Injectables, Skin Resurfacing, Lasers, and Hair Restoration


Chapter 30

Injectables, Skin Resurfacing, Lasers, and Hair Restoration



Injectables



1. Substances that are injected into the dermis or subcutaneous tissue to alter facial shape, appearance, and/or aesthetics


• There is no ideal injectable and each carries its own individual risk/benefit profile.


• Do not inject any injectables obtained by a patient from any other location than your office.


2. General complications of injectables


• Inadvertent arterial injection: Immediately stop the injection and attempt to aspirate the substance. Can reduce risk by injecting slowly, using a small needle


• Inadvertent venous injection: Treatment is conservative and includes massage, warm compresses, and nitroglycerine patch.


• Inadvertent placement of injectable: If the patient develops problems, can try to debulk the filler (i.e., hyaluronidase)


3. Types of injectables (see Table 30.1)


• Hyaluronic acid


▪ Synthetic compound used to “fill” soft tissues (i.e., deep rhytids, etc.)


○ Nasolabial fold, perioral rhytids: Inject into subdermal space


○ Tear-trough deformity: Inject subperiosteally


▪ Example products


○ Juvederm


○ Restylane


○ Perlane


▪ Reversible with hyaluronidase


• Botulinum toxin A (botulinum toxin type-A cosmetic, Dysport)


▪ Chemodenervation


○ Mechanism of action: Inhibition of acetylcholine release at the neuromuscular junction


○ Useful for dynamic rhytids


▪ FDA approved for glabella rhytids and crow’s feet


○ May be used off-label for other sites legally but cannot be advertised for these off-label uses


▪ Onset of action: 24 to 72 hours, but may take up to 2 weeks for maximum effect


▪ Duration of action: 3 to 4 months


▪ Example products


○ Botox cosmetic


○ Dysport


◆ Cannot be used in patients with milk allergy


▪ Potentiating medications


○ Penicillamine, quinine, calcium-channel blockers, and aminoglycosides


▪ Common uses


○ Glabellar rhytids: Chemodenervation of the corrugators


○ Crow’s feet: Chemodenervation of the lateral orbicularis oculi


◆ Can lead to lateral brow elevation due to unopposed action of the frontalis m.


○ Bunny lines: Chemodenervation of the levator labii superioris alaeque nasi and nasalis


○ Forehead rhytids: Chemodenervation of frontalis m.


◆ Hyperactive frontalis m. can mask eyelid ptosis; thus, chemodenervation of the frontalis can lead to upper eyelid ptosis.


➔ Treatment includes α-adrenergic eyedrops (e.g., Iopidine), which causes stimulation of Mueller’s m. and elevation of the upper eyelid by 2 mm.


○ Horizontal nasal lines: Chemodenervation of the procerus m.


▪ Complications


○ Unexpected brow position changes (elevation or ptosis)


◆ Depends on which muscles are denervated


◆ Elevators of the medial brow: Orbicularis oculi, corrugator supercilii, depressor supercilii and procerus


◆ Elevators of the lateral brow: Frontalis


○ Upper eyelid ptosis


◆ Diffusion of drug through the orbital septum to the levator m. (most common), which usually occurs with primary treatment to the glabellar region


◆ Chemodenervation of hyperactive frontalis m.


• Botulinum toxin type B


▪ FDA approval for treatment of cervical dystonia and hemifacial spasm


▪ Comparison with toxin A


○ Acidic (more painful on injection), stable as a liquid, longer shelf life, shorter duration of action, faster onset, greater radius of diffusion


▪ Can be used if patient develops antibodies to Botox cosmetic


▪ Example products


○ Myobloc


• Bovine collagen


▪ Example products


○ Zyderm I and II, Zyplast


▪ Approximately 3% of patients will exhibit hypersensitivity reactions.


○ Must test skin 4 weeks before injecting


• Poly-L-lactic acid


▪ FDA approved for human-immunodeficiency virus (HIV) lipoatrophy


▪ Injected subcutaneously in the cheek, submuscularly in the orbital region, and subperiosteally in the temples region


▪ Example products


○ Sculptra


▪ Patients require multiple injections every 4 to 6 weeks for several months.


