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Surgery and Cosmetics

Doris M. Hexsel, MD

Filling Agents

Doris M. Hexsel, MD

Monday, April 04, 2005

Soft tissue augmentation (STA) techniques are minimally invasive surgical procedures in which filling agents (fillers) or surgical techniques alone are used to increase or replace local volume. They are highly effective in the rejuvenation, as well as the aesthetic and functional restoration, of the face. As cited by Arnold Klein, they represent three-dimensional treatments and the results are technique-dependent.

Fat grafting is recognized as the first STA technique used for cosmetic purposes. 1 The constant improvements in liposuction techniques have permitted this technique to remain up to date, as fat is still considered to be a filler of great utility today.

Since the end of the nineteenth century, the need for filling materials has increased. Fillers are used to replace volumes lost as a result of aging or certain pathological conditions, or in order to enhance the beauty of the face. Over this period, oils and paraffins,2,3 followed by liquid silicones, were used as filling agents,4 later to be abandoned due to the problems that they caused. STA techniques developed slowly until the 1980s, when there was renewed interest in the use of these materials.

The introduction of bovine collagens, the first fillers recognized as being effective, led to a new era in the use of fillers, in which their value and importance in the treatment of aging and in beauty enhancement of the face were consolidated. 5

Indications

The main indications for fillers are lip augmentation (see Figures 1 and 2), facial wrinkles and lines (see Figures 3 and 4), depressed scars (see Figures 5-7), asymmetries, and other subcutaneous facial defects.4,6,7 In recent years, lost volume of the face is a new, modern and natural indication for fillers.

Figures 1 and 2: Before Restylane® and 2 months after Restylane® in the correction of nasolabial fold, peri-oral wrinkles, and lip augmentation

Before Restylane® and 2 years after Restylane® in the treatment of nasolabial fold

 

Before treatment with liquid injectable silicone of 350cs, 3 months after, and 5 years after the correction of trauma scars on the upper lip (from Sebbin Laboratories, France)

 

Lips are considered to be one of the most important facial structures in the beauty of the face. Because of the natural loss of volume of the lips with aging, as well as the appearance of peri-oral wrinkles, lips and the peri-oral area are often classical targets for fillers. Transitory fillers, such hyaluronic acid and collagen, are the preferred fillers for lips.8

Wrinkles have a number of causes (photodamage, muscular action, sleep habits) and should be approached based on the nature of their origin. As tissues vary in their consistency, different fillers may be recommended, and even combined, in the treatment of the same patient.6

Some fillers can be injected only at specific skin levels; others are more versatile and can be injected at various levels, superficially or at greater depth. Different materials may be necessary to replace lost volume to achieve an appropriate degree of consistency and to obtain a more natural appearance. Different fillers can be injected during the same treatment session, depending on the nature of the treatment to be performed.6

Superficial wrinkles are usually fine lines and can be treated with intradermic and transitory fillers. Deeper wrinkles and folds require subcutaneous fillers. Currently, the most widely used transitory fillers contain hyaluronic acids and collagens, such as Restylane® and Perlane®, Hylaform® and Hylaform Plus®, Juvederm® in three different concentrations, and CosmoDerm® and CosmoPlast®. These versatile fillers produce very natural results, as they replace natural compounds from the skin. A further advantage offered by these products is that they can be injected superficially and subcutaneously.

All permanent fillers provoke some fibrosis around the implant, leaving the skin with a harder-than-normal consistency.9 They can be used for the replacement of denser tissues, like bone and cartilage, and in the restoration of the facial contour. Polylactic acid (PLA) represents a new generation of fillers that can promote a new collagen formation from small volumes injected at deep levels for facial contour restoration. Liquid-injectable silicone seems to be safe in small amounts delivered by micro-droplet technique. In the correction of scars, it gives long-lasting results (see Figures 5-7).

As yet, there is no definitive classification of filling agents. Here, we present classifications based on materials and durability:

 

Table 1. Classification of fillers according to materials. 


