Chapter 5 Fillers
General Filler Characteristics
1) Describe the ideal filler
Biocompatible, inexpensive, easily obtained, stored, and used, long-lasting and reversible, predictable with minimal migration, useful in multiple tissue planes, minimal side effects or complications
2) In what facial areas do fillers have greater longevity?
Relatively static areas, such as nasolabial folds, or areas rendered less dynamic by Botox allow for more sustained results. Filling dynamic areas of the face, such as the lips, reduces duration of filler effect.
Fat as Filler
3) How should fat be harvested, prepared and injected to ensure maximal effect?
Gentle harvest of the fat with low pressure suction coupled with gravity sedimentation or balanced centrifugation helps to preserve fat architecture. Coleman’s technique of small aliquot injection in multiple tissue planes aids in revascularization of the transferred fat.
Collagen Derivative Fillers
4) Describe Zyderm I, Zyderm II, and Zyplast?
Available in 1977, Zyderm I, derived from bovine collagen, is 95% type I and 5% type III collagen. Zyderm II has almost twice the concentration of bovine collagen of Zyderm I. These two formulations are injected in the more superficial dermis to treat fine to moderate lines, wrinkles, and scars, but they are degraded in about 3 months time.
Zyplast results from cross-linking bovine collagen with glutaraldehyde and has greater tissue longevity. It can be used in the deep dermis for deeper lines and folds but is degraded in 3 to 6 months time.
Allergic reaction for these products with bovine collagen has been reported as high as 5 percent. Therefore, antecedent skin testing with Zyderm I (about 0.1 ml) should be performed. Skin should be observed after several days and after 1 month for signs of allergic reaction. Of special note, the injection of Zyplast has resulted in retinal artery thrombosis.
5) How do Cosmoderm/Cosmoplast differ from Zyderm/Zyplast?
CosmoDerm 1, CosmoDerm 2, and Cosmoplast are analogous to Zyderm 1, Zyderm II, and Zyplast but are human collagen dermal fillers and do not require skin testing. Cosmoderm is used for more superficial lines, while Cosmoplast is used for more pronounced wrinkles. Results last up to 6 months.
6) What are the contraindications of injectable collagen?
Autoimmune disease, deep pock or ice pick scars, immature or indurated scars, and positive skin reactions are contraindications.
7) What is Evolence?
Approved in 2006, Evolence is a cross-linked porcine collagen indicated for moderate to deep facial wrinkles and the nasolabial fold. Evolence proved superior for the treatment of nasolabial folds to Zyplast beyond 6 months.
Hyaluronic Acid Analogues
8) What is hyaluronic acid (HA)?
Hyaluronic acid is a naturally-occurring polysaccharide in human soft tissues such as skin, cartilage, and bone. It is identical in form in all mammalian species. Thus, there is no concern for allergenicity. Hyaluronic acid is hydrophilic and aids in tissue hydration. HA decreases with age, which results in reduced skin turgor, increased wrinkling, and a general deflation of tissues.
9) What is the half-life of HA?
The half-life of HA is only 1 to 2 days.
10) What is Restylane?
Restylane is a cross-linked HA from a bacterial source that can last from 6 months to 1 year. Restylane can be used for moderate to severe facial wrinkles and the nasolabial fold. It should be injected at the mid to deep dermis.
11) Describe Hylaform and Hylaform Plus?
Approved in 2004, Hylaform and Hylaform Plus are avian hyaluronic acids indicated for mid to deep dermis correction of moderate to severe facial wrinkles and the nasolabial fold. Hylaform Plus has a larger particle size compared with Hylaform. Results can last 1 year.
12) What is Captique and how does it differ from Hylaform?
Approved in 2004, Captique differs from Hylaform in that it is obtained from a bacterial source. It is indicated for mid to deep dermis correction of moderate to severe facial wrinkles and the nasolabial fold. Results may last 1 year.
13) What is Juvederm?
Approved in 2006, Juvederm is a dermal filler that lasts up to 12 months and is indicated for correction of moderate to severe facial wrinkles and folds. Juvederm Ultra is thinner, while Juvederm Ultra Plus is thicker. Juvederm Ultra Plus can be used to restore volume but should be injected in the deep dermal or subdermal level.
14) What is Perlane and how is it different from Restylane?
Perlane is an HA derivative that is more viscous with a much larger gel particle size than Restylane. Perlane should be injected at the deep dermal or subdermal level to treat deeper folds. Results can last up to 1 year.
Radiesse and Sculptra
15) What is Radiesse, formerly Radiance?
Radiesse contains calcium hydroxyapatite beads in an aqueous gel. Fibrous encapsulation of the hydroxyapatite particles produces a long-term result. Radiesse may last up to 2 years and should probably not be used in the lips.
16) What is Sculptra?
Sculptra is composed of injectable poly-L-lactic acid polymer that provides a gradual increase in dermal thickness and facial volume. Results may last two years. It is FDA approved only for the treatment of HIV-associated lipodystrophy of the face.
17) Discuss intrinsic problems of injecting permanent fillers?
Permanent fillers can lead to permanent complications that are difficult to treat or correct. Moreover, areas treated with such substances may not age in the same way as the rest of the face.
18) What is Artefill?
Artefill is the first and only permanent filler approved by the FDA and available for use in the US. It contains polymethylmethacrylate in bovine collagen and lidocaine. Artefill is indicated for the correction of the nasolabial fold. It is not to be used for lip augmentation or in known keloid formers.
