABC News wants to talk to you.

Have you tried do-it yourself plastic surgery or home Botox injections?

In tough economic times, many try to cut costs, including in their beauty regimen. Despite the risks, some people have decided to skip the doctor -- and obtain and self-administer cosmetic treatments.

If you have self-injected products like Botox, Restylane, Juvederm, silicone, and other substances, 20/20 would like to hear your story.

Please fill out the form below, including information about your experience, and a producer may be in contact with you.

You can tell ABC all about it here.

Medical Assistant's can not inject Botox!

I've seen and head about medical estheticians, medical assistants and even front desk staff administering Botox injections.

It's not legal, as this story on the prosicution of a medical assistant clearly shows.

Betty Guerra’s monthslong nightmare is over.

The 45-year-old former medical assistant learned today from her attorney that the 10 felony counts against her on allegations of “unlawful practice of medicine” will be dismissed, she said.

“I always believed things would work out the right way,” she said tearfully. “I cannot be punished for something I didn’t do.”

Guerra’s July arrest sparked controversy over what medical assistants can and cannot do. Specifically, there was confusion over whether they are able to give shots.

Guerra was accused of unlawfully administering cosmetic injections, an act commonly performed by medical assistants throughout Nevada.

The state attorney general’s office did not specifically say charges against Guerra would be dropped but indicated it won’t be pursuing the case.

“The complaint against Betty Guerra submitted to the Attorney General’s Office by the Board of Medical Examiners has been contradicted by the subsequent actions by the Board,” Attorney General Catherine Cortez Masto said in a statement. “Therefore, it is fair for us to conclude that it would be difficult to prosecute this case beyond a reasonable doubt.”

Guerra’s attorney, Jason Weiner, said this evening that the attorney general’s office had sent him a copy of an unfiled motion dismissing the case earlier in the day. He would not be able to provide the Review-Journal with a copy of that motion until Wednesday, he said.

After Guerra’s arrest, physicians became concerned about what duties their medical assistants could perform.

Former medical board director Louis Ling said that upon reading a 30-year-old law, he concluded that the assistants could not give shots. With flu season coming on, he then attempted to draft emergency regulations that would allow them to give flu shots, but not Botox or other cosmetic injections.

However, that effort was shot down when a judge recently ruled that the board, in considering the regulations, had violated the open meeting law.

The board later reversed its position, determining that state law allows medical assistants to administer everything from flu shots to Botox. Medical assistants could give shots as long as they are under the “direct supervision” of a physician. Most health officials and doctors take that to mean the physician is on premises.

Ling resigned on Friday.

Guerra, a mother of three who was a physician in her native Peru, said she has been under incredible stress since her arrest and lost her job because of the publicity surrounding her case.

“It was a nightmare. I could not even sleep or eat all this time, wondering what was going to happen.”

Still, she said she harbors no anger.

“Now, I start all over. But it’s just another experience in my life.”

Via Review Journal story.

Bootox: Botox & Restyland injections in your feet?

I came across this article from Australia on Botox and Restylane being injected in womens feet.

IT'S the subject of whispered conversations over cocktails deep within Flemington's Birdcage. The secret weapon a flock of fashionistas rely upon to teeter upon 10cm stilettos all day long at the races.

Botox and filler injections for the feet are the latest crazes in cosmetic surgery to make their way to Flemington - and the solution, according those with cash to splash, to the old racing conundrum of how to wear those towering pumps and not end up carrying them home after the final race has been run.

For about $1500, some doctors, such as Bondi-based cosmetic surgeon Michael Zacharia, will inject hyaluronic acid (Restylane) into the balls of the feet.

The fluid, commonly injected into joints to treat osteoarthritis, numbs the parts of the foot that become strained by wearing sky-high heels.

And judging by the height of the footwear that was racing out the door of Melbourne boutique Miss Louise yesterday, 10cm heels will indeed be spotted around the Birdcage today.

Dr Zacharia, who has been doing the procedure for just over a year, said the foot filling provided "internal padding for the feel at that point of pressure underneath the balls of the feet. Instead of using those silicon pads inside your shoes, this is an internal way of doing it."

The procedure, however, is a lot more expensive than purchasing a pair of silicon inner-soles. At $750 per foot, the fillers will last for about six months.

Dr Zacharia said three or four people this week had told him they wanted the foot fillers for the Spring Racing Carnival, but he warned those considering the treatment that the sensation immediately following the injections could be uncomfortable.

"I've been told that for about 10 minutes afterwards it feels like you are walking with marbles in your feet, or it's like there is something in your shoe," he said.

The other procedure women are turning to is "bootox" - having Botox injected into the balls, arches and soles of the feet to paralyse the sweat glands, which Dr Zacharia said would also set you back about $1500.

Australasian College of Podiatric Surgeons president Mark Gilheany said while women might think the procedures were magic solutions to stiletto-fatigue, foot fillers could be masking symptoms of more serious problems.

He warned that for people experiencing a significant amount of pain standing in heels it could be a sign of partially dislocated bones or torn ligaments.

"If you require something of that (surgical) nature then you could have an underlying problem," he said.