▪ Advantages: Results may last for more than 2 years.


▪ Disadvantages: Can result in nodule formation in dynamic muscles of the face (especially the lip and eye)


• Fat grafting


▪ “Autologous filler”


▪ Advantages: No risk of hypersensitivity


▪ Disadvantages: Requires a donor site (harvest of adipocytes), with processing, before injection; resorption; unpredictable graft survival; longer recovery time


▪ Method


○ Aspiration


○ Sedimentation


◆ Balanced centrifugation


◆ Gravity (optimal but lengthy)


○ Injection into the deep dermis


◆ Small amount of fat per pass


▪ Optimizing survival


○ Avoid: Large canula aspiration, filtration, rinsing, straining, or drying



Table 30.1


Common Facial Fillers Currently Available for Use in Soft-Tissue Augmentation






















































































































































































FILLER TYPE NAME (MANUFACTURER) INDICATION DURABILITY ADVANTAGES DISADVANTAGES MARKET STATUS
Autologous products Viable fat Deep defects Variable; months to years Abundant supply, safe, inexpensive Donor site morbidity, variable reproducibility, requires processing No FDA/EEA approval required
Autologous collagen/autolagen Collagenesis, Beverly, MA; Isolagen, Exton, PA Moderate to deep defects Months to years; processed from excised skin Can be stored up to 6 months, safe Donor morbidity, painful, costly FDA approved/CE mark
Bovine collagens Zyderm 1 (3.5% dermal collagen) (INAMED, Santa Barbara, CA) Superficial defects, fine lines, acne scars 2 to 4 months Safe, reliable, contains lidocaine, ease of administration Allergic reaction in 1% to 3%, short-term results, requires skin testing before use, reactivation of herpes is possible with lip injections FDA approved/CE mark
Zyderm 2 (6.5% collagen) (INAMED, Santa Barbara, CA) Moderate defects, deeper acne scars, lip augmentation 2 to 6 months Same as Zyderm 1 Same as Zyderm 1 FDA approved/CE mark
Zyplast (3.5% cross-linked collagen) (INAMED, Santa Barbara, CA) Deep defects, lip augmentation 2 to 6 months Same as Zyderm 1, more viscous and resistant to degradation Can cause skin necrosis if used in glabella, allergies in 3%, requires skin testing FDA approved/CE mark
Cadaveric collagens AlloDerm (acellular human dermis; comes in sheets of varying sizes) (LifeCell, Branchburg, NJ) Deep wrinkles or scars, lip augmentation 6 to 12 months Safe, no allergy testing required Expensive, surgically implanted, often causes temporary swelling, occasionally palpable, shrinkage with time FDA approved/CE mark
Cymetra (micronized, injectable form of AlloDerm) (LifeCell, Branchburg, NJ) Deep wrinkles or scars, lip augmentation 3 to 6 months Safe, no allergy testing required, contains lidocaine Can cause skin necrosis if used in glabella, costly, often clumps within needle FDA approved/CE mark
Cell-cultured collagen Cosmoderm (35 mg/mL collagen) (INAMED, Santa Barbara, CA) Superficial defects, shallow wrinkles and acne scars 3 to 4 months Safe, no allergy testing required, contains lidocaine Short-term results, most common side effects include cold symptoms (4%), flu symptoms (2%) FDA approved/CE mark
Cosmoplast (35 mg/mL cross-linked collagen) (INAMED, Santa Barbara, CA) Deeper defects and wrinkles, lip augmentation 3 to 4 months Same as Cosmoderm Same as Cosmoderm FDA approved/CE mark
Avian-derived hyaluronic acids Hylaform gel (INAMED, Santa Barbara, CA) Moderate defects, lip augmentation 3 to 4 months Safe, reliable, no allergy testing required Short-term results, immunologic reactions in patient allergic to avian products (eggs) FDA approved/CE mark
Hylaform Plus (INAMED, Santa Barbara, CA) Moderate to deeper defects, facial wrinkles, and folds. 3 to 4 months Same as hylaform gel Same as hylaform gel, superficial injection may lead to skin discoloration FDA approved/CE mark
