Tissue Filler

CHAPTER 57 Tissue Filler

Soft tissue augmentation has been performed since the 15th century, when physicians transplanted fat en bloc to correct defects, usually facial disfigurements related to wartime injuries. The modern era began in 1981, when the U.S. Food and Drug Administration (FDA) approved Zyderm I, a suspension of 3.5% bovine collagen with 0.3% lidocaine. Although not particularly long lasting or effective for a great deal of indications, it was sufficient to treat acne scars and fine lines and wrinkles, such as nasolabial folds, oral commissures, and crow’s feet.

Over the past 25 years, products and techniques have evolved so that there are now about 300 different filling materials. Table 57-1 lists the most common filling materials used around the world. Modern techniques and products are used not only for the classic indications for soft tissue augmentation, but also to rebuild and renew faces by replacing lost tissue volume so that they appear much younger.

TABLE 57-1 Most Common Filling Materials Worldwide

Indications

The indications for soft tissue augmentation have evolved over the years. Although they remain in the realm of cosmetic treatment, some, such as the soft-tissue injectables for human immunodeficiency virus (HIV) lipoatrophy, are life-changing. The areas of treatment have also expanded from the injection of nasolabial folds (Fig. 57-1), oral commissures, crow’s feet, and glabella to neck lines, hands, cheeks (Fig. 57-2), bridge of the nose, chin (Fig. 57-3), and any area of atrophy.

Figure 57-1 Radiesse injection of the nasolabial folds. Before (A) and 3 (B), 6 (C), and 12 (D) months after treatment. Volume injected (in milliliters): baseline, 4; 1 month, 0; 6 months, 2; total, 6.

Figure 57-2 Radiesse injection of the cheeks. Before (A) and 3 (B), 6 (C), and 12 (D) months after treatments. Volume injected (in milliliters): baseline, 8; 1 month, 5; 6 months, 5.7; total, 18.7.

Figure 57-3 Radiesse injection of the chin. Before (A) and 3 (B) and 12 (C) months after treatments (no 6-month postinjection photograph available). Volume injected (in milliliters): baseline, 6; 1 month, 0.8; 6 months, 2; total, 8.8.

Contraindications

There are both absolute and relative contraindications, as well as those that are generally applicable to all fillers and those that are specific to certain fillers.

• Allergies: Although there is still some limited use of bovine material, it is limited to Zyderm and Zyplast (Inamed, Santa Barbara, Calif) and Artefill (currently off the market). Any allergy to bovine protein precludes the use of these materials, and skin testing must take place before use. Animal sources are rarely used for fillers any longer, although there are exceptions. There is one hyaluronic acid product from avian sources (cock’s comb); however, this does not require skin testing. Most materials are based on hyaluronic acid, which will be discussed in detail and which does not elicit a delayed hypersensitivity response. In addition, only rarely do these materials contain lidocaine, so allergy is not a substantive problem.

• Active infection: Any active infection or skin disease in the area to be injected is a contraindication.

• Location: Injection of robust substances such as Zyplast, Cosmoplast, and biphasic fillers into the glabellar complex must be avoided.

• Patients who are pregnant or breast-feeding should not undergo augmentation.

Relative contraindications include the following:

• Unrealistic expectations.

• Body dysmorphic disorder or patients seeking a psychological boost after a life-changing event such as a divorce, death of a family member, or loss of a job. Patients should wait and let things settle down before rushing into a procedure that may or may not be right for them and will not solve the emotional issue.

• Use of anticoagulants. Preparation for the injections to prevent bruising, particularly when using biphasic fillers, should consist of discontinuing aspirin and vitamin E for at least 72 hours, and if the patient is on warfarin to consult with the patient’s primary care physician regarding the feasibility of discontinuing the drug for a few days. If this cannot be done, the patient should not be injected with biphasic fillers and extreme caution must be taken even with hyaluronic acid fillers. Topical vitamin K cream twice a day for a week before and after will significantly decrease the bruising.

Initial Examination and Patient Preparation

A complete history and physical examination should be performed before soft tissue augmentation, and particular emphasis should be placed on any prior injections or Botox treatments, what the patient is using for skin care, and any allergic reactions or difficulties with any cosmetic procedures in the past.

Obtaining good-quality photographs before injection is strongly encouraged in all patients.

Informed consent should include all the pertinent information regarding possible side effects, cost, and alternative treatments, as well as a statement at the end that the patient has been asked if he or she has any further concerns or questions and stated that he or she does not. It is also prudent, if at all possible, to schedule another session for the patient 2 to 3 weeks after treatment to see if what both the patient and the physician desired has been accomplished. Do not call this a session “for a possible touch-up,” but one for injection in case it is needed. When possible, always try to schedule two injection sessions so that if there are any issues they can be easily resolved. The problem with calling a second injection a “touch-up” is that often the patient feels that there was something done incorrectly with the first injection and will be hesitant to pay for a “touch-up.”

Equipment for Soft Tissue Augmentation

• Injectable material of choice

• Appropriate-gauge needles for the material of choice

• Anesthetic material

• Topical vitamin K

• Alcohol swabs for skin preparation

Material for Injection

This is the point where things become very complicated because there are a myriad of materials available for use. It is not possible to obtain expertise or even experience with all filling materials that are currently available; however, familiarity with a few will provide an armamentarium that will be sufficient for most needs (Table 57-2).

TABLE 57-2 Common Uses of Major Fillers

Collagen Products from Human Fibroblasts

CosmoDerm has for the most part replaced Zyderm because it is the same material with the same indications, but with the collagen derived from human foreskin fibroblasts. Therefore it does not require allergy skin testing. CosmoPlast is the same as Zyplast except that it is also derived from human tissue.

Collagen Products from Bacterial Hyaluronic Acid

Most of the materials available now are based on hyaluronic acid. Hyaluronic acid products have become very popular around the world, and there are indeed many of them, but the most significant in this category are the products from Qmed in Sweden (Restylane, and Perlane Restylane fine lines) and those from Inamed-Allergan (Juvéderm Ultra, Juvéderm Ultra Plus, and Juvéderm Fine Line—also known as Juvéderm 24, Juvéderm 30, and Juvéderm 18). All of these products are manufactured by bacterial fermentation in the laboratory, after which the hyaluronic acid undergoes various degrees of cross-linking and folding to increase the longevity of the implant. Without any manipulation of the molecule to increase cross-linking and molecular weight, the implant would be very short lived because pure hyaluronic acid lasts only hours to a few days when injected into the skin. There is a product in use in Asia called Hyalan that is actually injected into the skin to act as a moisturizer. Hyaluronic acid traps and attracts water to it. This is also the reason that when hyaluronic acid is injected as filler the end result is a smooth surface—because water is absorbed into the area of injection. Although there is great similarity between the two types of hyaluronic acid fillers available, there is much debate as to which is the longer lasting, which produces smoother results, and which is more comfortable for the patient. The higher–molecular-weight products are used for more aggressive augmentation such as for scars, lip augmentation, and some degree of sculpting. The lower–molecular-weight products are used for fine lines such as crow’s feet and lip lines. Midrange products are used for the majority of augmentation needs such as the treatment of nasolabial folds, oral commissures, and the glabellar area.

The most common fillers used in the United States are Restylane and Perlane (Medicis, Scottsdale, Ariz) and Juvéderm Ultra and Juvéderm Ultra Plus (Allergan, Irvine, Calif), although there are some others available.

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May 14, 2017 | Posted by admin in GENERAL & FAMILY MEDICINE | Comments Off

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