"It's not something that is routinely done and I haven't seen any clinical trials to say whether the injection of a biological cushion into the foot is effective.

"If there was anything that really worked I'm sure I would know about it. It seems like a waste of time when you can stick a cushion in your shoes and take some paracetamol."

Botox? Restylane? Juvederm? Lose the wrinkles & get a job.

The unemployment rate for the month of June for the U.S. was hovering around 9.7% according to the U.S. Bureau of Labor and Statistics. Some of my own family members have found themselves out of work after being in management positions for years only to be replaced by younger, cheaper laborers. Skilled individuals are being turned down for new job opportunities, but for what reasons?

People I know who are out of work state that they are told they are "over qualified" for the open position, or their salary requirements are "too high" for the company to met during these struggling economic times. Okay. I understand that.

Recently, our medical spa was interviewed by a local newspaper who was writing an article about older unemployed people turning to cosmetic services in order to freshen their image to compete with younger job candidates. The article stated that job competition is fierce and while candidates are polishing up their resumes, they're seeking aesthetic services to polish up their bodies and faces. Other physicians interviewed for this article stated that people ranging from 40 years old and up, predominately women, are looking to have these procedures performed.

When we were approached about this article I was dumbfounded for I truly did not know of any of our clients who came in saying, "hey, can I get some Botox and filers to erase these lines on my face to compete for this sales job against this 25 year old right out of college? And, why your at it, can you get rid of these flappy arms and turkey neck I have?" And, believe it or not, we were approached for our comments on the same topic for a major magazine.

Our medical spa is close to Philadelphia and New York City and we are surrounded by thriving companies like Merck, Johnson & Johnson, Olympus, etc. so we're not in a rural area by any means, and I still wasn't aware that older job candidates were racing to have these procedures performed to increase their chances of landing a new job. I have seen an increase in new clients because of new technologies and products we have added which weren't available a few years ago.

I'm very interested in knowing if your practice has seen an increase of clients undergoing cosmetic procedures to compete for a job and, if so, what procedures are they seeking to have performed? Are they predominately male or female and what is their approximate age range? If this truly is a real "situation" perhaps we're missing a marketing opportunity to offer these individuals discounted bundled packages to assist them with their quest.

Author: Paula D. Young RN runs internal operations and training at Young Medical Spa and is the author of the Medical Spa Aesthetics Course, Study Guide, and Advanced IPL & Laser Training course for medical estheticians and laser technicians.

Submit a guest post and be heard.

Comparison of what's in a Dermal Filler: Radiesse, Restylane, Perlane, Juvederm Ultra, & Sculptra

What's in Restylane or Perlane? Here's a synopsis.

Radiesse

1.3 cc syringe, active ingredient is 30% "powdered synthetic bone"
Very good for nasolabial folds, cheekbones, jaw lines. Not good for lips. Lasts about 3-6 months after the 1st treatment, about 12-18 months after the second treatment. Considered "semi permanent" because the collagen that it stimulates will last for years after the product has dissolved. Cannot be dissolved with any chemicals such as Hyaluronidase. Can also be used on the backs of the hands.

Restylane

1.0 cc syringe, made out of cross linked Hyaluronic acid.
Lasts about 6 months. Tends to absorb a little water, which causes some temporary swelling. Good for nasolabial folds, lips, mild to moderate wrinkles. It can be dissolved with Hyaluronidase. Lasts from 3-12 months; 6 months is about average.

Perlane

1.0 cc syringe, similar to Restylane
The "particle size" in the Perlane is larger, which makes the Perlane thicker. It tends to be used for deeper wrinkles and contouring. It is very good for deep nasolabial folds, straightening the jaw line. It can be dissolved with Hyaluronidase. Lasts 3-12 months; 6-9 months is about average.

Juvederm Ultra ( Juvederm 24 HV outside the US)

0.8 cc syringe, similar to Restylane
Injects very smoothly and tends to flow nicely under the skin. Very good for lip enhancement. Absorbs a little less water than Restylane so there is a little less swelling, which may be important in the lips. Even though the syringe is smaller, there is a higher concentration of Hyaluronic acid in the material which gives it about the same amount of Hyaluronic Acid as Restylane. It can be dissolved with Hyaluronidase. Lasts 3-12 months; average is about 9 months, less in the lips.

Juvederm Ultra Plus (aka Juvederm 30 HV in other countries)

0.8 cc syringe, similar to Juvederm Ultra, but 20% thicker
Very good for deep nasolabial folds. Softer than Radiesse, less likely to leave a palpable lump in the skin.

Sculptra

One vial can produce 6-10 cc of material.
Comes as a powder, must be mixed with water and local anesthetic at least 2 hours prior to use, preferably mixed 24 hours prior to use. The initial effect only lasts for a few days. The fluid is absorbed, but the powder is left behind. The powder causes the skin to get thicker. 3-6 treatments, space 1-2 months apart, are needed. Vigorous massaging is needed 5 times per day for a few weeks after the material is injected (this is done by the patient at home). Very good for replacing lost volume in the cheeks.

Dallas Plastic Surgery: Lecture on Restylane, Perlane & Radiesse.