I - FILLERS THAT USE BIOLOGICAL MATERIALS FROM HUMAN BODY
1. Autologous
a) Autologous fat transplantation
b) Autologous dermal grafting
c) Blood/Subcision®
d) Vein grafting
e) Autologen®
f) Isolagen®
2. Heterologous
a) Dermalogen®
b) AlloDerm®
c) Cymetra®
d) Fascian®
e) CosmoDerm®
f) CosmoPlast®
II - FILLERS THAT USE BIOLOGICAL MATERIALS FROM OTHER LIVING BEINGS
1. Bovine collagen
a) Zyderm I and II®
b) Zyplast®
c) Arteplast®
d) Artecoll®
e) Artefill®
f) Koken Atelocollagen®
g) Resoplast®
2. Porcine collagen
a) Fibrel®
b) Permacol®
3. Hyaluronic acid from coxcombs of domestic fowl
a) Hylaform®
b) Hylaform Plus®
c) IAL System®

4. Hyaluronic acid bacterial fermentation
a) Restylane®
b) Restylane Fine Lines®
c) Perlane®
d) Juvederm®
e) Dermalive®

f) Dermadeep®

III - NONBIOLOGICAL OR INORGANIC FILLERS
1. Injectable silicone
a) Liquid Injectable Silicone Sebbin®, SilSkin®, Silikon® 1000
b) Biopolimer III® or Biocell Ultravital®
c) PS-35®
d) Bioplastique®
2. Methacrylates
a) Arteplast®
b) Artecoll®
c) Artefill®
d) Dermalive®
e) Dermadeep®
3. Expanded polytetrafluoroethylene (e-PTFE)
a) Gore-Tex®
b) SoftForm®
4. Polyacrylamid
a) Hidrogel®
b) Outline®
c) Aquamid®
d) Evolution®
5. Polylactic acid
a) New Fill®
b) Sculptra®
6. Hydroxyapatite
a) Radiance®

 

Table 2. Classification of fillers according to durability.


1. Temporary fillers
a) Autologous fat
b) Collagens
c) Hyaluronic acid
d) Polyacrylamides
e) Polylactic acid
2. Long-life or permanent fillers
a) Injectable silicones
b) Methacrylates
c) e-PTFE
3. Biphased fillers (2 phases: combination of 1 temporary and 1 permanent filler)
a) Bioplastique®
b) Arteplast®
c) Artecoll®
d) Artefill®
e) Evolution®
f) DermaLive®
g) DermaDeep®

Complications

Most complications resulting from the use of STA techniques are transitory and secondary to the trauma caused by the technique, injection, or implant of the filler.6,10 In general, they are common to all techniques and to all fillers and include erythema, edema, hematomas (see Figure 8), ecchymosis, and some infections, such as a recurrence of herpes.6

Hematoma and edema in the upper lip, after lip augmentation with Restylane®

Allergic reactions may occur with some fillers, such as hyaluronic acids11-13 and collagens,14,15 and but with prior testing they can be prevented. Granulomas and infections may occur and may be related to the patient, the technique, or the materials used.6,9

Greater, more persistent, and delayed complications are more common with permanent fillers and may also be provoked by technique-related problems.6 They include allergic reactions; recurrent edema with or without erythema; idiosyncrasy; granuloma;13,16 alterations to skin texture, consistency, and sensitivity in the treated region; the emergence of erythema and telangiectasia similar to rosacea;17 infections; and migration as well as spontaneous extrusion of the filling agent.

Excessive elevation, overcorrection and nodules, asymmetries and distortion, disease transmission, necrosis, lymphatic blockage, and embolism are eminently technique-related problems.

