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Surgery and Cosmetics

Davi De Lacerda, MD, FAAD

Fillers for the Body

Davi de Lacerda

Wednesday, December 14, 2011

Fillers are increasingly being used for both medical and cosmetic purposes - not only for facial areas but also for body contour and rejuvenation. Medically relevant body deformities may be caused by trauma or post-surgical defects, eg after tumor removal. They also result from medication-induced lipoatrophy, as seen with HIV treatment, or can be genetically determined, as in the case of Bernardinelli-Sapie syndrome.1

The aesthetics of the body immediately after puberty, in both men and women, derive from the volumetric proportions of muscle and fat in the proximal limbs, breast, abdominal area and buttocks. Ageing leads to significant body fat redistribution: fat accumulates in the abdomen, whereas there is progressive subcutaneous and muscular atrophy in the limbs.2,3

Fillers can contribute to a more aesthetic and healthy appearance of the body by restoring or improving volumes in deficient areas. As a general rule, volumes required to treat body areas are much larger than those used for the face. Therefore, this limits the choice of fillers to those products that are cost-effective.4

Fillers can be divided into self- or non-self-derived products. Non-self-derived fillers are classified either as resorbable or non-resorbable (permanent) products. A list of common fillers is displayed in Table 1. This article will summarize important aspects of fillers used for the body - their indications, advantages and drawbacks. Emphasis will be given to fat and hyaluronic acid (HA) fillers because they are safe and cost-effective, and provide excellent results.

Table 1. Common fillers used for body correction are marked in bold.

 

Self-derived Fillers

Tissue can be extracted from the body and re-injected elsewhere as a filler. Self-derived fillers require collection, processing, and an implantation technique specific for each tissue used.

Fat

Fat is used immediately after being collected by blunt cannulae. Liposculpture has been used for many decades, and offers excellent results in the hands of experienced surgeons. Risks are low, especially when tumescent anesthesia is used. Results are immediate and can last months to years (Figure 1).
 

Figure 1. Left-hand image: Cicatricial depression after wide melanoma excision. Right-hand image: Results 1 week after a second course of filler correction. The total volume used in the two sessions was 40 mL. Fat was aspirated from the abdominal wall. Results have been maintained 5 years after the procedure.

Fat remains the gold-standard procedure because it addresses simultaneously two major concerns of our patients: (i) removal of undesired fat, which tends to accumulated in anatomic areas such as the belly, love handles or thighs; and (ii) replacement with virtually identical tissue, providing similar properties to the lacking structure in the recipient area. Nevertheless, in addition to inherent complications of a surgical procedure, donor fat is not always available, particularly in those patients who need it most, ie those affected by lipoatrophy (Figure 2). In addition, graft-taking is not easily predictable - it may encapsulate, be irregularly or completely reabsorbed, or induce calcification. The latter may be mistaken in fat-augmented breast for neoplastic mammographic changes by an inexperienced radiologist.5-7

 

Figure 2. Fat collection from the abdomen. Amounts of filler are usually enough for facial procedures, but may not be sufficient for body filling, especially in patients who need it most, such as those affected with HIV-related lipoatrophy.

Fat transfer is an evolving technique. As well as improvements in fat harvesting, the placement of small volumes over several sessions (Coleman technique) can lead to prolonged graft survival. Enriching grafts with pre-adipocites can also improve results, as it is assumed that these cells are required for ultimately enhancing volume by replacing fat progenitor cells in the recipient area. Recently, mixing fat tissue with platelet-rich plasma (PRP) has become popular. However, there is not enough evidence as yet to prove that PRP significantly improves results.8-10

Cultured pre-adipocities may theoretically be a source of abundant filler after extraction of minimal amounts of tissue. The long-term risks of manipulating cells in Petri dishes for subsequent reinjection into our bodies, including the potential for inducing neoplasia, are realistic limitations to using cultured cells for cosmetic purposes.11-13

Non-self-derived Fillers

The ideal filler for the body is a sterile material that can be promptly placed into the subcutaneous compartment, producing significant long-lasting, fat-like volumetric changes without being rejected.