Bacterial-cultured hyaluronic acids Restylane/Restylane Fine (Medicis, Scottsdale, AZ) Superficial (Restylane Fine)-to-moderate defects, deeper wrinkle reduction, nasolabial folds, glabellar creases, lip augmentation 6 to 12 months Safe, reliable, predictable results, no allergy testing required, longer lasting than bovine collagens Rare immunologic reactions, higher incidence of bruising, pain, and postprocedure swelling vs. bovine collagens, higher cost FDA approved/CE mark
Perlane (Medicis, Montreal, Canada) Deeper defects, shaping facial contours, lip augmentation 6 to 12 months Same as Restylane Same as Restylane FDA approved/CE mark
Captique (INAMED, Santa Barbara, CA) Superficial defects, fine lines and wrinkles 3 to 6 months Safe, no allergy testing required, similar to Restylane Relatively new product, short-term results FDA approved/CE mark
Juvederm 18, 24, 30 (L.E.A. Derm, Paris) Superficial (18), moderate (24), and deep (30) defects 3 to 6 months Safe, predictable results, no allergy testing needed Short-term results, rare immunologic reactions, relatively new product FDA approved
Synthetics Sculptra (poly-L-lactic acid microparticles) (Dermik Laboratories, Berwyn, PA) Deep defects 1 to 2 years Long-term results, safe Rare, foreign body reaction, limited U.S. results/studies Approved for lipoatrophy; off-label for cosmetic purposes/CE mark
Radiesse (calcium hyodroxyapatite microspheres) (Bioform Medical, Franksville, WI) Deep defects, nasolabial folds, vertical lip lines, acne scars, marionette lines, volume restoration around cheeks 1 to 2 years Long-term results, no allergy testing required, no concern for antigenic or inflammatory reactions Can rarely develop nodules if injected superficially FDA approved/CE mark
Artecoll/ArteFill (polymethylmethacrylate microspheres in 3.5% bovine collagen and 0.3% lidocaine) (Artes Medical, San Diego, CA) Deep defects, glabella, nasolabial folds Permanent after nearly 50% resorption Unrivaled longevity, probably safe, but reports of persistent erythema at injection site Palpable if placed superficially or excessively; thus, avoid injecting into the lips and areas with thin overlying skin; requires allergy testing Preliminary FDA approval for cosmetic purposes/CE mark
Reviderm Intra (dextran beads in a hylan gel) (Rofil Medical International, Breda, The Netherlands) Deep defects, lip augmentation Months to years Long-term results, safe Postprocedural swelling, relatively new product to U.S. Not FDA approved/CE mark
Silicone/Silikon-1000 (liquid silicone) (Alcon Laboratories, Fort Worth, TX) Deep defects, lip augmentation Permanent Permanent, safe, long clinical experience Migration, foreign body reactions, poor reputation Off-label for cosmetic purposes
Endoplast 50 (elastin and collagen) (Laboratories Filorgra, Paris) Deep defects, lip augmentation 12 months Long-term results Allergy tests required, limited experience Not FDA approved/CE mark
Bio-Alcamid (96% water, 4% polyalkylimide) (Pur Medical Corp, Toronto, Canada) Deep defects Permanent Long-term results, removable, no allergy testing required, biocompatible Limited experience, inflammatory reactions, infectious complications, migration FDA approved/CE mark for HIV lipoatrophy
Aquamid (polyacrylamide hydrogel) (Contura International) Deep defects, lip augmentation Permanent Long-term results, compound plasticity High rate of granuloma formation, infectious complications Not FDA approved/CE mark

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Sep 2, 2016 | Posted by in Aesthetic plastic surgery | Comments Off on Injectables, Skin Resurfacing, Lasers, and Hair Restoration

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