Conclusions

Knowledge of the characteristics of the different cutaneous fillers (such as the level at which they can be implanted, depth to be injected, and others) is of fundamental importance for the correct indication and to obtain the best results.6

Fillers can be used in combination with other medical or surgical treatments in the same or different treatment sessions.6,9,18 As well as this advantage and the proven efficacy of these treatments, other advantages when compared to conventional surgery (such as the absence of scars, quick recovery, ambulatory nature, and minimal risk) make fillers an attractive alternative for doctors and patients and explain the enormous demand for such procedures in dermatological clinics throughout the world.

New filling agents are launched each year, stimulated by this promising market. These materials should neither be judged nor used solely on the basis of the patient's initial satisfaction or publicity campaigns, but rather on the medium-to-long-term results obtained from well-conducted scientific studies that permit their approval by competent authorities.6,9

The ideal filler should provide natural results in terms of both appearance and sensation, and it should be safe and effective for our patients.

 

References

  1. Neuber F. Fettransplantation. Chir Kong Verhandl Dsch Gesellsch Chi. 1893;22:66.
  2. Gersuny R. Ueber eine subcutane prosthese. Z Heilkd. 1900; 1:199-200.
  3. Khoo Boo-Chai MB. Paraffinoma. Plast Reconstr Surg 1965; 36:101-110.
  4. Orentreich DS, Orentreich N. Injectable fluid silicone. In: Roenigk RK, Roenigk HH Jr. Dermatologic surgery: principles and practice. New York: Marcel Dekker; 1989:1349-1395.
  5. Dzubow LM, Goldman G. Introduction to soft tissue augmentation: a historical perspective. In: Klein AW, ed. Tissue Augmentation in Clinical Practice: Procedures and Techniques. New York, NY: Marcel Dekker; 1998:1-22.
  6. Hexsel D, Dal-Forno T. Técnicas de Preenchimento Cutâneo. In: Ramos-e-Silva M, Castro MCR, eds. Fundamentos da Dermatologia. Atheneu: Rio de Janeiro, in press, 2004.
  7. Brown LH, Frank PJ. What's new in fillers? J Drugs Dermatol. 2003 Jun;2(3):250-253.
  8. Fulton JE Jr, Rahimi AD, Helton P, Watson T, Dahlberg K. Lip rejuvenation. Dermatol Surg. 2000;26(5):470-474; discussion 474-475.
  9. Hexsel D, Hexsel C, Iyengar V. Liquid injectable silicone history, mechanism of action, indications, technique, and complications. Sem Cut Med Surg. 2003;22(2):107-114.
  10. Duffi DM. The Silicone Conundrum: A battle of anecdotes. Dermatol Surg. 28(7):590-594,2002.
  11. Lupton JR, Alster TS. Cutaneous hypersensivity reaction to injectable hyaluronic acid gel. Dermatol Surg. 2000;26:135-137.
  12. Friedman PM, MD, Mafong EA, MD, Kauvar ANB, MD. Safety Data of Injectable Nonanimal Stabilized Hyaluronic Acid Gel for Soft Tissue Augmentation. Dermatol Surg. 2002:28:491-494.
  13. Acenero MJF, MD, Zamora E, Borbujo J. Granulomatous Foreign Body reaction Against Hyaluronic Acid: Report of Case After Lip Augmentation. Dermatol Surg. 2003;29:1225-1226.
  14. Sclafani AP, Romo T. Injectable Fillers for Facial Soft Tissue Enhancement. Facial Plastic Surgery. 2000;16(1):29-34.
  15. Ruszczak Z, Schwartz RA. Collagen Uses in Dermatology - An Update. Dermatology. 1999;199:285-289.
  16. Duffy DM. Injectable Liquid Silicone: new perspectives. Tissue Augmentation in Clinical Practice: Procedures and Techniques. Los Angeles, Marcell Dekker: 237-267,1998.
  17. White MI. Smart LM, MacGregor M et al. Recurrent facial oedema associated with a silicone-rubber implant. B J Dermatol. 125:183-185,1991.
  18. de Maio M. The Minimal Approach: An Innovation in Facial Cosmetic Procedures. Aesthetic Plast Surg. 2004;4.
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