About fillers and injectables
Any loss of volume, especially on the face, is always related to loss of innocence and youthfulness. First, lines begin to appear. Then the lines become deeper. What was plump becomes thinner and flat. Then more lines appear, growing in numbers. Like rubber bands that have been constantly pulled, fibroelastins and dermal supports begin to soften and stretch. Now, structures begin to follow gravity, creating the illusion of sadness and aging.
Volume lost should be replaced. One of the new developments in achieving volume replacement is by using fillers.
What are fillers? I think this has become a common household name. Just mentioning it doesn’t need any other explanations. It’s a filler, used to fill up a defect, correct a skin depression or a deep facial line or something. It is used to replenish lost volume, enhancing something that a client feels minutely or noticeably lost that is brought about by our normal aging and gravity. Our own body unfortunately degrades after time. Although our body continuously replaces our cells, some parts are not replaced as youthfully as we would expect. Proteins degrade and fibrin connections loss elasticity creating unwanted furrows and wrinkles.
But we have to agree on one thing. Fillers are just one of the many aesthetic tools that can address the same problem. Funny thing is, from the start of the 21st century, filler materials have boomed into the market, not only in South America and Europe, but also in Asia and America. Due to these numerous products, sometimes it is really confusing which one to use. The good thing here is that with numerous fillers, numerous specialists have also used them. This effect has resulted in the development of reports about their use and experiences, and right now, it has been an abundant array of data. Hence, our knowledge about indications, techniques and complications has been increasing, making us more able to deal with what kinds of result we can deliver to our clients’ desire. For more information about Fillers, the book on “Injectable Fillers in Aesthetic Medicine,” by Mauricio de Maio & Berthold Rzany (pub by Springer) is really fantastic and educational to read (http://bit.ly/bC2HAJ).
Let us not forget, however, that “one session only” filler delivery session is still a dream. Currently, achievement of happiness in its aesthetic form takes at least 2 to 4 sessions of filling delivery. Personally, I feel awkward in delivering substantial amount of fillers in one session, creating a super-enhanced look that sometimes can be frightening during the recuperation phases of healing. Of course, it is always safe to use these biodegradable fillers, especially if you are a beginner, or if it’s your first time to undergo (or do) the procedure, because after sometime, it gets resorbed and any unwanted result can dissipate. On the other hand, if its beautifully done, it will not last too. But if you like what you see, then go for the permanent fillers so that you don’t have to keep on coming back.
It’s also depressing to be putting in very small amounts in one session resulting in no result at all. There has to be a substantial amount invested here in order to see an effect. But don’t get confused in delivering little vs delivering too much. I get confused also, but I guess, too little is never appreciated and too much of anything is always bad. How will you know if you placed in just the right amount of filler?...a mirror is a best friend…well, also experience.
Let us start understanding the composition of a filler, how it reacts with our body, and how it achieves the goal on “filling.” There might be other preferences with other filler materials by other Plastic Surgeons or Dermatologists, but I just want to discuss some of my own choices here. The choice should always be a resolution based on the common understanding between patient and specialist regarding the purpose of filling, the effect it can produce and how long it will last.
Historically, silicone injection in the form of oil (silicone oil) was popularly used to correct volume loss or augment specific body parts. Unbelievably, it was cheap and easy to perform…anybody can do the injection, like a “fly-by-night” thing. After a few years, complications begin to appear. These complications include dermal hyperpigmentation (“rose spots”), abscess formation, gravitating fibrosis and loss of form. These complications are irreversible and permanent since the human body cannot degrade the silicone that was injected. More often, surgical resolution is needed, but resolves into a more morbid and sometimes debilitating outcome. Personally, silicone oil injection is not safe and is bound to develop complications.
Some concerns include allergic reactions after dermal filling. Earlier generations of fillers were developed from pigs. Bovine fillers like Endoplast-50 and Zyderm/Zyplast gave pleasing results in the management of fine to deep wrinkles and facial volume rejuvenation. Unfortunately, since these fillers are bovine origin, it’s always safe to do skin testing prior to the actual injection. But skin testing has been quite tasking and requires a lot of time and retesting; and quite sadly, clients lose their enthusiasm entirely about the procedure.
Biodegradable or non-biodegradable; cross-linked or not.
Biodegradability determines the longevity of the effects of the fillers. Different components determine their lasting effects. Some fillers are composed of calcium hydroxylapatite (Radiesse), which is like bone and therefore gets eliminated slowly…meaning, it provides a longer dermal filling/volume replacement result. Others have poly-L-lactic acid (Sculptra) that stimulates expansion of our own collagen which also provides lasting results. Lastly, dermal fillers with hyaluronic acids have many brands, each brand is different in its composition of HA, cross-linking and molecule size…just to cater the different indications and needs of the client and plastic surgeons as well.
Hyaluronic acid is a naturally occurring substance that is both biodegradable and biocompatible with the human body. HA is manufactured variably by cross-linking its molecules. Those without cross-linking are easily degraded by our body’s enzymes, but they are the thinnest and more viscous. These are “thin” fillers that usually take care of fine wrinkles without causing bulk and unwanted bumps. It cannot resolve volume loss.
Some fillers are cross-linked while others are not or in moderation. Cross linking creates a mesh, which also creates volume to the filler. Some are moderately cross-linked, while others are heavily cross-linked. Just like any other mesh, the heavier cross-linked dermal fillers tend to last longer and replace volume better. “Heavy” fillers take a longer time for our enzymes to degrade; and they are usually injected deep to avoid noticeable bumps or nodulations
Non-biodegradable or permanent fillers like Polyacrylamide hydrogel (Aquamid) have met some resistance in its use because of the possibility of long term infections and granuloma formations. But in the recent prospective RCT study by Michaela Ryan in a 5 year assessment of facial application of polyacrylamide hydrogel, showed good aesthetic outcomes with limited complications.