Less Popular Fillers and Fillers not FDA approved
19) What is Cymetra?
Cymetra is an injectable form of Alloderm. Its longevity is at most 6 months and is more expensive than HA derivatives. Its consistency is irregular and lumpy. It is indicated for lips, nasolabial folds, and deep wrinkles. It is contraindicated in patients with autoimmune connective tissue disease and in poorly vascularized surgical sites.
20) What is Fascian?
Fascian is injectable human cadaveric fascia (eg. fascia lata) that stimulates collagen formation and lasts up to 6 months. It has an irregular consistency and larger particle size, which makes precise injection more difficult. Fascian can be used as a volume enhancer for the nasolabial fold.
21) What is Gore-Tex?
Gore-Tex is expanded polytetrafluoroethylene (ePTFE) which will persist in tissue. However, it must be trimmed to fit the area to be augmented and palpability can be an issue.
22) What is Autologen?
Autologen is an acellular, collagen fiber filler extracted from human dermis in which the specimen is obtained from an individual during another surgery. Its production requires individual processing and is costly.
23) What is Dermalogen?
Dermalogen was made from cadaveric dermis. This allowed for mass production, greater quality control, and reduced cost. Dermalogen has not been made since 2001.
24) What is Isolagen?
Not FDA approved. Isolagen is a cultured autologous fibroblast filler, which involves harvest of a dermal specimen from the patient and several weeks culture time. It has a delayed fill response as new collagen must be produced from these fibroblasts after injection over a period of months. Studies for the product have shown persistence at 4 years.
25) Can silicone be used as a dermal filler?
Silicone is not FDA approved for cosmetic use.
26) Describe various methods to reduce discomfort of filler injections?
Refrigerant sprays before needle insertion can blunt pain perception at the superficial level. This item should not be used on mucosal surfaces. Vibration massagers and ice are useful adjuncts. Pinching the skin at the time of injection can also reduce pain. Smaller gauge needles (eg. 30 or 32) with a tuberculin syringe can reduce injection pain. Topical anesthetics should be applied 30 to 60 minutes before injection and should not be used on mucosal surfaces. Articaine 4% (Septocaine), which has a higher pH than lidocaine, causes less pain upon injection. Infraorbital blocks for nasolabial folds and upper lips and mental blocks for marionette lines and lower lips provide anesthesia with minimal distortion.
27) Discuss the differences of anterograde and retrograde injection of fillers?
Anterograde injection may yield a softer forward movement through tissues and blunt the impact and pain of the needle tip. Some believe it pushes vessels away to prevent inadvertent trauma.
Retrograde injection may help avoid intravascular injection and may be useful in thin areas so that additional dissection pathways are not produced upon injection.
28) Describe linear threading, fanning, and cross-hatching and their utility in even symmetric filler injection and dispersal?
Linear threading can be done anterograde or retrograde and is most useful for the vermilion border and the nasolabial fold.
Fanning involves evenly spaced delivery in a clockwise or counterclockwise manner
Cross-hatching utilizes a series of threading injections made in a grid-like pattern to optimize filler use and create a more even contour.
29) Describe techniques to avoiding swelling and bruising?
Careful avoidance of visible superficial vessels is critical. Patients should avoid medications with anticoagulant effect at least several days before treatment. Firm pressure after treatment as well as post-injection ice packs can reduce swelling and bruising.
30) Describe common cosmetic complications of filler use?
Asymmetry, surface irregularities, undercorrection, and overcorrection are all relatively common and are technique and experience dependent.
31) How can one avoid nodule formation?
Use smaller-gauge needles (30 or 32 gauge) to control the amount of filler injected. Do not overcorrect areas and do not inject too superficially. Massage can be used to distribute filler more evenly.
32) Describe nodule management?
Home massage by the patient is a conservative approach. Corticosteroid injection as well as puncture and aspiration may be useful as well. Hyaluronidase can be used for HA analogues. Excision is the final option.
33) Comment upon intravascular injection prevention and management if intravascular injection occurs?
Slow injection with low pressure can be helpful. Injection of the angular artery during nasolabial fold correction or supratrochlear artery injection during glabella rejuvenation are two areas of concern. Sudden pain or blanching of the area could be warning signs of an intravascular injection. Once it occurs, a topical vasodilator such as nitroglycerin can be applied. One can inject hyaluronidase for HA fillers. Some have recommended LMWH daily for 1 week. Conservative treatment is the rule as these infrequently result in full thickness tissue necrosis.
34) Describe a reasonable approach to midface treatment with fillers?
Malar contour should be restored first. This results in a lifting and volumizing effect that can reduce the appearance of the nasolabial folds. Furthermore, this can reduce the need to treat the tear trough or orbitomalar area.
35) Describe additional filler applications?
Fillers can be used for the nasal dorsum and tip due to surgical depression or age-related atrophy. Fillers at the base of the columella can be used to lift the nasal tip. Fillers can be useful in smoothing the appearance of chin implants. They also have utility in plumping the sagging earlobe.
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Click on the links below to view a few of the chapters written by Dr. Hughes
Chapter 2: Photography in Plastic Surgery
Chapter 3: Facelift
Chapter 4: Fat Grafting
Chapter 5: Fillers
Chapter 6: The Role of Dermal Matrices in Breast Augmentation
Chapter 7: Scar Revision in Plastic Surgery
Come to Hughes Plastic Surgery in Los Angeles and Beverly Hills. You will be glad that you did.