Facial Fillers and Volumizers

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INTRODUCTION

The aging process is a very complex phenomenon, engendered by genetically determined intrinsic and extrinsic factors. Sun exposure with its cumulative ultraviolet effects, even not related to intrinsic aging, represents the most important leading cause of aging of the skin and its undesirable aesthetic effects. Ultraviolet exposure is aggravated by lifestyle and habits, such as cigarette smoking, poor nutritional practices and chemical exposure to different pollutants and irritants, which lead to biological and immunological changes. As a consequence, we see visible and histological signs of skin aging, such as decreased thickness of the epidermis, dermis and subcutaneous tissue, which are clinically manifested by smile lines, crow’s feet and facial creases. Over the last few decades, soft tissue augmentation using injectable fillers, combined with other modalities, has become the standard clinical approach for correcting these age-related defects ( Fig. 9.1 ). Soft tissue fillers can temporarily restore a smoother, younger-looking skin by helping to fill in these lines and creases, to recreate symmetry, volume and a smooth skin surface. The ease of performance, lack of down time and infrequency of complications have increased the popularity and patient acceptance of injectable fillers.

Ideal fillers (SCALES 1953):

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are not modified by liquids or organic tissues
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are chemically inert
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do not cause inflammatory reactions
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are non-carcinogenic or mutagenic
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are capable of resisting to mechanical tensions
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do not produce allergic reactions
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are capable of resisting to mechanical strains
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can be manufactured in different formats
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can be sterilized.

After the decision has been made to perform soft tissue augmentation, selecting the filling substance and proper technique are of utmost importance. However, with so many new products of different nature and longevity, and so many others waiting for approval for use in a particular market, it becomes increasingly important to know the properties, composition and mechanism of action of each particular filler, as well as their interactions and tissue responses. None of the currently available fillers meets all the desired criteria, but, while we still search for the ideal fillers, hyaluronic acid (HA) fillers have become the new gold standard in soft tissue augmentation, fulfilling many of our desired criteria. Although they are very well tolerated, the durability of the HA fillers and, to a lesser degree, collagen fillers varies from several months up to 1–2 years, depending on stabilization methods, molecular size and injection site. In contrast, silicone oil lasts for life and some other synthetic fillers stay for decades.

Whether they are permanent or temporary, all fillers have similar application techniques and are part of the treatment planning for use either alone or in combination with other modalities. In this chapter, we will discuss the current and most recent fillers, FDA and non-FDA approved, their characteristics and skin interactions, different formulations and presentation, best indications ( Fig. 9.2 ), techniques and complications.

EVOLUTION

The implantation of gold plates to correct cranial facial defects was first described by Fallopius in the 16th century. The search for the ideal material for correcting facial skin irregularities has continued for over 500 years. Many injectable or implantable substances that are not compatible with the human skin, or that have been adulterated in their formulation, have been proposed for cosmetically improving soft tissue defects. Over 100 years ago, autologous fat was one of the earliest agents used for soft tissue augmentation. Interest in autologous fat has continued, with the development of new and improved application techniques of structured fat grafting and microinjections (see Chapter 10 ).

The original concept of tissue augmentation in the modern era involved injecting collagen into the skin. It was believed that the collagen, which has been used for more than 30 years, would incorporate into the skin’s own collagen. However, it turned out that collagen only occupies space. That concept continued and was recently altered to include fillers derived from HA, which was also believed to be a passive filler. As it turned out, HA does promote a certain degree of fibroblastic activity. During the last decade, the technology of fillers and volumizers has begun evolving toward using fillers that would induce hyperplasia and make filling more efficient and long lasting.

Silicone is the oldest filling material to be used in the USA. It was first used in 1930. Since1965, both Orenttreich and associates and Barnett have used it for nasolabial augmentation, with good cosmetic results. The FDA has never approved silicone for cosmetic use.

In the 1950s, Gottlieb developed another dermal filler (Fibrel®), a gelatin matrix implant that is now only of historical interest. The principle was to use a fraction of plasma containing fibrinogen and prothrombin to fill up scars and wrinkles. The mechanism of action was based on the normal coagulation and wound healing process, resulting in new collagen formation. Fibrel is no longer available. In 1981, for the first time, a form of xenogenic agent, bovine collagen, received FDA approval. Although those bovine collagen-derived fillers had great potential for hypersensitivity reactions, they had a good safety record and, therefore, have been the most widely used agents for the last 30 years. However, their short duration is a big disadvantage. The HA and hylan fillers represent a big breakthrough for augmentation technology, and they are among the most popularly used dermal fillers. Restylane® (Q-Med, Upsala, Sweden) was the first HA to be approved in the USA in 2003.

CLASSIFICATION

There are many different ways to classify fillers and volumizers, which leads to some degree of confusion. Traditional fillers have been biodegradable, meaning that they are absorbed and eliminated from the body. We will describe the most popular fillers in detail, according to their properties, tissue interaction, source and longevity, application techniques, side effects and complications. Since this is a market that is developing rapidly, there are many fillers waiting for FDA approval and the CE mark in Europe, which is much less rigorous than in the USA. We will discuss the most used fillers with biodegradable and non-biodegradable properties ( Table 9.1 ).

Table 9.1

Biodegradable and non-biodegradable fillers

Biodegradable	Non-biodegradable	Slowly biodegradable	Biodegradable with fibroplastic properties
AcHyal	Aquamid	Radiesse	Radiesse
Alloderm	Artefill (Artesense)	New Fill/Sculptra	Hyaluronic Acid/Hylan fillers
Autologen	Bioplastique		New Fill/Sculptra
Cymetra	Evolution
Bioinblue	Gore-Tex
Dermal grafting	Meta-Crill
Dermaplant	Silicone oil (Adatosil, Silikon 1000)
Elevess	Softform
Endoplast 50
Fascian
Fat
Human placental collagen
Hyal system
Isologen
Evolence
Juvederm
NewFill/Sculptra
Belotero
Perlane
Restylane (family)
Reviderm
Surgilift
Teosyal
Cosmoderm/Cosmoplast
Zyderm/Zyplast