Dermal Fillers

 Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

Unlike with the quilt (see Trapunto quilting) where you are taking the surface from flat to puffed, when dealing with the aging face the goal is to "fill" in a fold or crease that has lost volume to get it to a more "flat" surface. Soft tissue augmentation has become a popular means of addressing contour defects that result from aging, trauma and/or scarification (ie acne), or disease (ie HIV associated lipoatrophy).

ArteFill is made of permanent, non-resorbable microspheres (20%) of polymethylmethacrylate (PMMA) which become part of the patient’s own tissue, filling in the wrinkle for enduring correction. These microspheres range in size from 30-50 microns in diameter. These microspheres are suspended in a gel carrier (80%) of purified bovine collagen and 0.3% lidocaine. After the injection, the collagen degrades over a period of approximately 3 months. At the same time, the PMMA becomes encased in the patient's own collagen which is produced in response to the foreign material. It was the first FDA approved dermal filler. It comes in syringes containing 0.8 cc and 0.4 cc ArteFill. ArteFill is contraindicated in anyone with a known allergy to bovine collagen or lidocaine. A skin test must be done. If the skin test response is positive, the patient must not be treated with ArteFill. If the skin test response is equivocal, it is recommended that a second skin test be administered in the opposite arm and evaluated prior to the initiation of treatment. It is used in the glabellar frown lines, nasolabial folds, upper lip line and mouth corners. Adverse reactions include granulomas. Technique is critical in minimizing these reactions. It is recommended that the linear retrograde tunneling method be used in working with ArteFill. It is a product of Artes Medical.

Juvéderm™ is a smooth consistency gel made of hyaluronic acid approved by the FDA in June 2006. It contains the highest concentration of cross-linked hyaluronic acid currently available. Juvéderm™ Ultra and Juvéderm™ Ultra Plus are indicated for injection into the mid to deep dermis for correction of moderate to severe facial wrinkles and folds (such as nasolabial folds). Both are supplied in individual treatment syringes with 30- or 27-gauge needles for single patient use and ready for injection. Typically 1.6 cc is enough for each site. Correct only to 100% of the volume desired. It is important to avoid over correction. Patients should be limited to 20 mL of JUVÉDERM injectable gel per 60 kg (130 lbs) body mass per year. A linear-threading technique, serial puncture injections, or a combination of the two have been used to achieve optimal results. To avoid visible lumps and/or discoloration, avoid injecting too superficially. Side effects were usually mild to moderate lasting 7 days or less and included temporary injection site reactions like redness, pain, firmness, swelling and bumps. It is a product of Allergan.

Radiesse is composed of microspheres of calcium-hydroxylapatite suspended in an aqueous gel carrier. The biodegradable microspheres serve as a lattice upon which the body forms scaffolding for tissue infiltration. The spheres slowly degrade. The improvement is effective for 9-18 months. It also has the ability to stimulate new collagen formation. Radiesse was recently approved by the FDA for the correction of moderate to severe facial folds and wrinkles around the nose and mouth, including nasolabial folds. Radiesse is biocompatible and does not require pre-testing. It is provided in a sterile, pre-filled, single use syringe containing 1.3 cc intended for treatment or a 0.3cc syringe intended for touch-ups and small volume applications. Side effects may include swelling, bruising, pain, itching, and tenderness at the injection site. These conditions typically resolved on their own within one to two days. It is a product of BioForm Medical.

Restylane was approved by the FDA in 2003. It is a non-animal stabilized hyaluronic acid gel. Restylane is free from animal proteins. This limits any risk of animal-based disease transmissions or development of allergic reactions to animal proteins. Perlane is a more robust form of Restylane intended for use in the deep dermis and at the dermal-fat junction. Restylane is indicated for the correction of moderate to severe facial wrinkles and folds. The most commonly observed side effects are temporary redness and swelling at the injection site, which typically resolve in less than seven days. Both are made by Medicis.

Sculptra is an injectable implant that contains microparticles of poly-L-lactic acid (PLA), a biocompatible, biodegradable, synthetic polymer from the alpha-hydroxy-acid family. It is reconstituted prior to use by the addition of sterile water for injection to form a sterile non-pyrogenic suspension. The particles of PLA stimulate the formation of new collagen in the skin, adding volume over time. The results are not immediate and a series of three or more treatments, spaced approximately one month apart, are usually recommended. PLA degrades more slowly than some filling substances, and longevity of 18-36 months (after 3 treatments) is possible. Sculptra may be injected either into the superficial dermis for the treatment of wrinkles and acne scars or subdermally to add volume to the cheeks, temples, and hands to correct contour deformities. The most common device related adverse effect was the delayed occurrence of subcutaneous papules, which were confined to the injection site and were typically palpable, asymptomatic and non-visible. It is a product of Dermik/Sanofi-Aventis.

Most are associated with minor adverse effects. Rarely more serious adverse effects will occur. These serious complications include the following:

• Rarely, death (eg, secondary to anaphylactic shock or sepsis)
• Stroke
• Anaphylactic reactions
• Blindness secondary to thrombus formation in the retinal artery after arterial injection periorbitally or from needle trauma: The use of higher viscosity materials (eg, Zyplast, Cymetra) should be avoided near the eyes or in the glabellar region. The needle should always be directed away from the eye.
• Local skin necrosis secondary to occlusion of cutaneous arterioles. This complication can be recognized early as vasoconstriction (blanching) and pain at the injection site. Immediate administration of heat, massage, and nitroglycerin paste can help to minimize or reverse permanent injury.
• Cystic reactions to implanted material or foreign body abscesses. These reactions are usually treated with incision and drainage and intralesional steroids.

Patients should expect to experience some degree of pain during injection, which varies for each product based on pH and whether the product is suspended or reconstituted in buffered lidocaine. Transient erythema can last as long as 36 hours after treatment, beyond which, hypersensitivity must be considered. Topical anesthetics and ice-cold compresses can be used to minimize the pain of injection.

References

• Cosmetic Interventions for HIV-Associated Lipoatrophy by Graeme J. Moyle, MD, MBBS -- MedScape Article
• Dermal Fillers by Roberta D Sengelmann, MD --eMedicine Article
• The Aging Face: More Than Skin Deep by Tina Alster, MD & others--MedScape Article
• Semipermanent and Permanent Dermal/Subdermal Fillers; Supplement to Plastic and Reconstructive Surgery, Vol 118, No 35, Sept 1, 2006