Micro or macromolecule
This is one manufacturing technology that is an added feature. Micromolecules can seep into small spaces in the dermis correcting fine to moderate wrinkles primarily over volume. Macromolecules, on the other hand, the bigger version tends to correct volume primarily. Giving back the volume eliminates the lines created by the loss of it. In addition, macromolecules do not migrate.
Below are some of the dermal fillers I use. Again, other plastic surgeons may have different preferences and reasons, but these are just my own tools.
Radiesse (http://www.radiesse.com/) is one form of soft tissue injectable fillers that is composed of micro spheres of synthetic calcium hydroxylapatite (30%) that is combined with a common hydro gel (70%). Since the hydroxylapatite component has similar chemical and structural characteristic as bone and teeth, it doesn’t elicit any chronic inflammatory or immune response; and more importantly, it does not migrate. (Grabb & Smith Plastic Surgery. Ch 45, 2007). Initially, this was approved by the FDA for filling of oromaxillofacial defects, soft tissue depressions, and laryngeal augmentation. In 2006, FDA approval for Radiesse was extended to the treatment of deep nasolabial folds and lipoatrophy.
What happens after injection of Radiesse is that the carrier gel is gradually absorbed by the body and new collagen formation occurs around the calcium hydroxylapatite microspheres. Based on studies, this calcium hydroxylapatite has been found out to be biocompatible and non-antigenic, meaning, sensitivity testing is not necessary prior to delivery. This is a temporary filler but lasts quite long, about 12 – 18 months (but some reports up to 6 years). There has also been reports about formation of small submucousal nodules in the lip occurring after shallow delivery of the filler for lip augmentation, so better go a little deeper or use a finer filler if dealing with the lips instead. The manufacturer of Radiesse is Bioform Medical, Inc. at http://www.bioforminc.com.
Sculptra (http://www.sculptraaesthetic.com/) consists of poly-L-lactic acid (PLLA) which is basically a biodegradable polyester derived from corn starch and sugar canes. This initiates the expansion of the body’s own collagen, resulting in a more lasting appearance. This was approved by the FDA in 2004 for the treatment of facial lipoatrophy secondary to HIV-associated medications. Now, Sculptra is being used to correct deep facial lines, frown lines, deep scars and deep nasolabial lines. This is usually delivered subdermally in a criss-cross (cross-hatch) pattern to minimize subdermal bumps later on. Sometimes, it’s best to dilute this filler to prevent the small bumps or papules from occurring which is usually not visible, but can be felt when pressing on the area injected. Some clinical trials showed that Sculptra can lasts up to 2 years.
Skinfill (http://www.webpromoitalia.com/) is based on a fluid Hyaluronic Acid gel that is stabilized with a new technological process called Coesix. Basically, this process decreases cell degeneration resulting in the longevity of result and durability of the “filling-up” effect we want to achieve. The same Coesix technology makes this filler very easy to introduce in the subdermal area It minimizes patient discomfort and some side reactions associated with crosslinked fillers.
Cross linked fillers are usually used to improve depth and volume and are generally viscous and dense. Cross linking creates a molecular mesh that increases its volume and therefore replaces “loss of volume” more adequately. Non-cross linked fillers are generally fluid and are usually used for facial hydration, fine wrinkle management and improves skin elasticity.
Skinfill is an affordable solution to lip augmentation and correction of moderate to deep facial wrinkling. Although this product is marketed by Promoitalia, it is distributed locally in the Philippines my Aemed, Inc.
Restilane (http://www.restylane.com/) is a partially cross-linked hyaluronic acid (HA) which can be used for correction of moderate to deep facial wrinkling and lip augmentation. Since HA occurs naturally in the body, there is no cross or allergic reaction. It is also naturally degraded within the body within at least 6months onwards. Restilane also works well with moderate wrinkles and depressions and once of the best results are with the use for lip augmentation.
Teosyal Ultimate (http://www.teoxane.com/) is a newly developed HA based dermal fillers. Teoxane has developed different filler viscosity that caters to the different types of wrinkles, depressions and volume replacement. This works well with depressed nasolabial folds, marionette lines and lip augmentation. Viability of the fillers may also reach the stability duration of Radiesse, almost approaching 2 years after final injection. Sadly, this is presently unavailable in the Philippines but can be ordered through their sister company in Korea or HK.
It is quite important to mention Silicone as a form of dermal filler. Historically, silicone injections were very popular because of its availability and low cost. Volume replacement using Silicone injection was amazing during its early use, but today, its use as a dermal filler should totally be abandoned. The complications and controversies that are presently occuring are numerous and sadly, almost all cases of Silicone injections are bound to develop some form of complication after time. Unlike HA, the body cannot degrade silicone; hence, instead of degrading the silicone, the body develops fibrosis, causing noticeable lumps that is observed to gravitate. Dermal reaction which is observed as hyperpigmentation (“redness”) may also be permanent and irreversible.
In the end
I really don’t know if this documentation about fillers added to the confusion of everything. It is always nice to know how things work and how we use this knowledge to accompany our expertise in providing the right kind of services to our clients.
Visit my website at arnoldangeles.com to learn more about dermal fillers and other cosmetic services.