Non-resorbable (Permanent) Fillers

Liquid silicone, polyacrylamide gel and poly-methyl-methacrylate (PMMA) are non-resorbable fillers approved for body use in many countries. Non-resorbable fillers require fewer procedures for achieving satisfactory results and are inexpensive. The fibrotic reaction induced by permanent fillers may contribute to further volumetric improvement, in addition to the actual amount injected. Fibrosis may induce textures that are harder than fat, but this should not represent a problem if the filler is placed deeply enough in the subcutaneous layer; accordingly, most patients treated with permanent fillers describe satisfactory long-term cosmetic outcomes.

However, permanent fillers present a lifetime risk of inducing foreign-body granulomas. Devastating foreign-body reactions can develop decades after filler placement, particularly in the setting of distant bacterial infections or when pro-inflammatory drugs, such as interferon, are used. Intravascular injection of permanent fillers can also lead to irreversible necrosis, particularly when performed by untrained persons, as demonstrated below (Figure 3).14-16

 

Figure 3. Skin necrosis after inadvertent intravascular injection of liquid silicone for cellulite treatment in the buttocks. The injection was performed in a "cosmetic saloon" a week before.

Resorbable Fillers

Poly-l-lactic acid and hydroxyapatite are slowly resorbed products that also induce fibrosis. They are used for the treatment of lipoatrophic aging signs in the hands and décolleté. If injected superficially, granulomatous reactions may cause significant distress and require surgical removal. HAs and collagens traditionally marketed for the face also provide excellent results for smaller dermal scars (Figure 4). However, their cost is usually prohibitive for breast or gluteal augmentation. 
 
 

Figure 4. Treatment of dermal scars in the abdomen using porcine collagen (EvolenceTM) (blue and green arrows). The figure shows the scarred area before treatment (left-hand image) and 3 years after treatment (right-hand image), demonstrating long-term results. The scar indicated with the pink arrow was surgically removed. 

Body HA Fillers

Large-particle HA preparations for body implantation are available. The products are provided in large (10 mL or 20 mL) sterile syringes ready for injection. MacrolaneTM was the first product available and is the body-designed version of the traditional biphasic, non-animal, stabilized HA Restylane® line. There is a harder form for deeper application and a softer one for superficial corrections. VariofillTM is a monophasic HA filler alternative for body use.

The use of HAs in the face for more than two decades has provided good evidence for their safety. Body preparations of HAs are now marketed for breast augmentation - injection under the breast gland does not seem to cause problems and is easily identified by mammography. Nevertheless, the safety of placing HA into glandular tissue has been disputed. HA breast augmentation is less invasive than placement of silicone prostheses; however, because HA is a fast-reabsorbing material, the overall cost for maintaining results is significant.4,17

HA provides excellent and cost-effective results for reshaping smaller body-surface depressions, such as post-liposuction irregularities. It is also excellent for treating lipoatrophy in patients without enough donor fat areas. Accordingly, strategic placement of even moderate amounts of HA can lead to dramatic improvements, as seen in the gluteal correction of patients with severe lipoatrophy (Figure 5). The duration of results seen with HA body fillers is variable, ranging from a few months to years,15 and depends on technique and individual factors. 
 
 

Figure 5. Significant improvements in gluteal HIV-related lipoatrophy following an injection of 30 mL HA acid (MacrolaneTM FR20) into the depressed medial regions.

Adverse effects following the application of large amounts of HA filler to the subcutaneous compartment include migration and encapsulation. They can be reduced by using small volumes over several sessions, and treated by repositioning the product with massage or needle puncture of the fibrotic capsule, and subsequent pinching the area manually in order to spread the material into the surrounding tissue.

The use of fillers for the treatment of cellulite is controversial. Much of the problem is related to the large spectrum of presentation of cellulite and difficulties with its classification. Flacidity of the skin may also be mistaken as cellulite, further complicating conclusions.

Nevertheless, in my personal experience, fillers can be used for the treatment of superficial body irregularities in the buttocks and thighs in selected cases. The best available filler, and the only one I have experience with, owing to its acceptable risk, is HA. Its texture is very similar to natural tissue and can be applied with good results for deep furrows after the attached fibrous septum has been released with the subcision technique. Although some doctors use it immediately after the subcision, I prefer to wait at least a few months to avoid over-correction or unnecessary treatment with the filler.

I have not used volumizing fillers for minimal degrees of cellulite because I fear that the hygroscopic properties and potential for encapsulation can actually worsen skin surface irregularity, similar to what happens with localized weight gain. However, I speculate that injecting very soft fillers with mesotherapy techniques could potentially be helpful, possibly by improving dermal firmness.

In summary, although I believe fillers are potentially helpful for a subgroup of patients with cellulite, further studies are necessary to determine what are (i) the precise indications, (ii) the most appropriate fillers, and (iii) the best injection techniques.

Conclusions

Although fat remains the gold-standard filling material for body subcutaneous placement, large-volume resorbable HA fillers sold at reasonable cost have recently become available. They allow for convenient and minimally invasive procedures, turning body filling into a more attractive and safe cosmetic alternative. However, expertise in filling injection techniques and knowledge of the anatomy and aesthetics of the body are required for obtaining satisfactory results.

References

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  2. Kuk JL, Saunders TJ, Davidson LE, Ross R. Age-related changes in total and regional fat distribution. Ageing Res Rev 2009;8:339-348.
  3. Sepe A, Tchkonia T, Thomou T, Zamboni M, Kirkland JL. Aging and regional differences in fat cell progenitors - a mini-review. Gerontology 2010;57:66-75.
  4. Hedén P, Sellman G, von Wachenfeldt M, Olenius M, Fagrell D. Body shaping and volume restoration: the role of hyaluronic acid. Aesthetic Plast Surg 2009;33: 274-82.
  5. Kanchwala SK, Glatt BS, Conant EF, Bucky LP. Autologous fat grafting to the reconstructed breast: the management of acquired contour deformities. Plast Reconstr Surg 2009;124:409-418.
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  7. Carvajal J, Patiño JH. Aesthetic Surg J 2008;28:153-162.
  8. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg 2001;28:111-119.
  9. Salgarello M, Visconti G, Rusciani A. Breast fat grafting with platelet-rich plasma: a comparative clinical study and current state of the art. Plast Reconstr Surg 2011;127:2176-2185.
  10. Sterodimas A, de Faria J, Nicaretta B, Boriani F. Autologous fat transplantation versus adipose-derived enriched lipografts: a study. Aesthet Surg J 2011;31:682-693.
  11. Choi JH, Gimble JM, Lee K. Adipose tissue engineering for soft tissue regeneration. Tissue Eng Part B Rev 2010;16: 413-426.
  12. Jeong SH, Han SK, Kim WK. Soft tissue augmentation using in vitro differentiated adipocytes: a clinical pilot study. Dermtol Surg 2011;37:760-767.
  13. Cook A, Cowan C. The Stem Cell Research Community. In: StemBook: Adipose; 2009.
  14. Nicolau PJ. Long-lasting and permanent fillers: biomaterial influence over host tissue response. Plast Reconstr Surg 2007;119:2271-2286.
  15. Salles AG, Lotierzo PH, Gemperli R, et al. Complications after polymethylmethacrylate injections: report of 32 cases. Plast Reconstr Surg 2008;121:1811-1820.
  16. Fischer J, Metzler G, Schaller M. Cosmetic permanent fillers for soft tissue augmentation: a new contraindication for interferon therapies. Arch Dermatol 2007;143:507-510.
  17. Chaput B, De bonnecaze G, Tristant H, et al. [Macrolane(®), a too premature indication in breast augmentation. Focusing on the current knowledge of the product]. Ann Chir Plast Esthet 2011;56:171-179.
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